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GENERAL MEDICARE QUESTIONS

What do you mean by “Original Medicare”?
“Original Medicare” is what most people refer to as simply “Medicare.” The term Original Medicare came into use after Medicare Advantage plans were introduced as an alternative to traditional/original Medicare benefits offered through the federal government.

Can I see any doctor or use any hospital?
When you are enrolled in Original Medicare, you are free to use any doctor, hospital or other health care provider who accepts Original Medicare. This applies to Medicare Supplement as well. With a PPO or POS plan, you have the freedom to use any Medicare provider—even one that is not in your network. However, you may have higher out-of-pocket expenses if you use a non-network provider.

Does Medicare cover prescription drugs?
Original Medicare provides very limited coverage for prescription drugs, so most people find it helpful to have additional coverage. That’s why Medicare Part D was introduced. Medicare members now have the opportunity to get prescription drug coverage through a stand-alone Medicare Prescription Drug Plan (PDP), or as part of a Medicare Advantage plan that includes drug coverage (MAPD).

Do I need a Primary Care Physician?
With Original Medicare and Medicare Supplement coverage, you do not need to choose a Primary Care Physician (PCP). With Medicare Advantage coverage, it depends on the specific type of plan. With HMO plans, you must select a PCP who will coordinate all of your care.

Do I need a referral for a specialist?
No referrals required for in-network specialists.

Should I get a Medicare Supplement policy?
Original Medicare was not intended to cover all of your health care bills. For this reason, you may find that you need additional Medicare Supplement insurance. As the name suggests, it helps to fill the “gaps” in Medicare coverage—such as your deductibles and copayments—to lower your out-of-pocket costs. Another option for lowering out-of-pocket costs would be to join a Medicare Advantage plan. With this type of coverage, you have all the benefits of Original Medicare Parts A and B, plus additional coverage, eliminating the need for a Medicare Supplement plan.

What if I want to switch my coverage choice?
If you enroll in a plan that you feel is not meeting your needs, you may switch (or drop) your coverage during Medicare’s Annual Enrollment Period, which generally runs from October 15 through December 7 each year. Your coverage will begin on January 1 of the following year. In most cases, you must stay enrolled for that calendar year, starting with the date your coverage begins. In certain situations, however, you may be able to join, switch or drop plans during a special enrollment period. You can also make changes to your coverage during the Medicare Advantage Open Enrollment period which runs from January 1 through March 31 every year. Individuals may make only one election during the MA OEP

Can I get Medicare benefits if I am disabled?
Yes. If you’re under 65 and have been approved for Social Security disability benefits, you automatically get Medicare Part A and Part B. Your Medicare benefits will begin after you have received disability benefits from Social Security or, if applicable, certain disability benefits from the RRB (Railroad Retirement Board), for 24 months.

Can I get more information about my Original Medicare health coverage online?
Yes. You can register at www.medicare.gov for convenient and secure access to your personal Medicare information. You can use the site to track your health care claims; check your Part B deductible status; get information on your prescription drug coverage; sign up to get your Medicare and You handbook electronically; and much more.

MEDICARE ADVANTAGE PLANS

Is my enrollment in this plan based on my health history?
You can join a Medicare Advantage plan even if you have a pre-existing condition, except for End-Stage Renal Disease (ESRD).

If I have ESRD, am I eligible to enroll in a MA/MAPD?
Individuals with End-Stage Renal Disease are generally not eligible to enroll unless they are members of our organization and have been since their dialysis began.

When enrolling into a Medicare Advantage plan, do I need to include drug coverage if I have PAAD?
Yes. PAAD is a pharmaceutical assistance program and does not actually function as prescription coverage.

Am I required to continue paying my Medicare Part B premium if I enroll in a Medicare Advantage plan?
Yes. You are required have Medicare Part A and Part B to enroll in a Medicare Advantage plan.

Can I enroll in or switch a Medicare Advantage plan at any time?
No. Enrollment in a Medicare Advantage plan is generally for the entire year. Once you enroll, you may leave this plan or make changes to your coverage only during an open enrollment period or under certain special circumstances, such as when you move to a new address that is outside your plan’s service area.

Can I purchase a Medicare Advantage plan and a stand-alone prescription drug plan?
No. Enrolling in a Medicare Advantage plan will automatically end your enrollment in another Medicare health plan or prescription drug plan. However, you can choose a Medicare Advantage plan that include Medicare prescription drug benefits.

MEDICARE PRESCRIPTION DRUG (Part D) PLANS

Who is eligible to enroll?
To be eligible, you must be entitled to Medicare benefits under Part A and/or enrolled in Part B and live in New Jersey. You can only be enrolled in one Medicare-approved Part D prescription drug plan.

Is my enrollment in this plan based on my health history?
No. You will not have to answer any health questions to enroll in this plan.

Do all companies that offer this plan include the same pharmacies?
No. That is why it’s important to compare plans carefully. Ninety-eight percent of New Jersey’s pharmacies participate in Horizon Blue Cross Blue Shield of New Jersey’s network.

Do all companies that offer this plan cover the same drugs?
No. Compare each plan carefully. Obviously, the more drugs that are covered, the more likely you are to find the ones you need.

Can I enroll in Horizon’s prescription drug plan even if I have drug benefits with my health insurance plan from a previous employer?
Yes, you may switch your current health insurance plan from your previous employer to Horizon’s Prescription Drug Plan. However, if your current drug coverage is of equal or greater value than the standard Medicare-approved prescription drug coverage, you may want to keep your current coverage and wait to enroll in a Medicare-approved Prescription Drug Plan. (The organization offering your current coverage, such as your former employer, union or the insurance company they have hired, is required to tell you whether your current coverage is comparable.) If you later decide to join a Medicare Prescription Drug Plan, you will not be subject to the late enrollment penalty if your previous coverage was considered comparable. Your Medicare prescription drug plan may require information about your old coverage.

Do I need a prescription drug plan if I have PAAD?
Yes. PAAD is a pharmaceutical assistance program and does not actually function as prescription coverage.

Am I required to get a prescription drug plan?
No. However, if you choose to purchase a prescription drug plan after your initial Medicare enrollment period expires (three months after you reach age 65) you will be charged with a late enrollment penalty. This penalty is not assessed by Horizon BCBSNJ. This penalty is assessed and regulated by CMS.

Can I purchase a Medicare Advantage plan in addition to my stand-alone prescription drug plan?
No. Enrolling in a Medicare Advantage plan will automatically end your enrollment in another Medicare health plan or prescription drug plan.

MEDICARE SUPPLEMENT PLANS

Note: A pre-existing limitation may apply.

Is my acceptance guaranteed?
You can apply for a new plan at any time. If you submit your application during the six-month Medicare Supplement open enrollment period, or if you qualify for a Guaranteed Issue Right because you lost coverage under certain circumstances, you will be issued coverage. If you apply at any other time, you will have to answer medical-related questions, which determine whether you are issued coverage or denied coverage.

When can I enroll?
When you are first enrolled in both part A & B of Medicare and meet all of the eligibility requirements.

Can I enroll in a Medicare Supplement plan and a prescription drug plan?
Yes.

Can I change my Medicare Supplement plan at any time of the year?
Yes. Medicare Supplement plans can be changed at any time of the year.

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