If you've got Medicare questions, you're not alone. We receive questions from people all the time. People just like you who want to make the best, most informed decision possible. Here are some of the most commonly asked questions and our answers.
Medicare Advantage plans are offered through private insurance companies, like SummaCare. They are designed for those who are eligible for Medicare and they offer more coverage and lower out-of-pocket costs than Original Medicare. Most Medicare Advantage plans include Part D prescription drug coverage and extra benefits not offered by Original Medicare.
These types of plans offer coverage for Part D prescription drugs only. To enroll in this type of plan you must physically enroll by contacting a plan and completing the appropriate paperwork. You cannot or will not be automatically enrolled in this type of plan once you become eligible for Medicare.
An HMO plan typically only covers in-network benefits. To receive in-network benefits, you must seek care exclusively from providers in your network. With an HMO plan, you will be responsible for paying the cost of all care that is provided by non-network/out-of-network providers unless the care you receive from the non-network/out-of-network providers is pre-authorized or is for emergency or urgent care services.
An HMO-POS is similar to an HMO plan but allows you the flexibility to seek care from any Medicare-approved provider, though your out-of-pocket costs may be higher if you see providers outside of your network.
To view a list of your covered benefits and services, refer to your plan materials. These materials include items such as a Schedule of Benefits (SOB) or Evidence of Coverage (EOC.)
No, SummaCare members are not limited to Summa Health providers. SummaCare Medicare members with HMO plans can choose from thousands of doctors within the SummaCare SCMedicare network. SummaCare Medicare members with HMO-POS plans can see any doctor that accepts Medicare. Find out if your doctor is covered.
An HMO plan typically only covers in-network benefits. To receive in-network benefits, you must seek care exclusively from providers in your network. With an HMO plan, you will be responsible for paying the cost of all care that is provided by non-network/out-of-network providers unless the care you receive from the non-network/out-of-network providers is pre-authorized or is for emergency or urgent care services. An HMO-POS is similar to an HMO plan but allows you the flexibility to seek care from any Medicare-approved provider, though your out-of-pocket costs may be higher if you see providers outside of your network
The federal government contracts with private insurance companies to administer Medicare Advantage plans. They give us a per member per month amount of dollars to help us pay for your healthcare costs and also then allows the MAPD to provide all of the additional benefits like OTC, vision, dental, free gym membership, etc. Medicare beneficiaries have paid into all these benefits by paying taxes (FICA, Medicare tax, Social security, federal, etc.) during their working years.
If you are turning 65, you can apply for coverage beginning 3 months before your 65th birthday, the month of your 65th birthday and 3 months after your 65th birthday. If you are disabled, you can contact us for more information.
You may also be eligible to apply if you meet criteria for a Special Enrollment Period for individuals who, for example, have recently moved to our service area or recently qualify for Medicare. If you have questions about the Special Enrollment Period, you can contact us for more information.
There are four parts to Original Medicare.
Part A: This covers hospital bills for inpatient stays as well as things like home healthcare, hospice or nursing care. There usually is not a premium associated with Part A.
Part B: This covers doctor, outpatient hospital, diagnostic tests, ambulance, durable medical equipment and other home health care services that are not covered under Part A. There is a premium for Part B and this premium changes every year. Typically this premium is automatically deducted from your Social Security check.
Part C: This is for those who are enrolled in a Medicare Advantage Plan.
Part D: This is the voluntary prescription drug benefit program that went into effect in 2006. Part D gives all Medicare beneficiaries the option to purchase prescription drug coverage from the company of their choice. When you become 65 and you do not enroll in any other type of plan, you will have Original Medicare coverage. Original Medicare coverage by itself does not include prescription drug coverage.
All SummaCare Medicare Advantage Prescription Drug plans offer extra benefits not covered by Original Medicare. These include Part D prescription drug coverage, as well as dental, vision, hearing aid coverage, a quarterly allowance for non-prescription over-the-counter health related items and acupuncture services. In addition, a FREE gym membership is available with all plans. There are a number of other supplementary benefits that you don’t get with Original Medicare.
Absolutely not. You keep your Medicare card. It’s just that we administer the benefits and offer you additional benefits as well. So, you’ll use a SummaCare identification card when you visit your physician or require treatment. But keep your Medicare card in case you cancel your SummaCare membership.
Our contract with Medicare allows us to serve you only as long as you live in Allen, Ashland, Ashtabula, Auglaize, Carroll, Columbiana, Cuyahoga, Defiance, Fulton, Geauga, Hancock, Henry, Holmes, Huron, Lake, Lorain, Lucas, Mahoning, Medina, Mercer, Ottawa, Portage, Putnam, Seneca, Stark, Summit, Trumbull, Tuscarawas, Van Wert, Wayne and Wood counties in Ohio. If you move away from this area, or leave for more than six consecutive months, you must tell us in writing so we can disenroll you. At that point, you become covered under Original Medicare or you can enroll in another Medicare Advantage Plan or Medicare Advantage Prescription Drug Plan because you will be eligible for a Special Enrollment Period (SEP).
Yes, at any time. Simply complete the online form or call a Customer Service representative so we can help you change physicians and make the change to your records. Usually this change will be effective within 14 days from the time you call. We will notify you when this change is effective and you will receive a new SummaCare identification card with your new Primary Care Physician’s information included.
If you choose to enroll in SummaCare, your coverage from your current Medicare Advantage Plan will automatically be terminated. You can only belong to one Medicare Advantage Plan at a time. Keep in mind that there are only certain times during the year when you can change plans.
You may switch back to Original Medicare during the Medicare Open Enrollment Period (OEP) which runs from January 1 through March 31 of each year. After March 31, in most cases, you will have to wait until the Medicare Annual Enrollment Period (AEP), which runs from October 15 through December 7 of each year, to make this switch.
No. We will be there for you whether you’re healthy or sick. We will not disenroll you due to illness, no matter how severe.
SummaCare Medicare Advantage plans cover everything Original Medicare covers and more. Most of our plans also include Medicare (Part D) prescription drugs.
SummaCare makes it easy for you to find a doctor or hospital in our network. You can:
If you cannot find your current doctor(s) in our provider listing, please call us first. Because provider listings may change daily, our representatives can review the most current information.
No; however, we recommend you first seek care through your Primary Care Physician (PCP) to identify the most appropriate course of treatment and to determine the most appropriate specialist to provide the specialty care needed. Note: Pre-approval from SummaCare is needed before seeing a surgeon for back pain.
If you’re traveling outside of the service area, all SummaCare Medicare Advantage plans offer coverage anywhere in the country for emergency, urgent care and ambulance services and up to $25,000 per year for emergency services outside the continental United States. If you enroll in a SummaCare Medicare Sapphire (HMO-POS) plan or SummaCare Medicare Emerald (HMO-POS) plan, you can receive care from any Medicare-approved provider even if they are not in the SCMedicare network. Please note that your out-of-pocket costs may be higher if you select providers outside of our network.
If you have to fill a prescription while outside of SummaCare’s service area, we will cover your prescriptions at in-network pharmacies under the applicable co-payment amount while you travel. Our pharmacy network includes most national chains. If traveling, your out-of-pocket costs may be higher if you fill a prescription at an out-of-network pharmacy. To search for a pharmacy, use the Find Your Pharmacy tool. All SummaCare Medicare Advantage plans include Visitor/Travel Coverage. Please refer to the Summary of Benefits documents for more information.
SummaCare partners with MedImpact Direct, allowing your routine prescription drugs to be delivered to your home. This program is designed to ensure satisfaction and provide the convenience of home delivery.
You can search for practitioners who participate in the SummaCare network by using our online tool.
Find a primary care physician by using our online tool. You can search for a primary care physician by selecting "Family Medicine (PCP)," "General Practice (PCP)," "Internal Medicine (PCP)," or "Pediatrics (PCP)."
SummaCare partners with MedImpact Direct, allowing your routine prescription drugs to be delivered to your home. This program is designed to ensure satisfaction and provide the convenience of home delivery.
While some vaccines are covered under Part B medical coverage, Medicare Part D covers vaccines not covered by Part B (medical), as long as the vaccine is reasonable and necessary to prevent illness. Some examples of Part D-covered vaccines include Zostavax (Shingles) vaccine, Tetanus vaccine, and MMR (measles, mumps, rubella) vaccine.
If you’re in a Medicare drug plan and you have complex health needs, you may qualify to participate in a Medication Therapy Management Program, or MTM. MTM is a clinical program that provides education and information about your medications. It is designed to ensure that covered Part D drugs prescribed to targeted members are appropriately used to optimize therapeutic outcomes through improved medication use and to reduce the risk of adverse events, including adverse drug interactions. MTM is a service offered by SummaCare, through OutcomesMTM, at no additional cost to you! The MTM program is required by the Centers for Medicare and Medicaid Services (CMS).
Our plan groups each medication into one of six “tiers.” You will need to use SummaCare’s Medicare formulary (list of covered drugs) to locate what tier your drug is in to determine how much it will cost you. The amount you pay depends on the drug’s tier and what stage of the benefit you have reached.
The Medicare Annual Enrollment Period (AEP) begins October 15 and runs through December 7. During this time, you can select a plan for the next calendar year.
Your Initial Enrollment Period (IEP) occurs when you are newly eligible for Medicare. During this time, you can sign up for a Medicare Advantage plan. This enrollment period is different for everyone and is dependent on your current situation. Call SummaCare today to discuss the many circumstances that might place you in your Initial Enrollment Period or a Special Enrollment Period.
You can enroll if you are entitled to Medicare Part A and are enrolled in Medicare Part B. You must also reside in a county located within our service area.
31 counties in Ohio: Ashland, Ashtabula, Auglaize, Carroll, Columbiana, Cuyahoga, Defiance, Fulton, Geauga, Hancock, Henry, Holmes, Huron, Lake, Lorain, Lucas, Mahoning, Medina, Mercer, Ottawa, Portage, Putnam, Seneca, Stark, Summit, Trumbull, Tuscarawas, Van Wert, Wayne and Wood
If you are turning 65, you can apply for coverage beginning 3 months before your 65th birthday, the month of your 65th birthday and 3 months after your 65th birthday. If you are disabled, you can contact us for more information. You may also be eligible to apply if you meet criteria for a Special Enrollment Period for individuals who, for example, have recently moved to our service area or recently qualify for Medicare. If you have questions about the Special Enrollment Period, you can contact us for more information
During the Special Enrollment Period (SEP), you can make changes to your coverage if certain events happen in your life. For instance:
Call us, enroll online or mail us your paperwork.
After you’ve enrolled in a SummaCare Medicare Advantage plan, here’s what you can expect:
HMO stands for Health Maintenance Organization. It is a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency.
Absolutely not. You keep your Medicare card. It's just that we administer the benefits and offer you additional benefits as well. So, you'll use a SummaCare identification card when you visit your physician or require treatment. But keep your Medicare card in case you cancel your SummaCare membership.
All SummaCare Medicare Advantage Prescription Drug plans offer extra benefits not covered by Original Medicare. These include Part D prescription drug coverage, as well as dental, vision, hearing aid coverage, a quarterly allowance for non-prescription over-the-counter health related items and acupuncture services. In addition, a FREE gym membership is available with all plans. There are a number of other supplementary benefits that you don't get with Original Medicare.