Preferred Care Gold
Questions and Answers
Click on a question below to "jump" to the answer!
1. What do you get with Preferred Care Gold?
- The choice of Medicare prescription drug coverage, with no deductible for generic drugs.
- The choice of more than 4,500 local physicians and health care professionals.
- Worldwide coverage for urgent and emergency care.
- Coverage for routine dental care*.
- Coverage for eye exams, physicals and preventive care, doctor visits and lab tests.
- NEW for 2008 — a Nurse Advice Line for after-hours help, seven days a week.
- Free health, exercise and wellness programs to help you improve your life.
- Free SilverSneakers® Fitness Program fitness center membership benefits.
- Coverage for routine care anywhere in the U.S. with our travel benefit.
- $50 in HealthDollarssm to use toward health, wellness, and fitness programs, such as therapeutic massage, yoga classes, bowling or golf lessons, [even Meals on Wheels!*]
- Allowances to help with the costs of hearing aids and eye wear*.
- Virtually no paperwork!
* Any unused portion of the dental benefit, HealthDollars benefit or eye wear benefit cannot carry over from one calendar year to the next.
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2. How do you join Preferred Care Gold?
You may join Preferred Care Gold:
March 31.
- When you move into the Preferred Care Gold service area from somewhere else
and are losing your former Medicare health plan.
- If you have lost your employer-sponsored Medicare health plan coverage.
- If you are eligible for both Medicaid and Medicare.
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3. How do you sign up for Medicare Part D drug coverage?
Preferred Care Gold also offers Medicare prescription drug coverage (Part D). If you wish to join our Gold plan and you also want prescription drug coverage, you must select Medicare prescription drug coverage from Preferred Care.
Note: If you do not join a Medicare prescription drug plan when you first become eligible, you may have to pay a penalty if you join at a later date. The penalty can be 1% of the current premium for every month you delay enrollment for as long as you are enrolled in Part D coverage.
- You may enroll during the annual election period for Part D sign-up, from Nov. 15 through Dec. 31.
- If you are eligible for New York State’s EPIC (Elderly Pharmaceutical Insurance Coverage) program, you may be eligible to join Part D after December 31. To find out if you qualify, call EPIC at (800) 332-3742.
- If you are eligible to receive extra help with prescriptions (called Low Income Subsidy). To find out if you qualify, call the Social Security Administration Office at (800) 772-1213. TTY users may call (800) 325-0778. Or call the New York State Health Insurance Information, Counseling and Assistance Program at (800) 333-4114.
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4. What happens once you join our Gold plan?
- Joining Preferred Care Gold will automatically disenroll you out of any other Medicare managed care plan in which you may currently be a member.
- We will tell Medicare that you have joined our plan. Preferred Care Gold takes the place of Medicare. Keep your Medicare card for your records.
- All of your medical care should be provided by our health care professionals in our network.
- If you sign up for Medicare prescription drug coverage (Part D) with Preferred Care Gold, you will receive your Medicare prescription drug benefit through Preferred Care Gold. If you also have prescription drug coverage through the state’s EPIC program or a VA program, that coverage may continue as well.
- Emergency and post-stabilization services (follow-up care after a hospitalization or surgery), urgent care services, and dialysis are covered when you are outside of the service area, the same as when you are at home.
- If you obtain routine care from a health care professional who practices in the Preferred Care Gold service area but is not part of Preferred Care’s network of Medicare Advantage health care professionals, neither Preferred Care Gold nor Medicare will be responsible for the costs. Routine care includes foreseen services or care that you may need while traveling, such as allergy shots or physical therapy that you know you will need while you’re away from home.
- The cost of routine care from out-of-network health care professionals outside of Preferred Care’s service area will be covered 70% up to $3,000 annually, anywhere in the United States.
Preferred Care will not refuse coverage based on your current health status or anticipated use of health care services unless you have end-stage renal disease. If you have end-stage renal disease, current federal law does not allow you to join Preferred Care Gold unless you are already a Preferred Care member or have had a successful kidney transplant.
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5. What about our network of doctors and hospitals?
You may choose from Preferred Care’s network of more than 4,500 doctors and health care professionals, and all the hospitals in our service area. Our network of health care professionals includes physicians, nurse practitioners, therapists, and other health care professionals. They have agreed to provide your care and follow specific quality of care practices.
The Primary Care Physician (PCP) you choose:
- Understands your medical history and what is normal for you.
- Coordinates all of your medical care.
- Will refer you to a specialist when needed and will arrange for follow-up care after a hospitalization or surgery, even if you are out of the service area.
You can feel confident in the health care professionals in the Preferred Care Gold network. Each physician has been initially screened and is reviewed at least every three years for:
- New York State licensure
- Basic educational credentials, including Continuing Medical Education credits
- Malpractice insurance and malpractice claims (if any)
- Legal actions in any state
- Current drug enforcement agency license
- Sanctioning by CMS (the Centers for Medicare & Medicaid Services)
If you need a medical service not available within our network, you will be referred to another physician or hospital for your medically necessary care. For example, members needing certain types of organ transplants are referred to a Medicare-approved transplant center. Preferred Care Gold covers this medically necessary care.
In an emergency, you may seek treatment at the nearest hospital, regardless of the hospital’s location.
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6. How do we help you stay healthy and independent?
We believe that investing in your wellbeing now is preventive medicine for a better future, AND helps keep health care costs down. That’s why we offer the following health and wellness programs and services free to you:
NEW for 2008! 24-hour Preferred Care Nurse Advice Line
Get answers to your health questions any time with this new service from Preferred Care. We provide a nurse you can talk to after hours when your doctor’s office is closed. We’re just a phone call away, seven days a week, for:
- Help with a health problem in the middle of the night.
- Answers to “what do I do if” health questions.
- Finding information and resources about prevention and wellness, treatments, chronic conditions, and other health topics and concerns.
The Nurse Advice Line also features an audio library of more than 400 pre-recorded messages on general health topics. Get the knowledge and resources you need to make an informed health decision!
Preferred Care Wellness Center
Our Wellness Center in downtown Rochester offers a variety of programs and support services to help you take on life and live well. Improve or maintain your health and independence through classes and programs on:
- Exercise and fitness for all levels of ability
- Managing chronic health challenges (diabetes, kidney and heart disease, and more)
- Managing your weight and healthy eating
- Grief support
- Improving your memory
- Preventing falls and improving balance
- Fun seasonal activities, from cycling to gardening
The SilverSneakers® Fitness Program
Enjoy free fitness center membership benefits through the SilverSneakers Fitness Program. Join a participating fitness center in your neighborhood and take advantage of classes specially designed to help older adults keep fit, well and independent. SilverSneakers instructors tailor exercises to your ability level and help you monitor your progress. You have full use of the fitness center’s equipment and other amenities included in a basic membership, all for free!
HealthDollarssm
All Preferred Care Gold members receive $50 in HealthDollars to use toward a variety of health, wellness, or fitness classes or programs. Interested in therapeutic massage or a yoga class? Want to join a bowling league or take golf lessons? The choice is yours.
Medicine Bag Review
Preferred Care, together with Wegmans Pharmacy, offers this free program, especially for anyone taking four or more medications. It’s your chance to:
- Sit down one on one with a pharmacist and review all of your medicines
- Check for potential dangers in mixing different drugs
- Safely discard outdated prescriptions
Care Management
We offer many free, confidential programs to help when you need extra support during a serious or ongoing illness. Our team of nurses, social workers and other health care professionals is dedicated to helping you manage specific, chronic medical conditions. We work closely with your doctor to help you find the right support, resources, and information to manage and live well with:
- Diabetes
- Heart failure
- Cancer
- Kidney disease
- Lung diseases (asthma and COPD—chronic obstructive pulmonary disease)
- Behavioral health issues (mental health, drugs or alcohol)
Our care management programs are voluntary, confidential, and free as long as you are a Gold member.
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7. What makes us simple and easy to use?
As a Preferred Care Gold member:
- You will have one membership card and one prescription drug card (if you join our Part D prescription drug plan).
- Always carry and show your Preferred Care Gold membership card when you visit your doctor, and pay your copayment.
Our Member Services team can answer your questions about benefits and
your coverage for past and future health care procedures. Member Services offers:
- A real person to give personal attention to your questions about your health care coverage—no automated phone trees.
- A dedicated Gold Member Services team experienced in serving Medicare Advantage health plan members.
- Toll-free phone service weekdays from 7:00 a.m. to 8:00 p.m. Eastern Time, or visit us from 8:00 a.m. to 5:00 p.m. From November 15 through March 1, phone representatives also are available weekends from 8:00 a.m. to 8:00 p.m.
- Timely, accurate answers based on your particular health plan questions—we take the time to listen, and make sure you understand the answers.
The premium and benefit package for Preferred Care Gold may change at the beginning of each calendar year. It will not change during the calendar year unless the change is to the advantage of our members.
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8. What more good things are there to know about us?
Preferred Care’s Utilization Management Program is a process to review the health care services you receive. It makes sure that you get the right services for your health care needs—effective care that you are able to get in a timely manner, at a place that best meets your specific health care needs. Preferred Care asks certain questions when reviewing a service or making coverage decisions, such as:
- What is the quality of the care like?
- Do the benefits of getting this care outweigh its risks?
- Is this care right for your specific medical condition?
- Is this the only service that is available or are there other more cost-effective treatments?
- Does your health plan cover this type of care?
Utilization management decisions are based on the appropriateness of care. We use criteria to assure that decisions are made consistently by all health care professionals involved before, during, and after your treatment.
Preferred Care does not reward or offer incentives for employees or health care professionals to deny health care services. If you have questions about our review of your medical services or treatments, contact Member Services.
Maintaining member confidentiality is very important to Preferred Care. Preferred Care has adopted policies to ensure the confidentiality of your personal health information (PHI). A copy of that policy can be obtained from Member Services. The privacy policy also is available at www.preferredcare.org on the Web.
By receiving benefits under your Preferred Care certificate, you have consented to Preferred Care's use of the personal health information it receives—whether oral, written or electronic—for the purpose of treatment, payment or health care administration. Those purposes include, but are not limited to, disease prevention and management programs, coordination of health care treatment and benefits, utilization management, health data measurement, claims and fraud review, quality assurance, appeals and grievance processes, regulatory requirements and accreditation.
Preferred Care will not otherwise disclose your personally identifiable health information, including that contained in your medical records,—whether received orally, in writing or electronically—(including to your employer) without your expressed consent, unless otherwise required by federal or state law or regulation. Preferred Care also has internal policies and procedures to protect your PHI during the normal course of business, working with oral, written or electronic information.
Note: Preferred Care is not able to disclose information to your family, friends or others you may want to represent you without an Authorization to Disclose Information (ADI) form on file. ADI forms are available from Member Services. Changes to your policy (your address, doctor’s name, etc.) can only be made by you or with a Power of Attorney (POA) form on file at Preferred Care. Please call your attorney to obtain a POA form.
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9. Ready to join? It's easy!
- Complete, sign, and date a Preferred Care Gold application.
- Each person must complete his or her own form.
- Choose Preferred Care Gold with or without prescription drug coverage.
If you choose Preferred Care Gold with prescription drug coverage
- You may be billed directly by Preferred Care Gold.
- You may pay the monthly premium by check or money order.
- You may have the monthly premium for your health plan and the prescription drug plan taken from your monthly Social Security check.
NOTE: EPIC members are not eligible for premium deductions from their Social Security check.
NOTE: If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare does not cover.
If you choose Preferred Care Gold without prescription drug coverage
- You may be billed directly by Preferred Care Gold.
- You may pay the monthly premium by check or money order.
You will be billed monthly, but you may pay quarterly if you choose.
We must receive your application no later than the last working day of the month to meet Medicare’s deadline to be effective the first day of the next month. For example, if we receive your application on January 31, your coverage will begin February 1.
NOTE: Current state and federal confidentiality laws advise you to complete and return an Authorization to Disclose Information (ADI) form. Unless we have an ADI form signed by you, Preferred Care cannot disclose any information about your contract to anyone other than yourself, including your spouse and children.
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10. Want to learn more about Preferred Care Gold?
Call Preferred Care Gold Sales to ask questions, to reserve a seat at a neighborhood information meeting, or to schedule an in-home visit:
Monday – Friday, 8:00 a.m. to 5:00 p.m. Eastern Time
(585) 327-5760 or (888) 280-6205
TTY users may call (585) 325-2629 or (800) 252-2452
From November 15 through March 1, phone representatives also are available weekends from 8:00 a.m. to 8:00 p.m. at these numbers.
We look forward to hearing from you!
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This information is intended for marketing purposes only. While every effort has been made to ensure that it accurately reflects our plan, it is your Evidence of Coverage that governs the operations of your plan and payment of all benefits. Benefits, formulary, pharmacy, network premium and/or copayments/co-insurance may change on January 1, 2008. Please contact Preferred Care Gold for details.
H3305 / PCG 795 (9/07)
Last updated: September 28, 2007
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