Medicare

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Frequently Asked Questions

Who can enroll in a FamilyCare Health Medicare Advantage plan?

You can enroll in a FamilyCare Health Medicare Advantage plan if you:

  • Have Medicare Part A and Part B.
  • Live in our service area.
  • Don’t have End-Stage Renal Disease (ESRD). Some exceptions may apply.

What is Medicare?

Medicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare, a Medicare cost plan, a PACE plan, or a Medicare Advantage Plan.

When can you choose your coverage?

Your initial enrollment period begins three months before you turn 65 and continues until three months after you turn 65. This is important. Mark it on your calendar. The enrollment period is 7 months long. For example: If you turn 65 on July 15, you could sign up for Medicare beginning April 1. Your initial enrollment period would continue until October 31.

If you don't sign up for a Part D plan (or a Medicare Advantage plan that includes prescription drug coverage) when you are first eligible (or if you drop your prescription drug coverage), you may have to pay a late enrollment penalty.

What happens if you want to switch plans?

After your initial eligibility period, each year you have the opportunity to switch your coverage from October 15 to December 7. This is called the Annual Enrollment Period, and during this time you can switch from a Medicare Advantage Plan to Original Medicare (or vice-versa), switch from one Medicare Advantage Plan to another, or sign up for (or drop) prescription drug coverage.

During the Medicare Advantage Disenrollment Period, which lasts from January 1 to February 14, Medicare Advantage members can cancel their Medicare Advantage plans and get their coverage through Original Medicare. (They can also enroll in a stand-alone Part D plan during this period.)

What's a Special Enrollment Period? (Can you add, drop, or switch plans at other times?)

You can add, drop, or switch Medicare Advantage plans if you qualify for a Special Enrollment Period (SEP). Usually, you qualify for a SEP if you move outside of the area covered by your old Medicare Advantage plan. You may also qualify for a SEP if you are a member of the Oregon Health Plan (Medicaid) or if you receive Extra Help from Social Security to pay your Part D prescription drug costs. To find out if you qualify for a SEP, visit Medicare.gov or call 800-MEDICARE (800-633-4227); TTY/TDD call 877-486-2048 toll-free.

What is the difference between an HMO and a PPO?

FamilyCare Health offers HMO Medicare Advantage Plans. 

HMO means Health Maintenance Organization. In an HMO plan, you see doctors and other providers who are members of the plan's network. You will choose a Primary Care Provider (such as a doctor, nurse practitioner, or family nurse practitioner) who takes care of most of your routine medical needs. You get all of your care from network providers, including specialists and hospitals. In some cases, you may need a referral to see a specialist (for certain benefits). Except in an emergency or if you need urgent care, you need to get prior authorization from the HMO to see an out-of-network provider.

PPO means Preferred Provider Organization. With a PPO plan, you can see any healthcare provider in the health plan’s provider network. You do not need prior authorization to see an out-of-network provider, but may pay a higher amount for healthcare services. FamilyCare Health does not offer a PPO plan at this time.

What happens if I get care from a provider who is not part of FamilyCare Health’s provider network?

Our HMO plans are Community and Advantage Rx. Generally, if you are a member of one of these plans, you must get all of your care from providers in our network. If you need to see a provider outside of our network, ask your primary care provider (PCP) for a referral. Without a referral, neither FamilyCare Health nor Medicare will pay for your care, except in the case of an emergency.

If you have a medical emergency, get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. As soon as possible, tell us about your emergency. 

Can I keep my current doctor on my FamilyCare Health plan? 

FamilyCare Health partners with hundreds of local primary care physicians and specialists, so many of our members are able to continue seeing their favorite medical providers once they join one of our plans. To see if your doctor is a part of our network, see Find a Provider. If your doctor is not a part of our network, you may ask your doctor to join our plan. Or you can look for a different doctor in our network.

How do I find a new doctor or a hospital in the FamilyCare Health network? 

Contact Navigation Services for help choosing a new Primary Care Provider (PCP) or specialist. Or search for providers based on location, medical specialty, language, and more using the Find a Provider tool on this website.

What benefits come with my plan?

If you are a current member, check your Evidence of Coverage for your particular plan to see exactly what is and is not covered. 

How do I know if I have Part D coverage for prescriptions?

Our Medicare Advantage plans include prescription drug coverage. If you are a member of our plan, you have Part D coverage for prescriptions.

How do I know if my medicine is covered by FamilyCare Health?

To help you and your healthcare providers know which drugs we cover, we regularly update our drug list called a formulary. You can review and search our formulary. If a drug is not on the formulary, it is not covered by FamilyCare Health.

How do I find a participating pharmacy? 

To find a pharmacy in our network, use the Find a Pharmacy search tool on this website. 

How can I enroll in the Medication Therapy Management program?

The Medication Therapy Management (MTM) program is a free, voluntary program for members who take multiple medications for chronic conditions such as high blood pressure, high cholesterol, diabetes, and asthma. If you are in the MTM program, a pharmacist will look at all of your prescriptions to make sure you are not being over-medicated and that your drugs work properly with each other. To see if you qualify for MTM, call Navigation Services.

What costs am I responsible for if I sign up for a FamilyCare Medicare Advantage Plan?

The costs you pay each year depend on the plan you enroll in and the services you use. Our plans do not have a premium. You must pay your Medicare Part B premium. (If you are a member of the Community (HMO SNP) plan, the Oregon Health Plan (Medicaid) pays your Medicare Part B premium for you.)

To find costs for your plan, see your Evidence of Coverage.

Do I need to pay for extra coverage or insurance?

Medicare rules prevent recipients from enrolling in both a Part C Medicare Advantage Plan and a supplemental insurance plan (“Medigap”). If you currently pay for supplemental insurance and want to enroll with FamilyCare Health instead, you will have to cancel your supplemental insurance policy.

How can I get reimbursed if I paid for a service out-of-pocket?

Occasionally, members pay for a service that we cover. If this happens to you, you can send us a request for payment along with your bill and proof of the payment you made. See your Evidence of Coverage for details on requesting a payment.

Is assistance available if I’m unable to pay for my prescription drugs?

If you need extra help paying for prescription drugs, you may qualify for assistance from Medicare. To see if you are eligible for getting this "Extra Help" (called a Low-Income Subsidy), call one of these three offices:

  • Medicare at 800-MEDICARE (800-633-4227) toll free, 24 hours a day, 7 days a week. TTY/TDD users call 877-486-2048.
  • The Social Security Office at 800-772-1213 toll free, 7 a.m. to 7 p.m., Monday through Friday. TTY/TDD users call 800-325-0778.
  • The Oregon Health Plan (Medicaid) toll-free at 800-527-5772. TTY/TDD users call 800-375-286 toll free 8 a.m. to 5 p.m., Monday through Friday.

If you have HIV/AIDS, you may qualify for the AIDS Drug Assistance Program (ADAP). In Oregon, the ADAP program is called CAREAssist. For more information, call 800-805-2313 toll-free (TTY/TDD 711) or visit the CAREAssist website.

FamilyCare Health is an HMO with a Medicare and Oregon Health Plan (Medicaid) contract. Enrollment in FamilyCare Health Medicare Advantage plans depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. If you enroll in FamilyCare Community (HMO SNP), the Oregon Health Plan will pay your Part B premium for you. FamilyCare Community (HMO SNP) is available to people who qualify for Medicare and the Oregon Health Plan (Medicaid). Premiums, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Y0103_WEB_00354 — Approved (Updated 10/05/2017)

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