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General

What is Medicare?
Health insurance for people age 65 and older or some people under age 65 with disabilities.

What is Original Medicare?
Original Medicare is made up of parts A and B and is managed by the federal government. Original Medicare covers some medical benefits, but not prescription drug coverage.

Is it possible to have a Medicare Advantage Plan with a $0 monthly premium?
Yes, the federal government pays private insurance companies like Network Health to take care of an individual's Medicare coverage. As long as an individual continues to pay the Part B premium, the member is eligible for a $0-premium plan.

What does each Medicare part cover (Part A, Part B, Part C and Part D)?
See Medicare’s 4 Parts.

What is a Medicare Advantage Plan? 
See Types of Medicare Plans.

What is a Special Needs Plan? 
See Types of Medicare Plans.

What is Medicare Supplement Plan? 
See Types of Medicare Plans.

Am I eligible for a Network Health Medicare Advantage Plan?
To be eligible for one of our plans, you must meet the following criteria.

  • You must live in our service area.
  • You must be eligible for Part A and enrolled in Part B.
  • You must continue to pay you Medicare Part B premium.
  • You must not be diagnosed with end-stage renal disease (ESRD).

Where can find more information about Medicare benefits?
In October, you will receive the “Medicare & You” handbook, which will include all of the plans available in your area. Also in October, individual Medicare-approved plans will begin releasing specific plan information, including plan costs, a list of covered drugs and a list of network pharmacies. Information is also available at http://www.medicare.gov.

In addition, you may also request a free information kit from Network Health.

Enrollment

When can I enroll?
See When You Can Enroll.

How do I enroll?
See How to Enroll.

When will my coverage start?
If you select a plan during the Annual Enrollment Period (October 15 – December 7), your coverage will probably start on January 1. If you’re turning 65 and you enroll, your coverage will start on the first day of the month after you enroll.

What if I decide I want to leave my plan or switch plans?
Every year from October 15 to December 7, you can make changes to your Medicare Advantage Plan coverage. This is generally the only time you can switch plans, and any changes you make will be effective January 1.

From January 1 to February 14 you can drop your Medicare Advantage Plan and return to Original Medicare (parts A and B) coverage. If you return to Original Medicare, you may enroll in a Stand Alone Prescription Drug Plan.

There are a few other special situations when you can leave your plan or switch plans. For more details, see When You Can Enroll.

What’s the difference between the “Welcome to Medicare” appointment and an "Annual Physical"?
There’s not a great deal of difference between these two doctor visits. The main difference is when the visit happens.

  • The “Welcome to Medicare” appointment must happen within the first 12 months that you’re eligible for Medicare Part B benefits.
  • After the first 12 months, a wellness appointment is considered an annual physical whether you had a welcome appointment or not.

As far as what’s done in the two appointments, there are only a few differences. The annual physical addresses the following three items, and the “Welcome to Medicare” appointment does not.

  • Assessing the beneficiary’s cognitive function
  • Establishing a list of the beneficiary's risk factors, conditions and treatment options
  • Establishing a list of current providers and suppliers involved in the beneficiary's care

If my membership ends, what do I need to know?
If you disenroll by choice or your plan disenrolls you, you have certain rights and responsibilities, including the below.

Involuntary Disenrollment

If you are involuntarily disenrolled for any reason, your plan must:

  • Advise why the plan is planning to disenroll you
  • Why such action is occurring
  • Provide the effective date of termination
  • Include an explanation of your right to a hearing under our grievance procedures
  • Mail you a notice before submission of the disenrollment transaction to CMS

You have the right to make a complaint if your plan ends your membership. When a plan ends an enrollee’s membership, the plan will tell the enrollee the reason in writing and explain how the enrollee may file a complaint against the plan.

Voluntary Disenrollment

  • Your plan cannot discourage you from disenrolling after you indicate your desire to do so.
  • Your plan may send a disenrollment form to you upon request.
  • The disenrollment request must be dated when it is initially received by your plan.

For more information, see the chapter of your Evidence of Coverage called Ending Your Membership in the Plan.

Benefits, Medical Services and Costs

What is the benefit accumulator on my Explanation of Benefits?
The benefit accumulator is an explanation of your maximum out-of-pocket amount. The maximum out-of-pocket amount is a plan specific amount which is the most you’ll pay in medical costs in a calendar year. The applied amount is the amount you have paid up until the time that the Explanation of Benefits was printed.

Can I choose any doctor or hospital I want?
With a Network Health Medicare Advantage Plan, you have the right to choose in-network and out-of-network doctors. This means you can choose any doctor that accepts Medicare beneficiaries that is listed in our provider directory.

See Find a Doctor to search for in-network doctors.

What happens if I go to a doctor who is not in the plan’s network?
If you are a Network Health Medicare Advantage PPO member, that’s okay. You’ll be covered.

What does in-network and out-of-network mean? 
We have agreements with certain providers and pharmacies to provide you health care services and prescription drugs. These providers and pharmacies are considered in-network.

With our Medicare Advantage PPO plans, you can choose in and out-of-network providers. See Find a Doctor to search for in-network doctors.

You must use network pharmacies for your prescriptions to be covered. See Search Pharmacies to find those in our network.

How do I find out what's covered and what's not? 
See your Evidence of Coverage plan policy found in Member’s Corner. It includes all the details. Or, call a health care concierge with any specific questions.

How do I find out what I pay?
See your Evidence of Coverage plan policy found in Member’s Corner. It includes all the details. Or, call a health care concierge with any specific questions.

What is a copayment?
A copayment is set fee that you pay for some health care services or prescription drugs. Your copayment amounts will vary based on the type of plan you have. 

If I’m traveling and I need emergency care, am I covered?
We cover emergency care worldwide for most plans. When you are outside of Wisconsin, anywhere in the U.S., you can get emergency care at the same cost you would at home.

Can I have my monthly premium automatically taken out of my bank account?
Yes. You can choose to pay using an automatic bank withdrawal or by sending us a check. Members can also have their premiums withheld from their Social Security Administration checks.

What does maximum out-of-pocket mean?
Your maximum out-of-pocket is the most you’ll have to pay for health care services in a calendar year. You’ll never pay more than this for your total cost for all services. If you reach this limit, your plan pays 100 percent for your services for the remainder of the year.

Am I covered for dental services? 
We partner with Delta Dental to include dental care on many of our Medicare Advantage Plans. NetworkCares covers preventive and comprehensive dental services. Refer to your Evidence of Coverage for more details.

Vision Discount
For 2018, Network Health is working wtih EyeMed to bring you special discounts. Just show your Network health ID to participating providers to receive your discount. View vision discount program details.

Hearing Aid
For 2018, Network Health will offer a hearing aid discount program with Simpli Hearing. Members will find quality brand name hearing aids discounted to $1,220-$1,985. The discount program includes a one-year warranty, three office visits, one pack of batteries and one year of loss and damage insurance. Learn more about the hearing aid discount program.

A Complete Fitness Program at No Cost to You
Improve your health and live the life you want with SilverSneakers® Fitness. The program is included in most Network Health Medicare Advantage PPO Plan benefits and gives you membership at more than 13,000 gyms nationwide. This program is designed for all fitness levels and abilities, providing the fitness support you need. Learn more about SilverSneakers and find a location near you
.

Where can I get a flu shot?
There are several ways to get a flu shot.

  • Attend a Member Appreciation Event in October of each year. Watch for details in September.
  • If you get the shot at your doctor’s office, you will pay your normal copayment for a primary care doctor visit.
  • If you get the shot at a pharmacy, you will need to pay for it in full and then send a paid receipt to Network Health for reimbursement.

Is the shingles shot (Zostavax) covered?
The shingles shot is covered, but you’ll be responsible for part of the cost.

  • If you have prescription drug coverage with Network Health and you’re in the initial coverage phase, you will pay $40 if you get your shot at a preferred pharmacy, or $45 at a standard pharmacy.
  • If you get the shot at a doctor’s office, you will have to pay up front and then send Network Health a paid itemized receipt. *We will then reimburse you all but your copayment.

*Since Medicare has this benefit under the pharmacy Part D category, a doctor’s office has no way to bill the insurance company for pharmacy benefits, only a pharmacy can bill for Part D benefits.

Also, please note that Wisconsin SeniorCare does not cover the cost of this shot.

What if I need a wheel chair or scooter, where should I go?
Call a health care concierge at 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m.

We can guide you to the closest in-network provider. Television ads for companies providing these items are typically out-of-network for the plan and it may cost you more money out of pocket.

Are prosthetics covered?
Prosthetic devices are covered with the appropriate copayment. These are devices (other than dental) that replace a body part or function. Examples include pacemakers, braces, artificial limbs and breast prostheses. Certain supplies and repairs to prosthetic devices are also covered.

How can I get my diabetic medicines and supplies?
To help you understand the best options for obtaining your medications and supplies, call a health care concierge at 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m.

There are many television and magazine ads suggesting that you have your medications sent to you. Be aware that these groups are probably out-of-network and therefore would cost you more than other alternatives.

What’s observation care and how is it covered?
Being in the hospital under observation care or partial hospitalization may feel like being admitted to the hospital. But, observation care is for short-term treatment, assessment or reassessment of your condition. It’s used to determine if you should be fully admitted to the hospital or released. It’s considered an outpatient status rather than inpatient. We suggest you always ask what type of hospitalization it is when you’re in the hospital.

What’s skilled nursing facility care?
Skilled nursing facility care and rehabilitation services are provided on a continuous, daily basis, in a skilled nursing facility. This type of care includes the following.

  • A semi-private room, meals, skilled nursing, rehabilitative services and other services and supplies that are medically necessary
  • To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care. Medicare doesn’t cover long-term care or custodial care
  • If at any time your care is no longer both skilled and rehabilitative, you’ll no longer qualify for the skilled nursing benefit
  • Members on the NetworkCares (PPO SNP) Plan are subject to Medicare's three-day hospital stay requirement

What is custodial care?
Custodial care is sometimes confused with skilled nursing care, but in most cases, Medicare doesn’t pay for custodial care.

  • Custodial care is non-skilled personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or a chair, moving around and using the bathroom
  • It may also include the kind of health-related care that most people do themselves, like using eye drops

Drug Coverage

Who is eligible for Medicare Part D prescription drug coverage?
Anyone with Medicare Part A or Medicare Part B is eligible to enroll regardless of age, income or health conditions.

Do I have to have prescription drug coverage?
No. Having prescription drug coverage is your choice. However, if you don't enroll in a plan with prescription drug coverage when you are first eligible, it could result in a penalty or fee.

What if I don’t currently take any prescription drugs?
Even if you don’t need any prescription drugs now, you may still want to consider having prescription drug coverage. Most people need prescriptions as they age to stay healthy. Getting prescription drug coverage as soon as possible will ensure that you won’t have to pay a penalty later on.

Why is there a late enrollment penalty for not enrolling?
The penalty is simply a late enrollment fee. This penalty encourages people to have prescription drug coverage at the time they are eligible, instead of waiting to join after health problems develop and drug costs rise.

What if I can’t afford coverage?
If you’re struggling with your prescription drug costs now, or you think you can’t afford prescription drug coverage, it’s very important to apply for help.

  • You may get an application in the mail from the Social Security Administration (SSA). If so, complete this form and return it as soon as possible.
  • If you don’t receive this form, call the Social Security Administration at 800-772-1213. TTY users should call 1-800-325-0778.
  • You can also visit www.socialsecurity.gov.
  • Or, you can go to your State Medical Assistance office to apply.

How will I know if my current prescriptions will be covered?
You can look them up on our drug list, called the formulary. See Look Up Medications to search our list of covered drugs.

What is a drug tier?
A tier is the group or cost category a drug belongs to. The tier determines the cost of the drug, and generally the higher the tier the more you’ll pay. The formulary tells you what tier your drugs are on and how much each tier costs

What’s the difference between brand name drugs and generic drugs?
A brand name drug is a drug that is protected by a patent. The drug can only be made or sold by the company that holds the patent.

A generic drug is approved by the U.S. Food and Drug Administration as having the same active ingredients as a brand name drug. Generic drugs work the same as brand name drugs, but they generally cost less.

Are generic drugs as good as brand name drugs?
Yes, generic drugs are just as good as brand name drugs because they are approved by the U.S. Food and Drug Administration as meeting the same standards as brand name drugs.

What are over-the-counter drugs and are they covered?
An over-the-counter drug is a product that can be purchased without a prescription. These medications are usually not covered.

What is the donut hole or the coverage gap?
The prescription drug coverage gap is commonly called the donut hole. See How the Coverage Gap Works to learn more.  

What is a formulary and how do I use it?
The formulary is a list of drugs covered by your plan. You can use it to search for your drugs, find out if they’re covered and what they cost. It also provides information about any special requirements for using a drug. Some drugs might require approval or there may be limits on the amount of drugs available each time you fill your prescription. An abridged formulary includes only some of the drugs covered by Network Health. For more information click here or call a health care concierge at 800-378-5234 (TTY 800-947-3529)

What is a pharmacy directory and how do I use it?
This is a list of network pharmacies you can use to get your prescriptions filled. We also list pharmacies that are in our network but are outside of our service area. All network pharmacies may not be listed in this directory. To have your prescription drugs covered, you must use one of the pharmacies on this list, or call customer service at 800-316-3107 for more information. See Search Pharmacies to find network pharmacies in your area.

Can I have my prescription medications mailed to me?
Yes, you can have your medications sent to you by visiting express-scripts.com and signing up for home delivery. As an enrollee of our plan, you can get a long-term supply (up to 90 days) of drugs shipped to your home using our plan’s network mail order delivery program. Usually you will receive your mail order prescriptions within 14 calendar days. If your order does not arrive within the estimated timeframe, call Express Scripts Customer Service at 800-316-3107 (TTY 800-899-2114), 24 hours a day/7 days a week. 

Where do I find what I’ll pay for my prescription drugs?
What you’ll pay for drugs is listed in your Evidence of Coverage found in the Member’s Corner section of this website. This will tell you the copayment amounts you’ll pay for drugs. You’ll also need to look up your specific drugs on our drug list, called the formulary. The formulary will tell you what tier (or cost group) your specific drug is in. Costs will also be influenced by what stage of coverage you are in at the time of purchase.

Contacting Network Health

What number should I call when I need help?
Call our health care concierges at 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m.

When I call, why do you keep asking for all of my personal information?
The Health Information Portability and Accessibility Act (HIPAA) and Medicare guidelines have very specific requirements we must follow to protect your health information. We always have to ask you questions when you call to ensure you are the person you say you are (and not just someone using your phone number and name). This is all done to protect the privacy of your health information.

Can my spouse or a family member call Network Health for me?
Your spouse or a family member can call Network Health for you if we have your permission on file. This permission must be in writing and must be for specific individuals, not just a general family designation. Call 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m., for details about the documentation needed.

Attend a Meeting

Don't wait to learn more. Come to a free community meeting in your neighborhood to learn more about our plans and meet us in person. You're welcome to bring a friend, too.

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Research Rx

Visit our Research Rx Center to find local pharmacies where you can get prescriptions, which medications are covered, what they cost and more.

Find a Pharmacy Look Up Medications Go to Research Rx Center

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