Frequently Asked Questions

1. What is a Medicare Advantage (Part C) plan?

A Medicare Advantage plan is another way to get your Medicare coverage. Medicare Advantage Plans are offered by Medicare-approved private insurance companies, who must follow rules set by Medicare. You get your Medicare Part A and B coverage from the plan, not original Medicare. Many plans also cover additional services.

2. What makes me eligible to enroll in a Medicare Advantage plan?

To be eligible to enroll into a Medicare Advantage plan, you must be entitled to Medicare Part A and enrolled in Medicare Part B. You must live in the plan’s approved service area.

For some plans, like Special Needs plans, there will be additional eligibility requirements. For example- To be eligible for The Health Plan SecureCare SNP (HMO D-SNP), you also need to have Medicaid along with your Medicare.

3. Do I give up Original Medicare by joining a Medicare Advantage plan?

You do not give up Original Medicare. However, you do not use it when you are enrolled in a Medicare Advantage Plan. We will issue you an identification card to use during visits to your physicians, hospital or other health providers. Keep your Medicare card in a safe place in case you decide to go back to Original Medicare.

4. When can you enroll in a Medicare Advantage Plan?

Enrollment into a Medicare Advantage Plan is generally for the entire plan year. Once you enroll, you may only leave the plan or make changes to it at certain times of the year when an enrollment period is available or under certain special circumstances.

Initial Coverage Election Period (ICEP):

The ICEP is the period during which an individual newly eligible for Medicare Advantage may make an initial enrollment request to enroll in a Medicare Advantage Plan. This period begins three months immediately before the individual’s first entitlement to both Medicare Part A and Part B and ends on the later of: 1) The last of the month preceding entitlement to both Part A and Part B; or, 2) The last day of the individual’s Part B initial enrollment period. (The initial enrollment period for Part B is the seven month period that begins three months before the month an individual meets the eligibility requirements for Part B, and ends three months after the month of eligibility.)

Annual Election Period (AEP) October 15 – December 7:

During the AEP, Medicare Advantage eligible individuals may enroll or disenroll from a Medicare Advantage Plan. If you wish to enroll in a new Medicare Advantage Plan, like those offered by The Health Plan for January 1, you can do so by changing your plan during the Annual Election Period (AEP). This Annual Election Period runs from October 15 – December 7 of each year. Changes will take effect on January 1.

Medicare Advantage Open Enrollment Period (MA OEP) January 1 - March 31

During the MA OEP, Medicare Advantage plan enrollees may enroll in another Medicare Advantage plan or disenroll from their Medicare Advantage plan and return to Original Medicare. Individuals may make only one election during the MA OEP. Individuals may add or drop Part D coverage during the MA OEP. Individuals enrolled in either MA-PD or MA-only plan can swith to: MA-PD, MA-only, or Original Medicare (with or without a stand-alone Part D plan). The effect date for an MA OEP election is the first of the monthy following receipt of the enrollment request.

NOTE: The MA OEP does not provide an opportunity for an individual enrolled in Original Medicare to join a MA plan. It also does not allow for Part D changes for individuals enrolled in Original Mediare, including those enrolled in stand-alone Part D plans. The MA OEP is not available for those enroleed in Medicare Savings Accounts or other Medicare health plan types (such as cost plans or PACE).

Special Election Period (SEP):

Special Election Periods constitute periods outside of the usual ICEP, AEP, or MADP when an individual may elect a plan or change their current plan election. There are various types of SEPs, including (but not limited to) SEPs for: beneficiaries who receive assistance under Title XIX (Medicaid), those who receive Extra Help with Part D drug costs (LIS), those whose current plan terminates, who change residence, who would like to join a 5-Star rated plan and those who meet “exceptional conditions."

5. What if I am a member of another Medicare Advantage plan?

If you enroll into one of The Health Plan Medicare Advantage plans, the coverage from your current Medicare Advantage plan will automatically terminate. Medicare only allows you to be enrolled in one Medicare Advantage Plan at a time.

6. What if I am a member of a Medicare Supplement plan?

If you are already a member of a Medicare Supplement plan and wish to join a Medicare Advantage Plan, you can drop your Medicare Supplement plan. You cannot use the Medicare Supplement policy to pay for any expenses (like copayments, coinsurance, deductibles or premiums) you have under a Medicare Advantage Plan. If you drop the Medicare Supplement Plan you may not be able to get it back. Please see the official Medicare website at Medicare.gov for additional information.

7. Do I need to choose a Primary Care physician? If so, can I change my doctor selection at any time?

If you join one of our Medicare Advantage HMO plans, you must choose a Primary Care Physician (PCP) from our list of contracted providers. You may change your PCP selection at any time by calling our Customer Service Department.

8. Are there pre-existing conditions that won’t be covered under Medicare Advantage plans?

Once you become a member of a Medicare Advantage plan, there are no pre-existing condition clauses. This means that all covered services are covered for all members, regardless of whether you had the condition prior to enrollment.

9. What if I move outside of your service area?

Our contract with Medicare requires that you live inside of our approved service area. You are permitted to leave our service area for no more than 6 consecutive months. If you are outside of the service area for longer than 6 consecutive months, you will be disenrolled from the plan. If you permanently move outside of the service area, you must tell us in writing so that we can disenroll you. You will then be covered by Original Medicare and/or any new coverage into which you enroll in your new service area.

Service area counties are listed in each plan’s Summary of Benefits document.

10. What is a Special Needs Plan?

A Special Needs Plan (SNP) is a Medicare Advantage plan that provides benefits and services to people with specific needs, such as those:

With certain health conditions
Limited income

A person qualifying for a special needs plan could be any one of the following:

An institutionalized individual
An individual who receives both Medicare and Medicaid (dual eligible)
An individual with a severe or disabling chronic condition, as specified by CMS.

11. Do I still have to pay my Part B premium if I join a Medicare Advantage plan?

You must continue to pay your Medicare Part B premium, if not otherwise paid for by a third party (Like Medicaid), even if our plan premium is $0.

12. Am I covered if I am out of the area on vacation?

Emergency and urgent care services are covered even if you are out of the area.

Prescription Coverage

13. What is Medicare Part D Prescription coverage?

Medicare’s Prescription Drug benefit (Part D) is the part of Medicare that provides outpatient drug coverage. Part D is provided through private insurance companies that have contracts with the Federal government. Part D is NOT provided directly by Medicare.

14. Do I need a Medicare Prescription Drug Plan?

The Medicare Part D prescription drug plan is completely voluntary. If you want the coverage, you can get it through private companies like The Health Plan.

Please note: There could be a penalty if you do not join a Medicare Prescription drug plan when you first become eligible. Please see Medicare.gov or the Medicare & You handbook for more information.

15. What is extra help for Part D Rx?

Extra Help is a Medicare program to help people with limited income and resources pay Medicare prescription drug costs.

Some people automatically qualify for Extra Help, and are notified by Medicare.

If you didn’t automatically qualify for Extra Help, you can apply anytime by:

Visiting socialsecurity.gov to apply online.
Calling Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.
You may also be able to apply at your local state Medicaid office.

16. How can I find out if my prescriptions are covered?

Please access the Prescription Drug Formulary documents located on this website or call our office at 1.877.847.7915. Current members should call 1.877.847.7907. TTY 711.

17. What if I am travelling and need to fill a covered prescription?

We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non‑routine circumstances when a network pharmacy is not available

18. Do your plans offer mail order for prescriptions?

Yes, you can receive a 90 day supply of most of your covered medications by using our contracted mail order pharmacy. Generally, ordering a 90 day supply through the mail will cost you less than filling a 90 day supply at a retail pharmacy.

19. What if I already receive prescription drug coverage as part of my employer’s retiree benefits?

You decide what is best for you. If an employer or union offers prescription drug benefits, you should compare the plan and costs with those offered under The Health Plan prescription drug plans. It is an employer’s responsibility to inform their Medicare eligible retirees/employees if the prescription drug plan offered is considered to be creditable coverage. This means the coverage is on average, at least as good as the standard Medicare Part D benefit

Note: If your retiree plan is not considered creditable coverage and you choose not to purchase a Medicare Part D Prescription Drug Plan, you may have to pay more each month (a penalty) if you want to join a Medicare Part D Prescription Drug Plan later. Also, if your employer coverage has a Medicare Part D Prescription Drug Plan, your enrollment in The Health Plan Medicare Advantage Plan will automatically cancel your employer coverage even if you chose one of our plans without Part D prescription drug coverage.

General - Cost Shares

20. How can I find out the cost shares on your plan(s)?

Please access the Summary of Benefits or Evidence of Coverage documents located on this website or call our office at 1.877.847.7915. Current members should call 1.877.847.7907. TTY 711.

21. How do I pay the monthly premium, if applicable, for my plan?

Your monthly premium is paid to The Health Plan. You have three payment methods to choose from:

Get payment coupons and pay directly by cash or check each month.
Have your monthly premium automatically deducted from a checking or savings account.
Have your monthly premium automatically deducted from your Social Security check.

22. What is an out-of-pocket maximum?

The annual out-of-pocket maximum is the limit to how much you MAY have to pay out of your pocket in the form of copays and/or coinsurance for covered health care services each year. Once your share of total costs for covered health care services (excluding Part D prescriptions) reaches the plan’s out-of-pocket maximum, you will not have copays/coinsurance for covered medical services for the remainder of the calendar year.