Medicare Supplement 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 Resources. If there are any differences between this information and the plan documents, the plan documents will govern.
WHAT IS A MEDICARE SUPPLEMENT PLAN?
A Medicare Supplement plan pays benefits for services after Medicare pays their portion.
WHICH MEDICARE SUPPLEMENT PLANS ARE AVAILABLE?
Stanford offers two Medicare Supplement plans:
- Blue Shield Retiree Plan, available worldwide
- Health Net Medicare COB plan, available if you live within HealthNet’s HMO service area
WHAT IS THE DIFFERENCE BETWEEN THE MEDICARE COB PLAN AND THE OTHER SUPPLEMENT PLAN?
A Medicare COB plan (our Health Net COB plan) works like an HMO; you must receive care from your PCP or within your PCP’s medical group. If you receive care outside your assigned medical group, your benefits will be limited to services covered under Medicare only and must be provided by a doctor who accepts payment from Medicare.
Medicare Supplement plans work like a PPO; you can seek services from any licensed provider. However, if your doctor is in your medical plan’s network and accepts payment from Medicare, your costs will be lower.
DO I NEED TO SIGN UP FOR MEDICARE PART A AND B TO ENROLL IN ANY OF THESE OPTIONS?
Yes. You must be enrolled in both Medicare Part A and B to enroll in any of the options.
WHEN DO I NEED TO SIGN UP FOR MEDICARE PART A AND B?
To get information about signing up for Medicare Part A and B, contact the Social Security Administration at http://www.ssa.gov or (800) 772-1213 approximately three months before age 65 or within three months 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 Part D because all Stanford medical plans provide prescription drug coverage as part of the plan.
IF I ENROLL IN ONE OF THESE PLANS, DO I NEED TO FILL OUT ANY SPECIAL FORMS?
You do not need to fill out any forms unless you and/or your dependents are changing to a Medicare Supplement plan from a Medicare Advantage plan. If this is the case, then each family member must complete a Medicare Advantage Disenrollment Form. Call the University HR Service Team at (877) 905-2985 to get a Disenrollment Form(s). If you do not complete the Disenrollment Form on time, your Medicare stays assigned to the Medicare Advantage Plan until the following month.
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, as needed. A PCP can be an internist, a family or general practitioner, or a pediatrician for your child. You choose your PCP from the network of doctors in your health plan.
DO I HAVE TO CHOOSE A PCP?
You only need to choose a PCP if you select the Health Net COB Plan. If you do not select a PCP, one will be assigned to you. You are not required to choose a PCP if you choose the Blue Shield Retiree Plan.
DO I HAVE TO SEE A PCP TO GET A REFERRAL TO A SPECIALIST?
If you are enrolled in the Health Net COB plan, your PCP must refer you to a specialist. If you seek care outside the Health Net HMO network, your benefits will be limited to services covered under Medicare and must be provided by a doctor who accepts payment from Medicare.
If you are enrolled in the Blue Shield Retiree Plan, you may refer yourself to a specialist. However, your costs will be lower if you choose a specialist in your plan’s network of providers.
DO I HAVE TO FILE A CLAIM EACH TIME I SEE THE DOCTOR?
You may be responsible for submitting claims to your plan if you do not have Medicare Crossover Billing. You must establish Medicare Crossover Billing with your medical plan. Keep reading for more information.
WHAT IS MEDICARE CROSSOVER BILLING?
When you set up Medicare Crossover Billing, your medical provider automatically sends claims to Medicare. After Medicare processes the claim, notification is sent to your medical plan so your plan can pay their share of the charges. This free, convenient service reduces your claims paperwork.
If you do not set up Crossover Billing, you must wait until Medicare pays its benefits and you receive your Explanation of Medicare Benefits. Then, you have to submit a copy of it along with a claim form to your medical plan. This process creates more work for you and may result in a delay receiving full reimbursement.
HOW DO I SET UP MEDICARE CROSSOVER BILLING?
To set up Medicare Crossover Billing you must call your medical plan’s member services number on your medical ID card. They will ask for your 11-digit alphanumeric Member Beneficiary Identifier (MBI) located on your Medicare card and the effective date of your Medicare Part A and Part B coverage. Note: Health Net does not offer Medicare Crossover Billing outside of California.
HOW DO I FIND OUT IF THE PROVIDER I’M SEEING IS IN MY MEDICAL PLAN’S NETWORK?
You can call your doctor’s office and ask if they are part of the plan’s network, or view the medical plan’s provider directory on their Web site. See Contacts.
IS THERE ANY PENALTY IF I SEE A DOCTOR OUTSIDE THE PLAN’S NETWORK?
You may be responsible for additional costs not covered by your medical plan. Since a non-network provider has not agreed to any discounts with your medical plan you pay any charges not covered by your plan. Your non-network provider will normally bill you for these charges (also called “balance billing”).
When you see a network provider, there is no balance billing and your out-of-pocket costs are generally lower and more predictable.
ARE THERE ANY PRE-EXISTING CONDITIONS EXCLUSIONS?
No. There are no pre-existing condition limits in any of Stanford University’s medical plans.
HOW ARE PRESCRIPTION DRUGS COVERED?
Your prescription drugs are covered by your medical plan. The cost of your medication depends on whether or not it can be dispensed in a generic form or if it is included in the medical plan’s formulary.
WHAT IS A FORMULARY?
A formulary is a list of approved prescription drugs covered by the plan. The formularies for Blue Shield and Health Net have three tiers: generic, brand name, and non-formulary. This means your medication will generally be available to you, although the copayment depends on what tier it falls into – generic being the least expensive and non-formulary the most expensive.
To find out if a particular medication is on your plan’s formulary, go to your plan’s Web site or call their member services number on your medical ID card.
WHAT ARE THE PRESCRIPTION DRUG COPAYMENTS?
Compare medical plans for more information on your out-pocket costs. You can also review your plan’s Plan Summary, located in Resources.
DO ALL THE PLANS COVER EMERGENCIES?
Yes. The plans cover emergency care for injury or illness worldwide as long as you (or a family member, friend or representative) contacts the plan within 48 hours of receiving emergency care.
DO ALL THE PLANS OFFER A PREVENTIVE CARE BENEFIT?
Yes. The plans cover routine physicals every year for adults and children, plus annual well-woman exams. Look at the comparison chart to compare medical plans. You can also refer to the Plan Summaries, located in Resources, or contact for the plan directly to ask your questions.
DO ALL THE PLANS COVER VISION OR HEARING CARE?
Stanford plans cover routine eye exams and medically necessary treatment of your eyes, such as surgery. Your plan may have limited hearing benefits. For specific information, call your plan’s member services number listed on your medical ID card.
WILL THESE PLANS COVER MEDICARE’S DEDUCTIBLE AND COINSURANCE?
Each plan covers the Medicare deductibles and coinsurance for Medicare-approved services. However, you may be responsible for a copayment after Medicare and your medical plan pay their share. We recommend you wait until you receive your plan’s Explanation of Benefits (EOB) that will show your share of the cost.
HOW CAN I FIND OUT IN ADVANCE IF MY PROPOSED MEDICAL SERVICES WILL BE COVERED?
Refer to your plan’s Plan Summary and the Medical Plan Comparison Chart as a guide to what may be covered. Do not assume this is a guarantee that any particular medical treatment or service would be covered. Medical coverage is based on medical necessity as it applies to the diagnosis given. You can also call your plan’s member services number listed on your medical ID card.
WHAT IF I NEED MEDICAL CARE OUTSIDE OF CALIFORNIA OR THE UNITED STATES?
In the Blue Shield Retiree plan, you and your enrolled dependents have coverage worldwide.
If you are enrolled in the Health Net COB plan, you and your enrolled dependents must receive all of your care from your PCP. If you access services outside of your PCP’s medical group, your benefits will be limited to services covered under Medicare and must be provided by a doctor who accepts Medicare assignment. Only emergency care is covered outside Health Net’s service area.