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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 provides are prescription drug coverage, hearing and vision benefits, no monthly premium, 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 a Memorial Hermann Medicare Advantage 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, Memorial Hermann Advantage  plans offer $0 monthly premiums, 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 Memorial Hermann Advantage plans, 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 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 for a Memorial Hermann Advantage 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–February 14, 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 February 14 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 Memorial Hermann Advantage website.)

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    Memorial Hermann Advantage Member Questions

    When will I receive my membership ID card?

    Once you have enrolled in a Memorial Hermann Advantage plan and we have approved your enrollment through Centers for Medicare & Medicaid Services, you will typically receive your Memorial Hermann Advantage 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 $5 PCP office co-pays, $0 Part C plan premium, hearing and vision benefits, readmission preventive services, 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.

    What does Memorial Hermann Advantage PPO cover?

    Memorial Hermann Advantage PPO covers the same benefits you receive in Original Medicare, as well as additional health benefits like prescription drug coverage, a $5 PCP office co-pays, $0 Part C plan premium, hearing and vision benefits, readmission preventive services, fitness benefit, a 24/7 Nurse Hotline and more. You are not required to use doctors and other health care providers within the Memorial Hermann Advantage; however, costs to cover health care may be lower if you use providers within the plan’s network.

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

    Traveling as a Memorial Hermann Advantage member?

    When you are outside the service area and cannot access care from a network provider, our HMO and PPO plans will cover urgently needed care that you receive from any provider. In addition, our plans offer 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.

    The 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 HMO if it is not urgent/emergent services then you are responsible for all costs. For PPO you will be responsible for the out-of-network cost share for covered services (generally 40% of the cost). Refer to your Evidence of Coverage.

    What are the differences between out of area costs for HMO versus PPO?

    If HMO members go outside the network you will pay for the full cost for the care received. The plan will not pay for the service unless it is urgent/emergent care. For PPO you will pay the out-of-network cost share (generally 40% of the cost). Refer your Evidence of Coverage.

    If I’m traveling and I have a PPO plan, will I be covered for anything other than urgent and emergent?

    Yes, the PPO plan will pay for covered services like any other out-of-network benefit in the PPO plan (generally 40% of the cost).

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

    Yes, the HMO and PPO plans 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.

    NOTE: If you have the Memorial Hermann Advantage HMO or PPO Pack, your copay for urgent of emergent care while traveling is $0.

    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 24 hours of the ER visit and you would only be responsible for the inpatient hospital copay amount.

    What is the difference between referrals v. prior authorizations?

    You do not need a referral to see any Specialist for an office visit. You can make an appointment to see a specialist without a referral from your Primary Care Provider (PCP). However, certain services performed or ordered by the Specialist may require prior authorization. Examples of services that require a prior authorization before you receive the service are listed below. Refer to your Evidence of Coverage for a complete list of services requiring prior authorization.

    • Pain Management, Plastic Surgery and Wound Care
    • Inpatient Hospital, Physical and Behavioral Health (non-emergent)
    • Skilled Nursing Facility (SNF)
    • Durable Medical Equipment (DME)
    • Home Health
    • Diagnostic and Therapeutic Services
    • Occupational, Physical, and Speech Therapies

    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 40% for the plan's costs for brand drugs and 51% of the plan's costs for any generic drugs. Until your yearly out-of-pocket drug costs reach $4,950.

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

    After your total yearly drug costs reach $4,950, you will pay $3.30 for generic drugs and $8.25 for brand drugs or 5% coinsurance for these drugs whichever amount is greater.

    "Supplemental" Hearing Aid Benefit Clarification

    Memorial Hermann Advantage HMO plans will pay up to $250 every year toward the cost of hearing aids. Memorial Hermann Advantage PPO plans will pay up to $250 every year for hearing aids from an in-network or out-of-network provider. 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 Benefit for "Eye Wear/Contact Lenses" Clarification

    Memorial Hermann Advantage HMO plans will pay up to $50 every year toward the cost of eyewear. Memorial Hermann Advantage PPO plans will pay up to $50 every year for eyewear from an in-network or out-of-network provider. You pay no copay. If the cost of the eyewear is greater than the $50 maximum allowance every year paid by the plan, you will be responsible for the remaining cost.

    Service area versus Network Clarification

    Our service area includes Harris, Fort Bend and Montgomery counties. That means the all members must live in one of those 3 counties to be eligible for our plans. 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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