Questions & Answers

Medicare Definitions

Allowable Amount or Limiting Charge— An out-of-network physician can only balance bill (definition below) you up to the Limiting Charge. By law, the Limiting Charge is 15% over the Medicare-approved amount for physician services. There is no Limiting Charge for out-of-network providers of durable medical equipment and supplies. (Only for plans with Point of Service. See the Evidence of Coverage.)

Appeal — An appeal is something you do if you disagree with a decision to deny a request for health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn’t pay for a drug, item, or service you think you should be able to receive.

Balance Billing — Occurs when a provider bills you for more than the amount allowed by the plan for covered services. In-network providers are prohibited from attempting to collect payment from you for covered services unless it is your co-payment or coinsurance. Only out-of-network providers may balance bill under the plan, and only certain types of out-of-network providers are allowed to balance bill under Original Medicare. (Only for plans with Point of Service. See the Evidence of Coverage.)

Benefit Period — For Original Medicare, a benefit period is used to determine coverage for inpatient stays in hospitals and skilled nursing facilities. A benefit period begins on the first day you go to a Medicare-covered inpatient hospital or a skilled nursing facility. The benefit period ends when you haven’t been an inpatient at any hospital or SNF for 60 days in a row. If you go to the hospital (or SNF) after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Benefit periods do not apply to inpatient hospitalization in our plan.

The type of care that is covered depends on whether you are considered an inpatient for hospital and SNF stays. You must be admitted to the hospital as an inpatient, not just under observation. You are an inpatient in a SNF only if your care in the SNF meets certain standards for skilled level of care. Specifically, in order to be an inpatient in a SNF, you must need daily skilled-nursing or skilled-rehabilitation care, or both.

Brand-Name Drug — A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand-name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.

Catastrophic Coverage Stage — The stage in the Part D Drug Benefit where you pay a low co-payment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,550 in covered drugs during the covered year.

Centers for Medicare & Medicaid Services (CMS) — The federal agency that runs Medicare.

Coinsurance — The percentage of the total of the total cost of a drug or service that you pay each time you fill a prescription or receive a service.

Comprehensive Outpatient Rehabilitation Facility — A facility that mainly provides rehabilitation services after an illness or injury, and provides a variety of services including physician’s services, physical therapy, social or psychological services, and outpatient rehabilitation.

Co-payment — A fixed amount you pay each time you fill a prescription or receive a service.

Cost-sharing — Cost-sharing refers to amounts that a member has to pay when drugs or services are received. It includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before drugs or services are covered; (2) any fixed co-payment amounts that a plan may require be paid when specific drugs or services are received; or (3) any coinsurance amount that must be paid as a percentage of the total amount paid for a drug or service.

Cost-Sharing Tier — Every drug on the list of covered drugs is in one of four cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug.

Coverage Determination — A decision about whether a medical service or drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the service or prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage if you disagree

Covered Drugs — The term we use to mean all of the prescription drugs covered by our plan.

Covered Services — The general term we use to mean all of the health care services and supplies that are covered by our plan.

Creditable Prescription Drug Coverage — Prescription drug coverage (for example, from an employer or union) that is expected to cover, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty if they decide to enroll in Medicare prescription drug coverage later.

Custodial Care — Care for personal needs rather than medically necessary needs. Custodial care is care that can be provided by people who don’t have professional skills or training. This care includes help with walking, dressing, bathing, eating, preparation of special diets, and taking medication. Medicare does not cover custodial care unless it is provided as other care you are getting in addition to daily skilled nursing care and/or skilled rehabilitation services.

Customer Service — A department within our plan responsible for answering your questions about your membership, benefits, grievances and appeals.

Deductible — The amount you must pay for the drugs you receive before our plan begins to pay its share of your covered medical services or drugs.

Disenroll or Disenrollment — The process of ending your membership in our plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).

Durable Medical Equipment — Certain medical equipment that is ordered by your doctor for use in the home. Examples are walkers, wheelchairs or hospital beds.

Emergency Care — Covered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.

Evidence of Coverage (EOC) and Disclosure Information — This document, along with your enrollment form and any other attachments, riders or other optional coverage selected, which explains your coverage, what we must do, your rights and what you have to do as a member of our plan.

Exception — A type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor’s formulary (a formulary exception), or get a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).

Generic Drug — A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredients as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

Grievance — A type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

Home Health Aide — A home health aide provides services that don’t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.

Initial Coverage Limit — The maximum limit of coverage under the initial coverage period.

Initial Coverage Stage — The maximum limit of coverage under the initial coverage period. The federal government sets this amount every year. For 2010, this amount is $2,830. However, read the Evidence of Coverage or Summary of Benefits for the amount for your plan.

Late Enrollment Penalty — An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that expects to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions.

List of Covered Drugs (Formulary) — A list of covered drugs provided by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand-name and generic drugs.

Low Income Subsidy/Extra Help — A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles and coinsurance.

Medically Necessary – Drugs, services, or supplies that are proper and needed for the diagnosis or treatment of your medical condition; are used for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local community; and are not mainly for your convenience or that of your doctor.

Medicare — The federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant).

Medicare Advantage (MA) Plan — Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A (Hospital) and Part B (Medical) benefits. A MA plan offers a specific set of health benefits at the same premium and level of cost-sharing to all people with Medicare who live in the service area covered by the plan. Medicare Advantage Organizations can offer one or more Medicare Advantage plan in the same service area. A Medicare Advantage plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan or a Medicare Medical Savings Account (MSA) plan. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare Health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).

Medicare-Covered Services — Health care services that are covered by the Original Medicare plan. These are Medicare Part A and Medicare Part B coverage. Part A is hospital insurance that helps pay for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Part B is medical insurance that helps pay for doctors' services, outpatient hospital care, and other medical services that are not covered by Part A.

Medicare Prescription Drug Coverage (Medicare Part D) — Insurance to help pay for outpatient prescription drugs, vaccines, biologicals and some supplies not covered by Medicare Part A or Part B.

Medigap (Medicare supplement insurance) — Medicare supplement insurance sold by private insurance companies to fill “gaps” in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage plan is not a Medigap policy.)

Member (member of our plan, or “plan member”) — A person with Medicare who is eligible to get covered services, who has enrolled in our plan and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).

Network — A group of doctors, hospitals, pharmacies and other health care experts who contract with a health plan to take care of its members.

Network Pharmacy — A network pharmacy is a pharmacy where members of our plan can get their prescription drug benefits. We call them “network pharmacies” because they contract with our plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

Network Provider — “Provider” is the general term we use for doctors, other health care professionals, hospitals and other health care facilities that are licensed or certified by Medicare and by the state to provide health care services. We call them “network providers” when they have an agreement with our plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our plan. Our plan pays network providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services. Network providers may also be referred to as “plan providers.”

Organization Determination — The Medicare Advantage organization has made an organization determination when it, or one of its providers, makes a decision about whether services are covered or how much you have to pay for covered services.

Original Medicare(“Traditional Medicare” or “Fee-for-service” Medicare) — The Original Medicare plan is offered by the government, and not a private health plan like Medicare Advantage plans and prescription drug plans. Under the Original Medicare plan, Medicare services are covered by paying doctors, hospitals and other health care providers’ payment amounts established by Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share.

Out-of-Network Provider or Out-of-Network Facility — A provider or facility with which we have not arranged to coordinate or provide covered services to members of our plan. Out-of-network providers are providers that are not employed, owned or operated by our plan or are not under contract to deliver covered services to you.

Out-of-Network Pharmacy — A pharmacy that doesn’t have a contract with our plan to coordinate or provide covered drugs to members of our plan. As explained in the Evidence of Coverage, most drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply.

Part C — see “Medicare Advantage (MA) Plan”

Part D — The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.)

Part D Drugs — Drugs that can be covered under Part D. We may or may not offer all Part D drugs. Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs.

Point of Service — The HMO with a Point-of-Service (POS) Option is an additional benefit that covers certain medically necessary services you may get from out-of-network providers. When you use your POS (out-of-network) benefit, you are responsible for more of the cost of care. Always talk to your Primary Care Physician (PCP) before seeking care from an out-of-network provider. Your PCP will notify us by requesting approval from the plan (“prior authorization”).

Primary Care Physician (PCP) — A health care professional you select to coordinate your health care. Your PCP is responsible for providing or authorizing covered services while you are a plan member.

Prior Authorization — Approval in advance to get services or certain drugs that may or may not be on our formulary. Some in-network medical services are covered only if your doctor or other network provider gets “prior authorization” from our plan. Some drugs are covered only if your doctor or other network provider gets “prior authorization” from us. Covered drugs that need prior authorization are marked in the formulary.

Quality Improvement Organization (QIO) — Groups of practicing doctors and other health care experts that are paid by the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by Medicare Providers.

Quantity Limits — A management tool that is designed to limit the use of selected drugs for quality, safety or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.

Rehabilitation Services — These services include physical therapy, speech and language therapy and occupational therapy.

Service Area — “Service area” is the geographic area approved by the Centers for Medicare & Medicaid Services (CMS) within which an eligible individual may enroll in a certain plan, and in the case of network plans, where a network must be available to provide services.

Step Therapy — A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.

Supplemental Security Income (SSI) — A monthly benefit paid by the Social Security Administration to people with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security benefits.

Urgently Needed Care — Urgently needed care is a non-emergency situation when you need medical care right away because of an illness, injury or condition that you did not expect or anticipate, but your health is not in serious danger. Because of the situation, it isn’t reasonable for you to obtain medical care from a network provider.

 

Questions & Answers

General
What's Covered
Costs
Part D Transition Policy
Prescription Drug Coverage


General
Q: What is a Medicare Advantage HMO plan?
A: A Medicare Advantage HMO plan is offered by a private company that contracts with Medicare to provide you with all your Medicare Part A (hospital) and Part B (medical) benefits. It is a health maintenance organization, or HMO. The means it provides care through a network of providers. Care is coordinated through the primary care physician (PCP), who may refer people to specialists as needed. Referrals are generally required to see specialists.

Q: What is a Medicare Advantage HMOPOS plan?
A: A Medicare Advantage HMOPOS also provides care through a network of providers. However, it includes a point of service (POS) feature, which allows members to receive health care services outside of the network with authorization, although use of providers within the network is encouraged.

Q: What is a network?
A: Network providers are the doctors and other health care professionals, medical groups, hospitals and other health care facilities that have an agreement with us to accept payment in full. We have arranged for these providers to deliver covered services to members in our plan. The providers in our network generally bill us directly for care they give you. When you see a network provider, you usually pay only your share of the cost for their services.

Q: Should I still keep my blue and white Medicare Card?
A: Yes. However, as long as you are a member of our plan you must not use your red, white and blue Medicare card to get covered medical services (with the exception of routine clinical research studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in case you need it later. Here’s why this is so important: If you get covered services using your red, white and blue Medicare card instead of using our membership card while you are a plan member, you may have to pay the full cost yourself. If your 'Ohana ID card is damaged, lost or stolen, contact us at 1-888-505-1201 (TTY users call 1-877-247-6272) right away and we will send you a new card.

Q: If I don't like my 'Ohana plan, can I go back to Original Medicare?
A: Of course. You don't lose your Medicare benefits when you join our plan. However, there are limits on when and how often you change your Medicare plan options. Contact us at 1-888-505-1201 (TTY users call 1-877-247-6272) to find out more.

Q: Can I make a plan change from one 'Ohana health plan to another?
A: Yes, Medicare beneficiaries can change plans between November 15th and December 31st for a 2010 effective date.  If you have Medicaid, you may change plans at any time.  There are other reasons that could allow you to change plans.  Please contact us for details at 1-866-907-7649 (TTY users call 1-877-247-6272).

Q: Can I enroll in a 'Ohana Medicare Plan?
A: Yes, you can enroll in our plans for a 2010 effective date if you have Medicare Part A and Medicare Part B, you live in the plan's service area, and meet any other eligibility requirements.  Please contact us for details at 1-866-907-7649 (TTY users call 1-877-247-6272).


Top of Questions & Answers
 

What's Covered

Q: Will I have the same coverage as I do with Original Medicare?
A: Our plans are in place of Original Medicare and some offer extra benefits such as dental, hearing, vision and prescription drug coverage. If you have questions about whether your plan will pay for specific services, please read the Summary of Benefits or Evidence of Coverage or contact us at 1-888-505-1201 (TTY users call 1-877-247-6272).
Q: Can I receive emergency care?
A: You have the right to emergency care, when needed, anywhere in the United States and without pre-approval from us. Please read the Evidence of Coverage or contact us at 1-888-505-1201 (TTY users call 1-877-247-6272) for details.

Q: Do HMO or HMOPOS plans cover services that Medicare does not consider medically necessary?
A: An HMO or HMOPOS plan is not required to pay for services that are not medically necessary under Medicare. However, 'Ohana plans do pay for additional benefits not covered by Original Medicare. If you receive a service that is not covered by a plan, you are responsible for the cost of that service. If you are not sure whether a service is covered, you have the right to call us and ask for an advance decision.

Q: What do I need to do to get care?
A: Our plans work just like traditional health insurance. Just show your 'Ohana Member ID card (instead of your Medicare card) at the doctor's office. You may have a co-payment due at that time. That's it.

Q: What happens if my doctor is not familiar with 'Ohana Plans?
A: If your doctor or health care provider would like more information about 'Ohana, ask them to contact us at 1-888-505-1201 (TTY users call 1-877-247-6272). Our Customer Service representatives are ready to answer questions.

Q: Can 'Ohana ever drop my coverage?
A: Once you're enrolled, you cannot be disqualified for any medical condition. However, if you move out of our service area or commit fraud, 'Ohana reserves the right to disenroll you. Please read the Evidence of Coverage for complete details.

All Medicare Advantage plans commit to the program for a full year. Each year, 'Ohana decides whether to continue a plan for another year. Even if a Medicare Advantage Plan is discontinued, you will not lose Medicare coverage. If a plan is discontinued, 'Ohana must notify you in writing at least 60 days before your coverage ends. The letter will explain your options for Medicare coverage in your area.

Top of Questions & Answers
 

Costs

Q: Do I still have to pay my Medicare Part B premium?
A: Yes. When you join a 'Ohana plan, you must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. If you meet certain eligibility requirements for both Medicare and Medicaid, your Part B premiums may be covered in full.

Top of Questions & Answers
 

Part D Transition Policy

Q: One of the prescriptions I usually take isn't on the 'Ohana formulary. What should I do?
A: Read our 2010 Transition Policy.

Top of Questions & Answers
 

Prescription Drug Coverage

Q: What if I have to pay cash for my prescription because I do not have my 'Ohana insurance card?
A: You will need to request a reimbursement from 'Ohana by completing a reimbursement form and mailing it back to us form. Please make sure that you keep a copy of the form and the receipts for your records.

Q: How will I know if 'Ohana is going to pay me for the prescriptions when I did not have my 'Ohana insurance card?
A: We will send you a letter that informs you of our decision concerning the request for payment of your prescriptions. You should expect to receive this letter within 7 to 10 business days.

Q: What if I mailed my request for 'Ohana to pay for my prescriptions, but I have not received any information?
A: Please contact us at 1-888-505-1201 (TTY users call 1-877-247-6272). We will provide you information including whether or not we received your request.

Q: What prescriptions are covered by 'Ohana?
A: Read the full list of our covered prescription drugs (also called a formulary).

For information on Excluded Drugs, please click here to access the Evidence of Coverage. It is likely that we cover your drug or have an alternative for you. When you call, the pharmacy representative may also suggest a preferred brand or generic equivalent of your prescription. By using these, you may save money. If your doctor feels that you need to take a certain brand-name prescription drug, we have a review process in place that may allow you to do this. Need time to consult your doctor? Read our Transition Policy.

Q: Can I use my 'Ohana card at a lot of different pharmacies?
A: You may use your 'Ohana card at any pharmacy in our network. Find a pharmacy.

Q: Can I get prescriptions through the mail with 'Ohana?
A: Yes. Learn more.

Q: I'd like to get 93-day refills of my drugs. Is that possible?
A: Of course. If you do not qualify for extra help, the cost for a 93-day supply is three times the cost of a 31-day supply at pharmacies contracted to dispense a 93-day supply. To find out if your pharmacy is contracted to dispense a 93-day supply, please contact us at 1-888-505-1201 (TTY users call 1-877-247-6272).

Q: Can I get drugs from another country through 'Ohana?
A: No. Please read the Evidence of Coverage for more information.

Q: Can your plan refuse me coverage if I take a lot of prescriptions?
A: As long as you are eligible, our plan cannot refuse to offer you coverage. You should also consider using generic drugs, which may be less expensive than brand drugs.

Q: What if I don't understand something on this site?
A: At 'Ohana, we're committed to making this program truly easy. Just contact us at 1-888-505-1201 (TTY users call 1-877-247-6272). We'll take as much time as you need to answer any questions you have.

Q: I get some of my prescriptions through Medicare Part B. Now what?
A: You'll continue to receive them through Part B. Prescriptions received as part of a physician's services or because of surgery (as well as certain prescription drugs) are covered through Part B. Please contact us at 1-888-505-1201 (TTY users call 1-877-247-6272) if you need more information.

Q: What if I'm on a limited income or cannot afford Part D drugs?
A: You may qualify for extra help from the government—and if you're eligible, this assistance could really reduce the cost of your premiums and/or co-pays. Learn more.

Q: I was at the pharmacy and was told I do not have coverage. What should I do?
A: Please contact us at 1-888-505-1201 (TTY users call 1-877-247-6272).

Top of Questions & Answers

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