Frequently Asked Questions (FAQs)

Below are some frequently asked questions to help reference a better understanding of Medicare and your Medicare coverage options, including PSHP Medicare Advantage plans. If you cannot find the information you are looking for in this booklet or in the following FAQs, please call Member Services at 1-866-789-PSHP (7747),
8 a.m. – 8 p.m., 7 days a week. TTY/TDD users should, call 1-866-264-4141.

Q. How do I get ready to enroll in Medicare?
A. Your Initial Enrollment Period for Medicare starts 3 months before you turn age 65 and lasts for 7 months. To prepare for Medicare enrollment: Decide how you want to get Medicare coverage, including Part D prescription drug coverage—there are several options available. If you have drug coverage through a previous or current employer or union, contact your benefits administrator before you make any changes to your prescription drug coverage. Joining a Part D plan could cause you to lose your, your spouse’s, and your dependent’s employer or union health and/or prescription drug coverage. If you already have medical and/or prescription drug coverage through an employer, union, the Veterans Administration, TRICARE or other, check with them to find out how that insurance will work with Medicare. Also ask your primary care provider if he or she accepts Medicare assignment.

Q. Which Medicare program is right for me?
A. You can choose different ways to get the services covered by Medicare. There are things you should consider about each option to help you meet your needs: Cost—What will you pay out-of-pocket, including premiums? Benefits—Are extra benefits and services, like eye exams or hearing aids covered? (These may be covered by some plans.) Physician and hospital choice—Can you see the physician(s) you want? Are the physicians accepting new patients? Do you need a referral to see a specialist? Can you go to the hospital you want? Do you pay less to go to certain doctors or hospitals? Convenience—Where are the doctors’ offices? What are their hours? Is there paperwork? Prescription drugs—What will your prescription drugs cost under the plan’s formulary (list of covered drugs)? What are your drug needs? Pharmacy choice—What pharmacies can you use? Quality of care—Quality of care varies among plans, doctors, hospitals, and other health care providers. Giving good quality health care means doing the right thing, at the right time, in the right way, for the right person—and getting the best possible results. Quality information to help you make the best choices for your well-being is available at www.medicare.gov on the web, or by calling 1-800-MEDICARE (1-800-633-4227).

Q. What about penalties?
A. Your Initial Enrollment Period starts 3 months before you turn age 65 and lasts for 7 months. Except in certain cases, if you do not enroll in Medicare Part B during your Initial Enrollment Period, you will have to wait until the next Open Enrollment Period to enroll. Open Enrollment Periods are between January 1 and March 31 each year. If you do not take Part B when you are first eligible, the cost of Part B will go up 10% for each full 12-month period that you could have had Part B but didn’t sign up for it, except in special cases. You may have to pay this penalty as long as you have Part B. If you do not join a Medicare drug plan when you are first eligible to join (during your Initial Enrollment Period, and there is a period of 63 continuous days or more during which you don’t have creditable prescription drug coverage, you may have to pay a late enrollment penalty when you do join). This amount changes every year. You will have to pay a penalty as long as you have Medicare prescription drug coverage.

Q. What services are covered by PSHP Medicare Advantage Plans that original Medicare does not cover?
A.

• Annual Physical Examinations
• Routine Chiropractic care and Acupuncture Therapy
• Routine hearing examinations
• Routine eye examinations, Eyeglasses or Contact Lenses
• Worldwide emergency coverage

Q. What if I am planning to work past the age of 65?
A. You do not have to be retired to enroll in Medicare.

Q. How do I keep my coverage if I travel out of state or out of the country?
A. Original Medicare coverage outside the United States is limited to emergency and urgent care medical services provided in Canada when you travel on the most direct route through Canada between Alaska and another state. Medicare also covers emergency hospital, ambulance, and inpatient physician services if a foreign hospital is closer or easier to get to than any hospital in the United States (the “United States” includes the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa). In some cases, Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the United States. If you are covered by a Medicare Advantage Plan, you typically are covered for emergencies and urgent care anywhere outside of the plan’s service area.

Q. Are the PSHP Medicare Advantage Plans the same as Medicare supplement plans?
A. No—PSHP Medicare Advantage Plans are not supplement plans. Our plans provide coverage for Medicare Parts A and B, and much more. Unlike a Medicare Advantage plan, which replaces your Original Medicare benefits, a Medicare Supplement plan is purchased in addition to your Original Medicare benefits. Medicare Supplement policies are standardized into twelve plans – labeled “A” through “L,” each with its own set of benefits. These plans help cover the “gaps” in coverage that are left unpaid after Original Medicare pays its portion of your health care expenses. For this reason, these plans are often referred to as Medigap plans.

Q. Do I lose my Medicare benefits when I join a Medicare Advantage Plan?
A. No, you will not lose your Medicare benefits when you join a Medicare Advantage Plan. PSHP Medicare Advantage Plans are the administrators of your Medicare benefits. If you cancel your PSHP Medicare Advantage Plan coverage, your benefits will revert to original Medicare coverage unless you join another Medicare Advantage health plan available in your area.

Q. Do I have to pay Medicare premiums?
A. Yes. If you are entitled to Medicare Part A and are enrolled in Part B, you must continue to pay the Medicare Part B premium (if not otherwise paid under Medicaid or by another third party) in order to be eligible for a PSHP Medicare Advantage Plan. The Social Security Administration deducts the Medicare premium from your Social Security check or bills you directly. You also must continue to pay your Part A premium, if applicable.

Q. What if I have a medical emergency?
A. With the PSHP Medicare Advantage Plan, you’re always covered for emergencies wherever you are. If you become ill or injured, or you have an emergency medical condition, don’t hesitate to seek emergency health services. Call 911 or go to the nearest hospital emergency room or urgent care center.

Q. What happens after I become a PSHP Medicare Advantage Plan member?
A. When you enroll in a PSHP Medicare Advantage Plan, you will receive a confirmation letter from us, followed by your welcome packet and and ID card. In addition, you will receive an “Evidence of Coverage (EOC)” booklet in the mail. Your “Evidence of Coverage” booklet is your insurance policy with PSHP and is required by the federal government. It explains:

• Your plan benefits, coverage, rights, and responsibilities as a PSHP Medicare Advantage Plan member
• PSHP Medicare Advantage Plans rights and responsibilities as your insurer The “Evidence of Coverage” is an important document. Please review it and keep it with your insurance records

Q. Can PSHP discontinue my health care coverage?
A. Once you’re enrolled in a PSHP Medicare Advantage Plan, you cannot be disqualified for any medical condition and cannot be canceled for any medical condition you may develop. There are very few reasons why PSHP would discontinue your coverage. These include:

• If you move permanently outside the PSHP Medicare Advantage Plan service area or are temporarily absent for more than six (6) months
• Federal regulations also allow us to involuntarily disenroll you if you:
  • Fail to pay any required plan premium
  • Commit Medicare fraud

A complete description of your disenrollment rights can be found in your PSHP Medicare Advantage Plan Evidence of Coverage.

Q. If my PCP or other provider is not in the PSHP network, can he or she be added?
A. If your PCP or other provider is not currently in our network, please contact Member Services at 1-866-789-PSHP (7747). You may provide their name, address and phone number, and we will explore whether there is an opportunity to have them join our network.

Q. If my pharmacy is not in the PSHP network, can it be added?
A. If your pharmacy is not currently in our network, please contact Member Services at 1-866-789-PSHP (7747). You may provide the name, address and phone number of the pharmacy, and we will explore whether there is an opportunity to have them join our network.

Q. If a prescription drug I am taking is not in your formulary, can I request to have it covered?
A. Yes, if your plan includes Part D prescription drug coverage, but a certain medication is not covered on our formulary, you can contact us and ask for a “Formulary Exception.” In order to help us make a decision more quickly, you should submit supporting medical information from your doctor when you request an exception.

If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you can appeal our decision.

Q. If my physician wants me to take a prescription drug that is classified as non-preferred in your formulary, do I have to pay the non-preferred co-payment or co-insurance?
A. Not necessarily. If your plan includes Part D prescription drug coverage, you can contact us and ask for a “Tiering Exception” to have a Part D non-preferred drug covered at the preferred co-payment or co-insurance level. Ask your doctor to send us a supporting statement.

If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you can appeal our decision.