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Frequently Asked Questions

Basic Medicare Questions

What is Medicare?

Medicare is a federal health insurance program for people ages 65 or older. Others younger than 65 may also be eligible if they have certain disabilities or diseases, such as End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS), otherwise known as Lou Gehrig's disease.

Medicare is also made up of four parts:

What does Original Medicare cover?

Original Medicare is made up of Medicare Part A and Part B.

Medicare Part A covers most inpatient costs and can include the costs of hospital stays, skilled nursing facility care, and some hospice and homecare benefits.

Medicare Part B covers doctors visits, and can include the costs of X-rays, lab tests, chemotherapy and vaccinations.

What is Medicare Advantage?

Medicare Advantage, or Medicare Part C, is a Medicare-contracted plan provided by private insurance companies that offer additional benefits Original Medicare does not cover. Some additional benefits that Memorial Hermann Advantage HMO provides are prescription drug coverage, hearing and vision benefits, and a maximum cap on out-of-pocket costs.

Learn more about why a Medicare Advantage plan may be right for you.

Who is eligible for Medicare?

You are eligible for Medicare if:

  • You are 65 years or older.
  • You are under the age of 65 and have a qualifying disability.
  • You are a U.S. citizen or a permanent legal resident; and
  • ?You or your spouse has worked long enough to be eligible for Social Security or railroad retirement benefits ? usually having earned 40 credits from about 10 years of work ? even if you are not yet receiving these benefits; or
  • ?You or your spouse is a government employee or retiree who has not paid into Social Security but has paid Medicare payroll taxes while working.

Who is eligible for Medicare Advantage?

You qualify for Memorial Hermann Medicare Advantage HMO plan if you are already enrolled in Original Medicare (both Medicare Part A and Part B) and live in the Harris, Fort Bend or Montgomery counties in Texas

Learn about exceptions to Medicare eligibility.

What is the difference between Original Medicare and Medicare Advantage?

The biggest difference between Original Medicare and Medicare Advantage is that Medicare Advantage is run by private insurance companies and provides additional benefits that Original Medicare does not cover. For example, the Memorial Hermann Advantage HMOplan offers prescription drug coverage, hearing aid and annual vision examination coverage, and a maximum amount on out-of-pocket costs.

Some plans charge an additional premium for their Medicare Advantage plan, meaning that you pay both your Part B premium and your private insurance plan’s premium each month. With the Memorial Hermann Advantage HMO plan, there is no monthly plan premium, so you only have to pay your required Part B premium every month. For Part D Prescription Drug Coverage, there is an annual deductible of $300 for prescription drugs applicable to tiers 4 and 5 in our formulary.

 

Learn more about the difference between Original Medicare and Medicare Advantage.

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Questions About Medicare Costs

How much does Medicare Advantage cost?

The cost of Medicare Advantage plans varies by plan and by the health services and benefits you will need. To know the full cost, you need to know cost factors such as whether the plan charges a monthly premium, if there is an annual deductible, what the individual services copays are, what the maximum on out-of-pocket costs are, and whether or not you will need care in or outside of the plan's network.

What is a deductible?

An insurance deductible is the amount of money you must pay before your health insurance company makes payments toward your health care.

What is a copay?

Insurance copay is the amount you pay for a health care service, typically at the time of service. The amount of the copay depends on your plan and the health care service.

What is a premium?

An insurance premium is the amount you pay monthly, quarterly or yearly for health insurance. There is no monthly premium cost for being enrolled in the Memorial Hermann Medicare Advantage HMO plan.

 

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Questions About Medicare Advantage Enrollment

How do I enroll in a Medicare Advantage Plan from Memorial Hermann Advantage?

You can enroll in the Memorial Hermann Advantage HMO plan online, by phone, by mail or with the assistance of one of our licensed insurance agents. Refer to our enrollment instructions for more detailed information.

When can I enroll in Medicare Advantage?

You can enroll in a Medicare Advantage Plan at these times:

  • When you first become eligible for Medicare (3 months before you turn age 65 to 3 months after the month you turn age 65).
  • If you get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of disability.
  • Between October 15 - December 7 each year. Your coverage will begin on January 1 of the following year.
  • Between January 1– March 31, if you’re in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare. If you switch to Original Medicare during this period, you’ll have until March 31 to also join a Medicare Prescription Drug Plan to add drug coverage. Generally, your coverage will begin the first day of the month after the plan gets your enrollment request.

There may be special circumstances that allow you to enroll outside of the time periods listed above, including:

  • If you move out of your plan's service area
  • If you have both Medicare and Medicaid
  • If you qualify for "extra help"
  • If you live in an institution
  • If you were released from jail
  • Other special circumstances (such as losing employer group coverage)

Can I enroll someone else in Medicare?

Yes, you can help someone else enroll in Medicare or Medicare Advantage if you are a verified authorized representative. The individual you are helping must provide this in written consent. Learn more about helping someone enroll in Medicare.

What is a late enrollment penalty (LEP)?

You may owe a late enrollment penalty if you go without a Medicare Prescription Drug Plan (Part D), or without a Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage, or without creditable prescription drug coverage for any continuous period of 63 days or more after your Initial Enrollment Period is over. (Please note that by clicking on these links, you will be leaving the Memorial Hermann Advantage HMOwebsite.)

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Memorial Hermann Advantage HMO Member Questions

When will I receive my membership ID card?

Once you have enrolled in the Memorial Hermann Advantage HMO plan and we have approved your enrollment through Centers for Medicare & Medicaid Services, you will typically receive your Memorial Hermann Advantage HMO membership ID card within 10 days.

What does Memorial Hermann Advantage HMO cover?

Memorial Hermann Advantage HMO covers the same benefits you receive in Original Medicare, as well as additional health benefits like prescription drug coverage, a $0 PCP office co-pays, $0 Part C plan premium, hearing and vision allowances, fitness benefit, a 24/7 Nurse Hotline and more. You are required to use doctors and other health care providers within the Memorial Hermann Advantage Network.

Learn more about the Memorial Hermann Advantage HMO plan and what it covers.

Traveling as a Memorial Hermann Advantage HMO member?

When you are outside the service area and cannot access care from a network provider, our HMO plan will cover urgently needed care that you receive from any provider. In addition, our plan offers coverage for emergency care worldwide whenever you need it. Members are only responsible for the emergency room and or Urgent Care copays. If you are hospitalized, your copay will be refunded.

Memorial Hermann Advantage HMO does not provide coverage for out-of-network general/routine care services. All costs for these services will be the responsibility of the member.

Urgently needed care is a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical care. Urgently needed care may be furnished by in-network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. The unforeseen condition could, for example, be an unforeseen flare-up of a known condition you have.

What are my detailed costs when I am out of the network (and not just emergent and urgent care)?

For Memorial Herman Advantage HMO if it is not urgent/emergent services then you are responsible for all costs.

What if I’m traveling abroad, will I be covered?

Yes, the plan will pay for covered urgent/emergent care, or renal dialysis. However, you will be responsible for your bill at the time of service, but you may then submit your bill to the Plan for reimbursement minus your copay.

What happens when I reach my out of pocket maximum (MOOP)?

Once you have reached your maximum out-of-pocket costs, you stop paying out of pocket for all covered services except the services with benefit maximums (i.e. hearing aids, eyewear, SNF, and outpatient rehab services).

What if I go to the Emergency Room (ER) and am later admitted to the hospital, do I have to pay the copay for the ER and the hospital stay copay?

No, in that circumstance the ER copay is waived when you are admitted to the hospital within 48 hours of the ER visit and you would only be responsible for the inpatient hospital copay amount.

What is covered during the coverage gap (aka donut hole)?

You will also receive a discount on brand-name drugs and generally pay no more than 25% for the plan's costs for brand drugs and 37% of the plan's costs for any generic drugs. Until your yearly out-of-pocket drug costs reach $5,100.

What do I pay after I get out of the coverage gap?

After your total yearly drug costs reach $5,100, you will pay $3.40 for generic drugs and $8.50 for brand drugs or 5% coinsurance for these drugs whichever amount is greater.

"Supplemental" Hearing Aid Yearly Allowance Benefit Clarification

Memorial Hermann Advantage HMO plan will pay up to $400 every year toward the cost of hearing aids. You pay no copay. If the cost of the hearing aids is greater than the maximum allowance every year paid by the plan, you will be responsible for the remaining cost.

"Supplemental" Vision Yearly Allowance Benefit for "Eye Wear/Contact Lenses" Clarification

Memorial Hermann Advantage HMO plan will pay up to $200 every year toward the cost of eyewear.

Service area versus Network Clarification

Our service area includes Harris, Fort Bend and Montgomery counties. That means all members must live in one of those 3 counties to be eligible for our plan. Our provider network is not limited to these 3 counties, as any provider or hospital that is in our network, anywhere in greater Houston is "in the network."

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 co-payments/co-insurance may change on January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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