What is a plan premium?

A plan premium is the amount you pay each month for your Medicare coverage. Plan premiums can vary according to what plan you’re in.

What are copayments and coinsurance?

  • A copayment, or copay, is an amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.
  • Coinsurance is a percentage of the cost for services or prescription drugs. Coinsurance is usually a percentage (for example, 20%)

What is a deductible?

A deductible is the dollar amount you may have to spend before your plan starts paying its share of your covered costs.

What is a network?

A network is a group of doctors and other health care professionals, medical groups, hospitals and other health care facilities that have an agreement with an insurer to deliver covered services to members in its plan.

What is the Initial Enrollment Period (IEP)?

The Initial Enrollment Period (IEP), or IEP, is a 7-month period that you can enroll in Medicare. Your personal IEP centers around the “qualifying event” that makes you eligible for Medicare. Your Initial Enrollment Period (IEP) starts 3 months before the month you become eligible, includes the month you become eligible and ends 3 months after the month you became eligible.

What is the Annual Enrollment Period (AEP)?

Medicare’s Annual Enrollment Period begins October 15 and ends December 7 of each year. The choices you make during AEP take effect January 1 of the following year. During AEP, you may join, switch, or drop a Medicare Health Plan or a Medicare Advantage Plan with or without drug coverage.

What is the Open Enrollment Period (OEP)?

Open Enrollment takes place from January 1 through March 31 annually. It allows individuals enrolled in a Medicare Advantage plan to make a one- time election to switch to either another Medicare Advantage plan or switch back to Original Medicare.

What is the Special Enrollment Period (SEP)?

The Special Enrollment Period allows you to join, switch or cancel a Medicare Advantage and Medicare Prescription Drug plan when you have special circumstances. Some of these examples include:

  • You newly get, lose or have a change in your Medicaid or Extra Help status
  • You recently involuntarily lost your creditable coverage
  • You are leaving/losing/starting a job or union
  • You recently moved outside the service area for your current plan, or
  • you recently moved and this plan is a new option for you
  • You live in, are moving into, or recently moved out of a nursing home or long-term care facility

The Special Enrollment Period (SEP) reasons above are examples
and do not include all of the situations that may qualify for SEP enrollment.

What is a Generic Drug?

A generic drug is a prescription drug that is approved by the Food and Drug Administration (FDA) and has the same active ingredient(s) as the brand- name drug. Generally, a “generic” drug works the same as a brand name drug and usually costs less.

What is a Brand-Name Drug?

A brand-name drug is a prescription drug that is marketed with a specific brand name by the company that makes it, usually the company which researched and developed the drug. A brand-name drug has the same active ingredients and formula as its generic version.

What is a formulary?

A formulary is a list of prescription drugs covered by a plan. Medicare Part D is provided by private insurance companies, each company may decide which drugs to cover. Every formulary must meet the minimum standards and requirements set by the Medicare Part D guidelines.

What is Original Medicare?

Original Medicare is offered by the government, and not a private health plan like Medicare Advantage Plans and prescription drug plans. The term “Original Medicare” refers to Medicare Part A and Part B. Part A helps cover the cost of hospital-related care and Part B is the medical insurance component of Medicare.

Am I eligible for Medicare?

You may be eligible for Medicare if:

  • You are age 65 or older
  • You have a qualifying disability for which you have been receiving
  • Social Security Disability Insurance (SSDI) for more than 24 months
  • You have been diagnosed with end-stage renal disease (permanent kidney failure requiring a kidney transplant or dialysis)

Can I have both employer insurance and Medicare?

If an employee is still employed upon reaching age 65, federal laws require allowing the employee to remain on the group health insurance and to defer Medicare coverage until retirement. The employee has the right to reject the company’s plan and elect Medicare, but the company can offer no incentives for switching to Medicare.

If an employee remains on the group plan and signs up for Medicare, in groups of fewer than 20 employees, Medicare will be the primary coverage. In groups of 20 or more, the group coverage will be primary over Medicare.

What does Medicare Part A pay for?

Medicare Part A is hospital coverage. It helps pay for hospital stays and inpatient care in hospitals. This includes:

  • Care in special units, like intensive care
  • Skilled nursing services
  • Drugs, medical supplies and medical equipment used during an inpatient stay
  • Lab tests, X-rays and medical equipment used as an inpatient
  • Operating room and recovery room services
  • Hospice care for the terminally ill

What does Medicare Part B pay for?

Medicare Part B is medical coverage. It helps pay for doctor visits and outpatient care. This includes:

  • Doctor visits, including when you are in the hospital
  • Annual wellness visits and preventive services such as flu shots and mammograms
  • Medically necessary services and supplies needed to treat your medical condition

Will I pay a premium for Part A or Part B?

Most people don’t have to pay a premium for Part A as long as they or their spouse paid Medicare taxes for at least 10 years while they were working. There is a monthly premium for Part B.

What is Medicare Part D?

This optional coverage is provided through private prescription drug plans (PDPs) that contract with Medicare. Part D Helps provide prescription drug benefits. These can be sold as stand-alone plans or combined with Part C in Medicare Advantage Prescription Drug Plans (MAPDs).

Am I eligible for Medicare Part D?

Once you are enrolled in Medicare Part A or Medicare Part B, you are also eligible for Medicare Part D. If you don’t enroll during your Initial Enrollment Period, or do not have creditable prescription drug coverage, Medicare may add a Part D late enrollment penalty to your monthly Part D premium.

If you receive Extra Help to pay for your prescription drug costs, you do not pay any late enrollment fee.

What is the Part D late enrollment penalty?

An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that is expected to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more after you are first eligible to join a Part D plan. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions. For example, if you receive “Extra Help” from Medicare to pay your prescription drug plan costs, you will not pay a late enrollment penalty.

What are the different stages of Medicare Part D coverage?

There are four stages of Medicare Part D.

  1. The annual deductible stage – You pay the full cost of your covered prescriptions until you reach your deductible. (All ApexHealth plans have no annual deductible)
  2. The initial coverage stage – Once the deductible is met, members move into the “Initial Coverage” stage, after which members pay a copayment or coinsurance for each prescription, and the plan pays its share, until “total drug costs” (including the deductible and retail costs of drug purchases) reach the Initial Coverage Limit (ICL). Please reference your plan’s Evidence of Coverage for the annual Initial Coverage Limit (ICL).
  3. The coverage gap stage – The coverage gap begins after you have reached the initial coverage limit. When you’re in the coverage gap, you will pay no more than 25% of the cost for your plan’s covered brand-name or generic prescription drugs. The coverage gap ends when you have spent enough to qualify for catastrophic coverage. Please reference your plan’s Evidence of Coverage for the amount you need to reach to qualify for catastrophic coverage and any plan-covered coverage gap costs.
  4. The catastrophic coverage stage – This is the drug coverage stage that happens after you get out of the coverage gap (donut hole). With catastrophic coverage, you pay a reduced amount for covered drugs for the rest of the year.

What is the Medicare Part D Extra Help program?

Extra Help is a program to help people with limited income and resources pay for prescription drugs. Extra Help may lower your premiums, copays or coinsurance. It also helps provide coverage throughout the coverage gap and waives any Part D late enrollment penalty.

How do you apply for Extra Help with Medicare’s prescription drug costs?

There are multiple ways to apply for Extra Help. Here are three ways to start:

  • You can receive help with submitting your application from your ApexAssistant. They’re available seven days a week, from 8 a.m. to 8 p.m. local time from October 1 – March 31 and Monday to Friday, 8 a.m. to 8 p.m. local time from April 1—September 30. Call 1- 844-279-0508 (TTY users should call 711).
  • Apply online at Social Security’s website.
  • Call Social Security at 1-800-772-1213 or TTY: 1-800-325-0778, Monday to Friday, 7 AM to 7 PM.

What is a Medicare Advantage Prescription Drug plan (MAPD)?

A Medicare Advantage prescription drug plan (MAPD) is a plan that combines all your Medicare coverage into one plan. A MAPD plan includes Medicare Part A (hospital), Medicare Part B (medical) and Medicare Part D (prescription). These plans are provided by private insurers such as ApexHealth.

When can I enroll in an ApexHealth plan?

You can enroll in an ApexHealth plan during one of the following four enrollment periods:

  • Initial Enrollment Period (IEP), which begins when you’re first eligible for Medicare
  • Annual Enrollment Period (AEP), which occurs from October 15 through December 7
  • Open Enrollment Period (OEP), from January 1 through March 31
  • Special Enrollment Period (SEP), during special personal circumstances

How can I enroll in an ApexHealth plan?

During an enrollment period, there are a few different ways you can enroll in an ApexHealth plan. You can choose one of the following enrollment options:

  • Enroll with a licensed ApexAssistant over the phone
  • Enroll on www.apexhealth.com
  • Enroll on www.medicare.gov
  • Enroll using the plan’s paper enrollment form
  • Enroll with a licensed agent or broker who is appointed by ApexHealth to sell our plan(s)

How and when can I contact my health plan/Customer Service Hours?

You can contact Concierge Services. They’re available seven days a week, from 8 a.m. to 8 p.m. local time from October 1 – March 31 and Monday to Friday, 8 a.m. to 8 p.m. local time from April 1—September 30. Call 1- 844-279- 0508 (TTY users should call 711).

Can I see my specific doctor if I join an ApexHealth plan?

With ApexHealth HMOs, unless it’s an emergency, you usually must see a doctor that’s part of the plan’s network. You may be able to continue seeing your specific doctor but only if they are part of the plan’s network. You can call 1-844-279-0508 (TTY users should call 711) or check on our Provider Directory at www.apexhealth.com.

Will ApexHealth cover my prescriptions?

ApexHealth has its own list of covered drugs (called our plan Formulary). Be sure to check the list to make sure the drugs you take are covered. You can call our Concierge Services department at 1-844-279-0508 (TTY users should call 711) and we can check for you! You can also visit find our plan Formulary on our website at www.apexhealth.com.

Which pharmacy can I use when on an ApexHealth plan?

ApexHealth has a network of pharmacies you must choose from. Be sure to check our list of pharmacies to make sure the pharmacy you use is in our plan’s network at www.apexhealth.com. You can call our Concierge Services Department at 1-844-279-0508 (TTY users should call 711) and we can check for you.

Should I still keep my red, white and blue Medicare card?

Yes, keep your red, white and blue Medicare card in a safe place in case you need it later. It is important to remember, that you will use your ApexHealth member ID card when you go to doctors, hospitals, and/ or pharmacies.

Will I have the same coverage as I do with Original Medicare?

ApexHealth plans are required to cover all services and procedures that are covered by Original Medicare. Our plans also offer extra benefits not covered by Original Medicare, which include dental, hearing, vision, a fitness membership, prescription drug coverage and more.

Where can I receive emergency care?

You can receive emergency care in or out-of-network for the same copayment. Contact 911 for a medical emergency or go to the closest emergency department.

Do I still have to pay my Medicare Part B premium?

Yes, you must continue to pay your Medicare Part B premium unless it’s paid for you by Medicaid or another third party.

I forgot my ApexHealth ID number. Where can I find it?

You can view your virtual ApexHealth member ID card in your member portal once enrolled in the plan. You can also contact Concierge Services to request a replacement ID card at 1-844-279-0508 (TTY users should call 711).

How do I access care in the event of a disaster?

ApexHealth is committed to helping you access the care you need in times of natural disasters and emergencies. When a major disaster or emergency is declared by the President, a public health emergency is declared by the Secretary of Health and Human Services, or a disaster or emergency is declared by a Governor, ApexHealth will:

  • Allow access to Part A and Part B services and supplemental Part C plan benefits at specified non-contracted facilities;
  • Waive, in full, requirements for gatekeeper referrals, where applicable;
  • Temporarily reduce plan-approved out-of-network cost-sharing to in-network cost-sharing amounts;
  • Waive the 30-day notification requirement to members if all changes (e.g., reduction of cost-sharing and waiving of authorization requirements) benefit the member; and
  • Lift restrictions on refills of Part D prescription drugs so that members can fill prescriptions sooner than usual.

These actions will remain in place through the declaration period. Typically, the source that declared the disaster or emergency will clarify when it is over. If, however, the disaster or emergency timeframe has not been closed 30 days from the initial declaration, and if the Centers for Medicare and Medicaid Services (CMS) has not indicated an end date to the disaster or emergency, ApexHealth will resume normal operations 30 days from the initial declaration or such longer time as may be required by law, regulation, or the underlying circumstances.

If you are impacted by one of the above events and need access to prescription drugs, please have your pharmacy contact our pharmacy benefit manager’s help desk. The number is located on the back of your ID card and in the Evidence of Coverage. Early refill edits for the days’ supply requested by the pharmacy are available at the time of refill, up to the maximum extended days’ supply defined by the plan. For questions about accessing medical care, please call Concierge Services. The number is located on the back of your ID card and in the Evidence of Coverage.