Answers to frequently asked questions by Freedom Option members

Please use the following list to help you with any questions or concerns you may have regarding your Senior Care Plus benefits.

What is a PPO?
Who is eligible for coverage?
How do I apply for coverage?
What is my deductible for medical services? >
What is my "Copayment",  "Coinsurance", and "Deductible" (the amount that I pay)?
What should I do if I receive a bill?
What is my lifetime maximum benefit?
What if the charges are higher than "usual and customary"?
How are prescriptions covered?
I am leaving for a two-week vacation, and my prescription will run out before I return. What can I do?
How can I replace my lost Senior Care Plus membership card?
I will be moving soon. How do I notify Senior Care Plus of my new address?
What is the advantage of using preferred versus a non-preferred provider?
I do not know any of the doctors on your provider list. What should I do?
Do I need referrals or authorizations?
Does Senior Care Plus cover physicals?
What if Senior Care Plus were to leave the market or terminate their contract with Medicare? 

 

---

Senior Care Plus Answers to Your Questions

Q. What is a PPO?
A. PPO stands for Preferred Provider Organization. Senior Care Plus gives members the option of receiving medical care from participating providers (those listed in your Senior Care Plus Provider Directory) or nonparticipating providers (those not listed in your Senior Care Plus Provider Directory) or a combination of both. When receiving care from a participating provider, there is generally a copayment for an office visit. You must identify yourself to a participating provider by presenting your Senior Care Plus membership card. When receiving care from a nonparticipating provider, the appropriate coinsurance will apply for office visits.

Back to top

Q. Who is eligible for coverage?
A. Senior Care Plus members who meet eligibility guidelines as defined in the Senior Care Plus Evidence of Coverage (EOC) booklet are eligible for health-care coverage.

Back to top

Q. How do I apply for coverage?
A. Fill out all sections, sign, and date your "Senior Care Plus Application for Enrollment" and return it to Senior Care Plus. Please call the Senior Care Plus Enrollment Department at 775-982-3158 for more information.

Back to top

Q. What is my deductible for medical services?
A. There is no deductible to be satisfied for most services covered by the Freedom Options. There is only a $500 yearly deductible forInpatient Hospital and Mental Health Care when received out-of-network only. If you elect the Freedom Rx+ Package, there is also a $50 calendar year deductible for Basic and Major dental services. Please refer to your Evidence of Coverage for more information.

Back to top

Q. What is my "Copayment",  "Coinsurance", and "Deductible" (the amount that I pay)?
A. Some benefits have a copayment, a set amount you pay when you access services.  Other benefits have coinsurance, a percentage you pay when you access services.  Some benefits have no copayments or coinsurance at all.  Inpatient Hospital Services, Inpatient Mental Health Services, and Skilled Nursing Facility Services have a per stay copayment amount. See your Summary of Benefits and Evidence of Coverage for specific information regarding your financial responsibility when using our plan.

Back to top

Q. What should I do if I receive a bill?
A. You need to check with the provider to ensure that they have sent their billing to Senior Care Plus for processing. If the provider is not a participating provider, they may be willing to bill on your behalf. If so, you will need to have the provider send the bill to Senior Care Plus, PO BOX 20700, Reno, NV 89515. If the provider is unwilling to bill Senior Care Plus for you, then you must submit your record of payment along with the claim form indicating whether you or the provider should be reimbursed.

Back to top

Q. What is my lifetime maximum benefit?
A. The Freedom Options do not have a lifetime maximum benefit.  However, some benefits may have annual quantity maximums, such as Outpatient Prescription Drugs. See your Summary of Benefits and Evidence of Coverage for limitations.

Back to top

Q. What if the charges are higher than "usual and customary"?
A. If you are using a participating provider, you do not have to be concerned about usual and customary charges. Senior Care Plus has contracted fees with participating providers. If you are using a nonparticipating provider, you may be responsible for all excess charges (charges over and above usual and customary) and be billed by the nonparticipating provider for the balance of the bill.

Back to top

Q. How are prescriptions covered?
A. If Senior Care Plus provides your prescription benefit, you may have a participating pharmacy fill your prescriptions (refer to your Provider Directory). The pharmacy will fill prescriptions to the amount prescribed for up to a 30-day supply.  

For prescriptions that you need to take for more than a 30-day period, Senior Care Plus offers a Mail Order Prescription Drug Program, which provides for your prescription needs and delivers them directly to your door. For more information refer to your Pharmacy Handbook or contact the Senior Care Plus Customer Services Department.

Since Senior Care Plus uses a Formulary (a list of approved medications), your prescribed medication must be on the Formulary to be covered. Non-Formulary drugs are not a covered benefit; you must pay in full for these drugs. For Formulary generic and brand name drugs, you will pay a low copayment per prescription. There is a gap in coverage after you have spent $2,250 in yearly total drug costs where drugs are not covered unless you elect the Freedom Rx+ Option which includes expanded prescription coverage.

For a Formulary brand-name drug that has an approved generic-equivalent drug on the Formulary, you will pay the brand-name copayment amount plus the difference in cost between the generic drug and the brand-name drug.

Back to top

Q. I am leaving for a two-week vacation, and my prescription will run out before I return. What can I do?
A. Your pharmacist may contact our Pharmacy Prior Authorization Line to request a special authorization number. With that number, the pharmacist will fill your prescription for an additional 30-day fill with an additional copayment.

 Back to top

Q. How can I replace my lost Senior Care Plus membership card?
A. You can request a new membership card by calling our Customer Services Department at 775-982-3112, or 800-336-0123. Senior Care Plus will send a replacement card to your home address within seven to ten working days of your request. This is a sample of one type of Senior Care Plus membership card. Your card may contain different information to reflect the benefit plan that you selected.

Back to top

Q. I will be moving soon. How do I notify Senior Care Plus of my new address?
A. Senior Care Plus must have your correct address and telephone number. We notify members about any referrals, program or physician changes, and claims status by mail. Also, we want to make sure you receive each issue of our newsletter, For the Smarter Generation. Please contact our Customer Services Department before you move, or mail us a change of address card (available at your local post office).

Back to top

Q. What is the advantage of using a preferred versus a non-preferred provider?
A. With a participating provider, you enjoy:

• Substantial reductions in your out-of-pocket expenses
• No claim forms
• No bills for services that are above and beyond usual and customary charges (balance billing by providers)
• A copayment for many services

In addition, you can be assured that all of our participating providers are thoroughly reviewed for consistent delivery of quality care before and during their contract with Senior Care Plus.

Back to top

Q. I do not know any of the doctors on your provider list. What should I do?
A. Our Customer Services Representatives will verify which providers are currently accepting new patients and provide you with some basic information, such as the type of practice, location, office setting (clinic vs. private practice), and appointment procedures. You can also call the 24-hour Hometown Health Hotline at 775-982-5757 or 888-324-3243, option 1.

Back to top

Q. Do I need referrals or authorizations?
A. Yes. For certain tests, procedures, and hospitalization, as indicated in your Summary of Benefits or your Evidence of Coverage booklet, communication with Senior Care Plus would be appreciated. This will indicate when precertification is necessary. It is your responsibility to request precertification for certain procedures and tests. If preauthorization is not obtained your benefits will be reduced.

Back to top
 
Q. Does Senior Care Plus cover physicals?
A. Senior Care Plus covers routine physical exams, including tests normally made with the examinations. Senior Care Plus does not provide coverage, however, for a physical for work, sports participation, insurance, school attendance, or any kind of licensure.

Q. What if Senior Care Plus were to leave the market or terminate their contract with Medicare?
A. If we leave the Medicare program or change our service area so that it no longer includes the area where you live, we will tell you in writing. If this happens, your membership in Senior Care Plus will end, and you will have to change to another way of getting your Medicare benefits. All of the benefits and rules described in your Evidence of Coverage will continue until your membership ends. This means that you must continue to get your medical care in the usual way through Senior Care Plus until your membership ends.

Your choices will always include Original Medicare. Your choices may also include joining another Medicare managed care plan, or a Private Fee-for-Service plan, if these plans are available in your area and are accepting new members. Once we have told you in writing that we are leaving the Medicare program or the area where you live, you may change to another way of getting your Medicare benefits at any time. If you decide to change from Senior Care Plus to Original Medicare, you will have the right to buy a Medigap policy regardless of your health. This is called a “guaranteed issue right” and it is explained earlier in this section under the heading, “Do you need to buy a Medigap (Medicare supplement insurance) policy?”

Hometown Health Plan has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed, and either Hometown Health Plan or CMS can decide to end it. You will get 90 days advance notice in this situation. It is also possible for our contract to end at some other time, too. If the contract is going to end, we will generally tell you 90 days in advance. Your advance notice may be as little as 30 days or even fewer days if CMS must end our contract in the middle of the year.

Back to top

 

Revised October 2007