Answers to
frequently asked questions by Value 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 HMO?
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)?
Do I have to fill out a claim form? 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?
Am I required to select a Primary Care Physician?
What is the role of my Primary Care Physician?
I do not know any of the doctors on your provider list. What should I do?
Is my Primary Care Physician given any incentive not to send me to a specialist or not to provide me with appropriate care?
Do I need a referral for specialty care?
What is the role of a specialty care physician?
Does Senior Care Plus cover physicals?
I would like to see a chiropractor. Does Senior Care Plus cover that?
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 HMO?
A. HMO stands for Health Maintenance
Organization. Senior Care Plus contracts with doctors and other providers. You
select from among these providers to receive authorized medical care. Present
your Senior Care Plus membership card, and all you pay is your copayment,
coinsurance, or deductible, if applicable, for the services you receive. Senior
Care Plus pays the remainder of the bill.
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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.
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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.
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Q. What is my deductible for medical services?
A. There is no deductible to be
satisfied for services covered by the Value Options. If you elect the Value
Rx+ Package, there is a $50 calendar year deductible for Basic and Major dental
services. Please refer to your Evidence of Coverage for more
information.
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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.
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Q. Do I have to fill out a claim form? What should I do if I receive a bill?
A.
You do not have to fill out any claim forms for care received from authorized
and participating providers. The only bills for which you are responsible are
your copayments, coinsurance, deductibles, or bills for unauthorized services
acquired from a noncontracted provider. If you receive a bill for which you
believe you are not responsible, send it to Senior Care Plus to process or call
the Senior Care Plus Customer Services Department at 775-982-3112, for
assistance.
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Q. What is my lifetime maximum benefit?
A. The Value Options do not have a lifetime
maximum benefit. However, some benefits have annual
quantity maximums, such as Outpatient Prescription Drugs. See
your Summary of Benefits and Evidence of Coverage for limitations.
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Q. What if the charges are higher than "usual and customary"?
A. You do not have to
be concerned about "usual and customary" charges with the Value Options. Senior
Care Plus has contracted fees with participating providers for all
services.
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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.
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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.
| 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. |
|
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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).
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Q. Am I required to select a Primary Care Physician?
A. Yes. Senior Care Plus
cannot process your Application for Enrollment without a Primary Care Physician
selection. If you do not indicate a Primary Care Physician, we will select one
for you. You always retain the right to change your Primary Care Physician.
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Q. What is the role of my Primary Care Physician?
A. Your Primary Care Physician's
primary responsibility is to provide, arrange, and coordinate all aspects of
your health care.
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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.
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Q. Is my Primary Care Physician given any incentive not to send me to a specialist
or not to provide me with appropriate care?
A. No. Your doctor is
given incentives to provide you with appropriate care. Senior Care Plus reviews
the care that your Primary Care Physician provides on a regular basis to monitor
the frequency that he or she refers care and to be sure you are receiving
appropriate care.
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Q. Do I need a referral for specialty care?
A. Yes. You need a referral from your
Primary Care Physician before receiving any specialty care. If your Primary Care
Physician determines that you need medical care or services from a
specialty-care provider, he or she will make a referral from Senior Care
Plus to a participating plan provider. This referral will indicate how many
visits, the time period, and location. Contact Senior Care Plus if you have not
received your written referral in a timely manner.
Exception: Most OB/GYN
care does not require a Primary Care Physician referral.
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Q. What is the role of a specialty care physician?
A. A specialty-care physician
provides certain specialty medical care upon referral from your Primary Care
Physician.
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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.
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Q. I would like to see a chiropractor. Does Senior Care Plus cover that?
A. Your Primary Care Physician will
request a referral from Senior Care Plus, and you must receive a written
referral from Senior Care Plus prior to using any specialty services.
Chiropractic services are covered when covered by traditional
Medicare. Your office copayment applies.
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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.
Revised October
2007
