FamilyCare understands the importance of making smart informed decisions about health care. For many, Medicare is complicated and at times overwhelming. As a member of FamilyCare, we will work with you to help you understand your options, and assist in helping you choose the best plan for you.
We have put together a list of commonly asked questions to assist you. Should you have additional questions, please call our customer service representatives. They are local experts who are happy to answer your questions and help you get started.
Customer Service Hours:
Monday through Friday, 8 am to 8 pm
During the Annual Election Period (October 15 - December 7), hours 8 am - 8 pm, 7 days a week
Portland metro: (503)-345-5702
Toll-Free: 1-866-798-CARE (2273)
TTY: 1-800-735-2900
1. What are Medicare Parts A through D?
Medicare Advantage plans combine the benefits of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) in a single plan. Medicare Part C is another term for Medicare Advantage. Medicare Advantage plans often include Medicare Part D (prescription drug coverage), too. Medicare Advantage Plans are NOT the same thing as supplemental coverage.
2. What is a Low-Income Subsidy?
A Low-Income Subsidy is “Extra Help” for people with Medicare who have limited income and resources to pay for Medicare prescription drug coverage. If you qualify for “extra help,” you will receive help paying the monthly premium for Medicare prescription drug coverage. The amount of extra help you get will be based on your income and resources. You can apply for extra help by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visiting www.socialsecurity.gov.
3. When can I first enroll in Medicare?
You can enroll in Medicare up to 3 months before your 65th birthday. For example, if your 65th birthday is in July, you are entitled to enroll in Medicare Part A and Part B as early as April 1.
4. If I had a pre-existing condition such as cancer, can I still join the health plan?
The only pre-existing condition that will keep you from qualifying for our plan is End Stage Renal Disease (ESRD).
5. Do new members need to pass a physical exam to join the health plan?
No. New and current members are not required to pass a physical to get or keep coverage in our health plans.
6. Will I lose my Medicare if I join a Medicare Advantage plan?
No, you will not lose your Medicare benefits. You will receive your Medicare benefits through our Medicare Advantage plan.
7. If I am enrolled in Medicare Part A, do I also need to enroll in Medicare Part B to join a Medicare Advantage plan?
Yes. You must be enrolled in both Medicare Part A and Part B to join a Medicare Advantage plan.
8. Do I have to keep paying for Medicare Part B when I join your plan?
Yes, all Medicare Advantage members must have Part B coverage. Unless Medicaid pays your Part B premium for you, you will still have to pay your Part B premium. Most people do not pay a premium for Medicare Part A (Hospital). Unless you are one of the few people who pay a Part A premium, you will not have to pay the Part A premium to join one of our health care plans.
Your copy of Medicare & You 2012 tells about these premiums in the sections called “How Much Does Part A Coverage Cost?” and “How Much Does Part B Coverage Cost?” This explains how the Part B premium differs for people with different incomes. Everyone with Medicare receives a copy of Medicare & You each year in the fall. If you’re new to Medicare, you should receive it within a month after you sign up. You can also download a copy of Medicare & You 2012 from the Medicare website, www.medicare.gov. Or, you can order a printed copy by phone at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
9. What is a “Medigap policy” or “Medicare Supplement Insurance?”
The terms “Medigap” and “Medicare Supplement Insurance” mean the same thing; they are private insurance plans that help pay some of the healthcare costs that original Medicare doesn’t cover. They are NOT the same thing as a Medicare Advantage plan, which provides recipients with all of their Medicare benefits.
10. Can I use a Medigap policy to pay for a Medicare Advantage plan’s out-of-pocket costs, such as co-pays?
If you join our Medicare Advantage Plan, you don’t need a Medigap policy. If you already have a Medigap policy, you can’t use it to pay for co-payments, deductibles or premiums. You may want to drop the Medigap policy, also known as supplemental insurance. Furthermore, if you already have a Medicare Advantage Plan, you can’t purchase a Medigap policy unless you’re switching back to Original Medicare.
11. If I have a Medicare Advantage plan, should I get a Medigap policy, too?
Medicare Advantage plans generally cover many of the same benefits that a Medigap policy would cover, such as extra days in the hospital beyond the original Medicare benefit.
12. I am turning 65 next month, do I have to join the same Medicare Advantage plan as my spouse or can I stay in Original Medicare?
You can choose a different Medicare Advantage plan or you can stay with Original Medicare.
13. Why must I have Medicare to qualify for your plan?
We have a contract with Medicare. Our contract only lets us enroll people who have Medicare Part A and Part B.
14. Can I enroll in multiple Medicare Advantage plans?
No. Medicare will only let people enroll in one Medicare Advantage plan at a time.
15. What is the difference between all your plans?
Each plan has specific premiums, co-pays, co-insurance, and deductibles. Some of the benefits are also different, depending on the plan.
16. I’m not a MyPlan member, but I want to know more about your Medicare Advantage plans. Can you send me information?
Yes. We have an enrollment kit that can answer your questions about our MyPlan Medicare Advantage plans. Contact Customer Service at 1-866-798- CARE (2273), TTY users call 1-800-735-2900, Monday to Friday, 8 am to 8 pm.
17. I am a member of a MyPlan Medicare Advantage plan. How do I get more information about my benefits, cost sharing or the formulary?
All of these documents are available online. Click your MyPlan plan name, to the left, and you will be able to see the Evidence of Coverage, Formulary, Provider/Pharmacy Directory, and other important documents. You should have received copies of an Evidence of Coverage, Formulary and Provider/Pharmacy Directory in the mail. If you have not received them or cannot locate them, you can review the information online by using the link mentioned above or by calling Customer Service at 1-866-798-CARE (2273), TTY users call 1-800-735-2900, Monday through Friday, 8 am to 8 pm.
18. Is there any way I can find the information online?
Yes. All of these documents are available on this website by hovering over "FamilyCare Medicare" in the drop-down menu at the top of the page, then "Health Plans," clicking the plan you’re interested in and then clicking the link to the document you are interested in viewing. For example, to view the Summary of Benefits for MyPlan Medicare Option R, hover over "FamilyCare Medicare," then "Health Plans" clicking "MyPlan Medicare Option R," and then clicking "Summary" on the page that opens.
1. I do not get extra help and I am not on Medicaid. What is my monthly Premium?
If you qualify for a Low Income Subsidy (LIS), this may reduce your monthly premium. Contact Customer Service at 1-866-798-CARE (2273), TTY users call 1-800-735-2900, Monday to Friday, 8 am - 8 pm, to learn more. Please have the Member’s ID Number ready when you call.
2. What happened to PremierCare Select Rx?
FamilyCare will not be renewing PremierCare Select Rx effective January 1, 2013.
From October 15th through February 29, 2012, Select Rx members have the option of enrolling in another plan for 2012. They can enroll in a Medicare Advantage plan, a Section 1876 cost plan, or a Part D plan. However, if you want your new plan to take effect on January 1st, the new plan must receive your application by December 31st.
If your new plan receives your application in January, your new plan will take effect on February 1, 2013. If your new plan receives your application in February, your new plan will take effect on March 1, 2013.
3. What happened to PremierCare Advantage Rx?
FamilyCare will change PremierCare Advantage Rx to MyPlan E effective January 1, 2013. If you are an Advantage Rx member, you will become a MyPlan E member.
You do not have to complete any paperwork or do anything else if you wish to become a member of MyPlan E.
4. If my dad has to pay a premium for your plan, he wants it withheld from his Social Security check. How long should he wait after he elects to have premiums withheld before calling back to determine if there is a problem with the withholding?
It can take up to three months for Social Security withholdings to begin. If funds are not drawn by this time, we will contact you directly.
Knowledge Note: MyPlan Premiums are due by the 10th of each month. There are three payment options:
5. What is my cost for Ambulance services?
The co-pay for ambulance is $100 per trip. If you are admitted to the hospital for an inpatient stay, then the co-pay is waived. However, the co-pay for members of our Medicaid/Medicare plan (MyPlan C) is $0.
6. How do I get reimbursed for a bill I have paid?
Send us your request for payment, along with your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records.
7. Does your MyPlan health plans cover routine eye exams?
Yes. All of our plans cover one routine eye exam each year.
8. What vision provider should I use for routine services?
Members can go to any eye doctor or optical store that is a member of the Vision Service Plan (VSP) network. VSP is a nationwide network with 56 million members. Search the network by visiting the VSP website, www.vsp.com.
9. Do any of your plans cover preventative dental cleaning?
No, we do not offer dental care at this time.
10. How much will I pay if I am in the hospital?
It depends on your plan and whether you are seen as an inpatient or an outpatient. This information is available in the Evidence of Coverage on this website. Hover over "FamilyCare Medicare"in the drop-down menu at the top of the page, then "Health Plans," and click the link to your MyPlan name on the list. Once on the MyPlan page, click the link to the Evidence of Coverage and search for specific co-pays.
11. How much do I pay if I need hospice or home health care?
The co-pay for a home health visit is $20. However, members of MyPlan C have $0 co-pay for home health visits.
12. If I become ill in the middle of the night or on a weekend, and go to the nearest emergency room, will I be covered? And, how much will it cost?
Yes. The co-pay for emergency care is $50. If you go to the emergency room and are admitted to the hospital, the emergency room co-pay is waived. However, members of MyPlan C have $0 co-pay for emergency room visits.
13. What is my co-pay for durable medical equipment like a wheelchair?
You pay 20% of the contract-allowed cost.
14. Do I need a referral for non-emergency, acute inpatient hospital visits?
Yes. Any inpatient stay needs to be approved in advanced unless it is for an emergency.
1. What doctor or clinic is closest to me?
You can search for this information by visiting the Find A Doctor page or by searching the Provider/Pharmacy Directory for a provider or clinic near your zip code.
2. How do I find a network doctor?
You should have received a copy of the Provider/Pharmacy Directory in the mail. It lists pharmacies in our network. If you have not received the directory or cannot find it, you can see a copy by clicking Provider/Pharmacy Directory. You can also click A Doctor to search for doctors by name or by location.
3. How do I find a network pharmacy?
You should have received a copy of the Provider/Pharmacy Directory in the mail. It lists pharmacies in our network. If you have not received the directory or cannot find it, you can see a copy by clicking Provider/Pharmacy Directory.
4. What Oregon counties does the plan serve?
You can enroll in a MyPlan plan if you live in Clackamas, Clatsop, Morrow, Multnomah, Umatilla or Washington counties.
5. Does the MyPlan provider directory include primary care providers?
Yes.
6. Is Myplan an HMO or PPO? What type of health plan is this?
FamilyCare Health Plans is an HMO.
7. What is the difference between an HMO and PPO?
“HMO” stands for health maintenance organization. With our HMO, you see doctors who are members of our provider network. You’ll have a primary care provider who takes care of most routine medical needs. You can see any provider in our network without prior authorization, including specialists. If you want to go to a doctor outside of our network, you need to get prior authorization from our plan.
“PPO” stands for preferred provider organization. You can see any doctor you want, but you’ll pay more if you see a doctor who is not a member of the PPO network.
8. What hospitals can I go to?
Use the Provider/Pharmacy Directory to find hospitals that are in our network or search online by clicking A Doctor. You can go to any hospital that accepts Medicare patients as long as they are willing to bill FamilyCare for care.
9. Will I be covered outside the plan’s service area?
Our plans cover emergency service and dialysis anywhere in the US. If your plan includes Part D coverage, you can fill prescriptions anywhere in the US.
Our plans also cover emergency care anywhere in the world. However, members of MyPlus plan do not have worldwide coverage.
Knowledge Notes: A “medical emergency” is when you—or any other prudent layperson with an average knowledge of health and medicine—believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.
10. Can my PCP refer me to a non-contracted /out-of-network provider?
You need an authorization to see an out-of-network provider. Your Primary Care Physician’s (PCP) office can contact FamilyCare for you.
11. Do I need approval to see contracted network specialists?
No. However, any services you receive must be covered by your plan. Some services may require prior authorization.
12. How long can I be out of state visiting before I lose my coverage?
If you are outside of our service area for six consecutive months, we are required by CMS to process your disenrollment from our plan.
13. Do you have doctors who speak my language?
We have providers who speak a variety of languages, including Spanish, Vietnamese, and Russian. If we do not have a provider who speaks your language, we have interpreter services that we can schedule for onsite appointments.
14. My mother is moving into an assisted living community in her neighborhood. Can she still join FamilyCare?
Yes, as long as she still resides in our six-county service area: Clackamas, Clatsop, Morrow, Multnomah, Umatilla, and Washington counties in Oregon.
1. When can I end my membership with your plan?
In most cases, you must stay enrolled through the end of the calendar year.
During the Annual Election Period each year from October 15th through December 7th, you can change Medicare Advantage plans or disenroll and return to Original Medicare. You can also disenroll during the Medicare Advantage Disenrollment Period (MAPD) From January 1st through February 15th.
However, in certain situations, you may be able to join, switch or drop a Medicare Advantage plan at other times. Some of these situations include:
2. How do I end my membership in your plan?
Usually, to end your membership in our plan, you simply enroll in another Medicare Advantage plan or in a Section 1876 cost plan during a Medicare enrollment period. (You will not be automatically disenrolled if you enroll in a Medigap plan). If you want to disenroll without enrolling in a different plan, you can speak to our Sales Department by calling 1-866-225-CARE (2273), TTY users call 1-800-735-2900, Monday through Friday, 8 am - 8 pm, or notify us in writing.
3. If I elect to end my coverage, how long will I be covered by your plan?
Once we receive a Medicare-permitted request to end coverage, we will continue to cover you to the end of the month. For example, if we receive your request to disenroll on July 15th, we will cove r you through July 31st.
4. If I switch to another plan, how long will I be covered by your plan?
It depends on whether you switch during the Annual Election Period (AEP) or during a Special Enrollment Period (SEP). If you switch during AEP, we will continue to cover you through December 31st. Your new plan will take over your coverage on January 1st. If you switch during an SEP, we will cover you through the end of the month when we receive notice of the change. For example, if we receive notice on July 15th that you are changing plans, we will cover you through July 31st.
5. What if I am hospitalized on the day my membership ends?
In most cases, we will continue to cover your hospital stay until you are discharged—even if you are discharged after your new coverage begins.
6. Can you ask me to leave your plan?
No. If you feel that you are being asked to leave our plan because of a health- related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-2273). They are available 24 hours a day, 7 days a week.
1. What do you pay for a Part D vaccination?
MyPlan covers 100% of the cost of the vaccines for flu, pneumonia, and hepatitis B under our preventive services benefit. Other vaccines—like the vaccines for shingles or tetanus—are covered under Medicare Part D. You may have to pay a deductible or co-pay for Part D vaccines.
The simplest way to get your immunization is to go to a network pharmacy and ask the pharmacist to give you your shot. That way, there will be no co-pay for the doctor’s visit. You can also get the vaccine at a pharmacy and take it to the doctor to get your shot. If you do this, you will pay a co-pay or co-insurance for the office visit.
Another option is to get both the vaccine and the shot from your doctor. If you do this, you’ll pay the doctor for the full cost of the vaccine, plus any co-pay for the office visit. Then you can ask us to reimburse you for the cost of the vaccine (minus any co-pay for a Part D vaccine).
2. How much do I pay out-of-pocket for a prescription?
How much you pay depends on your plan and the prescription. The FamilyCare health plan page will have a link to the Evidence of Coverage and Formulary, which will help you determine the co-pay for a drug.
3. What is the Coverage Gap Stage (donut hole)?
The coverage gap (or donut hole) is one of four different drug stages.
Knowledge note: Family Care MyPlus (our “dual plan” for people with Medicaid and Medicare) has only two stages. There is no deductible and no “donut hole.” As soon as the total out-of-pocket costs reach $4,700, you enter the catastrophic coverage stage.
4. Does your plan cover generic drugs in the Coverage Gap?
No, but you receive a discount on generics and brand-name drugs. Keep using your FamilyCare plan card. Using your card each time you fill a prescription ensures that you will get the correct coverage and manufacturer discounts applied to your prescriptions and that the money you spend counts toward your out-of-pocket costs.
5. If I do not get extra help and I’m not on Medicaid, what is my plan’s yearly drug deductible?
6. If I already paid for my deductible, then what are my costs for generic and preferred brand name prescriptions for 30-day supply?
7. How do I know what drugs are covered?
Members should have received a Formulary in the mail. You can also click the “Part D Drug List (Formulary)” link on this website to view the Formulary online.
8. I currently have prescription drug coverage with another plan. How will I know if my prescription drugs will be covered under your plan?
You can compare your current prescription drugs to the drugs listed in our Formulary, which members receive in the mail. If you are not a member or you do not have your Formulary, you can see it online by clicking Part D Drug List (Formulary).
9. What can I do if I join your plan and my prescriptions are not covered, if the Formulary changes, or if my drug is restricted in some way?
You can change to another drug. In some situations, you may be able to get a temporary supply of the drug. This will give you and your provider time to change to another drug or to file a request to have the drug covered. Or you can request an exception and ask the plan to cover the drug or remove restrictions for the drug. If you ask for an exception, your provider must submit a statement supporting your request. The provider’s statement must indicate that:
OR
OR
OR
You can request an exception in writing. You can mail a written request to FamilyCare Health Plans at:
825 NE Multnomah St., Suite 300,
Portland, OR 97232 or
Fax it to us at (503)-471-2176.
10. Does your plan cover seasonal flu shots?
Yes
11. Is a tetanus shot covered by Part D?
Yes
12. What is Medication Therapy Management (MTM) and how can I enroll your MTM program?
MTM is not a program benefit. This is a service FamilyCare offers to members based on medical need. Medication Therapy Management is a voluntary program for members who take multiple medications for a chronic condition such as high blood pressure, high cholesterol, diabetes, or asthma. There is no co-pay or co-insurance for MTM.
If you are in the MTM program, we look at all your prescriptions to make sure you are not being over-medicated and that your drugs work properly with each other. A pharmacist may call you to talk about all of the drugs you take, including any over-the-counter medications.
If you are interested in enrolling in the MTM program, please call Customer Service at 1-866-798-CARE (2273). TTY users call 1-800-735-2900. We are available Monday to Friday, 8 am - 8 pm. To learn more, click Drug Management & Safety.
13. What is a Formulary?
The Formulary is a list of drugs that we cover. It also tells what tier a drug is in and whether it’s subject to quantity limits, step therapy, or prior authorization rules. Medicare reviews and approves our Formulary, which is available by clicking the link Part D Drug List (Formulary).
14. What does QL stand for on my formulary?
“QL” stands for “Quantity Limit.” For safety or other reasons, we limit the amount of a drug the pharmacy can issue. A quantity limit can affect the amount of drug or the length of time. (For example, 120 tablets per 30 days)
15. What does PA mean?
“PA” stands for “Prior Authorization.” Prescriptions for drugs marked “PA” must be approved by the plan in advance in order to be covered. You can see a list of the drugs that require prior authorization by clicking the link to the MyPlan plan that you are interested in and clicking the Prior Authorization link.
16. What does ST mean?
“ST” stands for “Step Therapy.” If a drug is marked “ST,” you have to try one or more other drugs before the plan will cover the step therapy drug. You can see a list of the drugs that are part of the step therapy program by clicking the link to the MyPlan plan you’re interested in and clicking the Step Therapy link.
17. What if a medication is not on the Formulary?
If the drug is not in the Formulary, it is not covered by our plan. Your provider may find a covered drug that meets your medical needs and is effective for you. Your provider can ask the plan to make an “exception” and cover the drug.
18. Can I find quantity limit days supply information for your Formulary drugs on this website?
No, but you can call Customer Service at 1-866-798-CARE (2273), TTY users call 1-800-735-2900, Monday to Friday from 8 am-8 pm. You can also have your doctor call our pharmacy support department. That number is (503)-471-2126. Your doctor can also call pharmacy support toll-free at 1-800-335-3205, Extension 2126. The pharmacy support department is available Monday to Friday, 8 am - 5 pm.
19. If a drug is going to be removed from your Formulary, how will I find out? How much advance warning will I get?
If we remove your drug from our Formulary, we will notify you at least 60 days before the change becomes effective, or when you request a refill (at which time you will receive a 60-day supply). Formulary Change Notices will also be available online, once they are available.
20. What if I use up my prescription before my next refill date? Will I be able to get another refill?
It depends on the drug. Some drugs will require a prior authorization if there is a quantity limit and you go over this limit.
21. If someone steals my medication or if my house got flooded, could I replace my prescription without waiting?
Yes.
22. Where do I get my diabetic supplies?
You can purchase supplies for delivering insulin to the body from pharmacies or DME suppliers in our network. These supplies include syringes, needles, alcohol swabs, gauze, insulin pens and supplies, and needle-free syringes. These are automatically processed as a Part D benefit under Medicare.
For other kinds of supplies, we prefer that you order them from one of the durable medical equipment (DME) companies in our provider network. These supplies include lancets, glucose meters and test strips, and drugs used by external or implanted pumps. In some cases, these drugs may be covered through a pharmacy. However, the co-insurance may depend on whether you get these at a pharmacy or DME company.
Knowledge note: Network pharmacies and DME providers are both listed in the Provider/Pharmacy Directory, click theProvider/Pharmacy Directory or A Doctor link to see a list of network pharmacies or search for one near you.
23. I think I may qualify for extra help for prescription drug coverage from the Social Security Administration. Do you know where I could get information about extra help?
Medicare provides “Extra Help” to pay prescription drug costs for people who have limited income and resources. To see if you qualify for getting Extra Help, call:
24. What are the advantages of using the mail-order pharmacy?
For most drugs, if you order a 90-day supply of drugs through our network mail- order pharmacy, you only pay for a two-month supply. Our network mail-order pharmacy is CVS Caremark. You also don’t have to make a special trip to the pharmacy because your drugs are delivered to your mailbox.
25. My mom just got onto Medicaid. Could she pay less for her prescriptions right away if she gives a copy of the Medicaid eligibility letter to the pharmacy?
Customer Service will ask the member to send in the Award letter from their Social Security Office so the Enrollment Department can update their Low Income Subsidy (LIS) list. Once we receive this award letter, there is a 24-hour turnaround time for the update. Please contact Customer Service by calling 1-866- 798-CARE (2273) Monday through Friday from 8 am - 8 pm.
26. I will be visiting a friend out of state for a month and I’ll need to fill my prescription while I’m there. Do you have any network pharmacies in other states?
Yes, we have network pharmacies nationwide. Our network includes Albertsons, Bi-Mart, Costco, Fred Meyer, Rite Aid, Safeway, Target, Walgreen and Wal-Mart. You can go to any pharmacy that is part of the CVS Caremark system.
Before you go on your trip, we recommend that you get a copy of your prescription from your provider.
(503)-345-5702
1-800-458-9518
1-800-735-2900 TTY
Hours: Monday – Friday, 8 am – 5 pm
Medicare Sales:
1-866-225-2273 or 503-345-5701
Fax: (503) 345-5720
Email:
medicaresales@
familycareinc.org