Medicare HMO FAQ
These questions and answers summarize some of the plan’s highlights. For a complete description of your benefits, please refer to the appropriate Plan Summary document in the Resource Library. If there are any differences between this information and the plan documents, the plan documents will govern.
What is a Medicare Advantage Plan?
A Medicare Advantage plan is an HMO that accepts your Medicare benefits as payment. Stanford offers two Medicare Advantage plans: Health Net Seniority Plus, Kaiser Permanente Senior Advantage.
With a Medicare Advantage plan, you enroll in an HMO and then assign (sign-over) your Medicare benefits to that HMO. It works like any other HMO. You must go to your HMO provider whenever you need care. Your only out-of-pocket costs are your copayments for services that you receive. There are no claim forms, and the HMO coordinates with Medicare for you.
Do I need to sign up for Medicare Parts A and B to enroll in a Medicare Advantage plan?
Yes. You must be enrolled in both Medicare Parts A and B.
When do I need to sign up for Medicare parts A and B?
To get information about signing up for Medicare Parts A and B, contact Social Security Administration at http://www.ssa.gov or (800) 772-1213 at least three months before turning age 65 or within three month before you retire.
Do I need to sign up for Medicare Part D?
Part D is Medicare’s prescription drug program. You do not need to sign-up for Medicare Part D because all of Stanford medical plans provide prescription drug coverage as part of the plan.
If I enroll in a Medicare Advantage Plan, do I need to fill out any special forms?
Yes. Call the University HR Service Team at (877) 905-2985 to get a Medicare Advantage Enrollment Form. The form will be mailed to you or you may print the form, and then you must complete and return it to the address on the form by the 10th day of the month before your retirement date.
Your retiree medical coverage will begin the first day of the month following your retirement date. Example: You retire July 31 and want your retiree medical coverage to start August 1. Your enrollment forms must be received by Stanford Benefits no later than July 10.
What happens if I don't complete my Medicare Advantage form on time?
Your enrollment in the Medicare Advantage plan will be delayed and you may need to find a personal policy, or elect COBRA coverage, until your Medicare Advantage enrollment is processed and your coverage starts. Your coverage start date depends on the date Stanford Benefits receives your completed enrollment form.
If the enrollment forms are received by the 10th day of a month, your retiree medical coverage will begin the first day of the month following your retirement date.
If your enrollment forms are received after the 10th of a month, the effective date of your retiree medical coverage will be delayed. Your forms must be received by the 10th of a month in order for coverage to be in place by the first of the following month.
How do I change from a Medicare Advantage Plan to a Medicare Supplement Plan?
You and any dependent enrolled in the Medicare Advantage plan each have to complete a Disenrollment Form to leave a Medicare Advantage plan and move to a Medicare Supplement plan.
When you enroll in a Medicare Advantage HMO plan you assign (sign-over) your Medicare benefits to the HMO. When you change to a Medicare Supplement plan, you must notify the HMO plan and Medicare to release your Medicare benefits back to you. Stanford Benefits is available to help you to make this enrollment change. However, the form is also available in Resources.
What is a primary care physician?
A primary care physician (PCP) is a doctor you choose to manage all your health care. Your PCP provides preventive and routine care and refers you to specialists and hospitals when needed. A PCP can be an internist, a family or general practitioner or pediatrician for a child. You choose your PCP from the network of doctors in your medical plan.
Do I have to choose a PCP?
You must choose a PCP in the Health Net HMO plan. If you do not select a PCP, one will be assigned for you. If you enroll in the Kaiser Permanente plan you are not required to choose a PCP.
Can I change my PCP?
Yes. To change your PCP, call your HMO’s member service number on your medical ID card.
Can each member of my family go to a different PCP?
Yes. You and your dependents can have different PCPs. When you get your medical plan identification card in the mail, be sure it identifies the PCP you selected. If you have been assigned a PCP, check with your HMO’s member services to make sure the provider is a good match for you. If you want to change, member services can help with that too.
Do I have to get a referral from my PCP to get an annual OB/GYN exam?
No. As long as the gynecologist is part of your PCP’s medical group, you can refer yourself.
What happens if I get care outside my HMO network without my PCP's referral?
The HMO pays nothing toward the cost of care unless it is considered an out-of-area medical emergency.
Do the HMO Plans cover emergencies?
Yes. The HMO plans cover emergency care for injury or illness worldwide as long as you (or a family member, friend or representative) contacts the HMO within 48 hours of receiving emergency care.
Important: There is no coverage for non-emergency treatment or routine care you receive out of your HMO network.
If you have questions about emergency care or getting care when you travel, call your HMO’s customer service number located on your medical ID card.
Do the HMO Plans offer preventive care benefits?
Yes. The HMO plans cover routine physicals every year for adults and children, plus annual well-woman exams. To compare the medical plans’ preventive care benefits, look at the comparison chart.
Do the HMO plans cover vision care?
Stanford’s HMO plans cover routine eye exams and medically necessary treatment of your eyes, such as surgery. Additional eyewear benefits or discounts may be available. Contact your medical plan’s customer service center using the phone number on your medical ID card.
What is coordination of benefits?
Coordination of benefits helps prevent duplication of payments for the same services when you or your dependents are covered under more than one medical plan. For additional information, see your HMO’s Plan Summary, located in Resources, or call your HMO’s member services number located on your medical ID card.
Are there any pre-existing conditions exclusions?
No. There are no pre-existing condition limits or exclusions in any Stanford medical plans.
How are prescription drugs covered?
Your prescription drug coverage is part of your HMO plan. The cost of your medication depends on whether or not it can be dispensed as a generic or brand name, or if it is included in the plan’s formulary.
What is a formulary?
A formulary is a list of approved prescription drugs covered by the HMO plan. The formulary for Health Net has three tiers: generic, brand name and non-formulary. This means your medication will generally be available to you, although the copayment depends on the tier to which the drug belongs. Generic drugs are the least expensive, and non-formulary drugs are the most expensive.
Kaiser’s formulary has two tiers: generic and brand name.
To find out if a particular medication is on your HMO’s formulary, go to your HMO’s website or call the member services number located on your medical ID card.