Preferred Care GoldAnwhere

Questions and Answers

Click on a question below to "jump" to the answer!

• How does a PPO differ from an HMO?
• How is a Medicare PPO, such as Preferred Care GoldAnywhere, different from other Medicare plans?
• What do I get with Preferred Care GoldAnywhere?
• How do I join Preferred Care GoldAnywhere ?
• How do I sign up for Medicare Part D drug coverage ?
• What if I am currently enrolled in another Medicare managed care plan ?
• How can Preferred Care GoldAnywhere help me stay healthy and independent?

• Is Preferred Care GoldAnyhere simple and easy to use?
• What else should I know about Preferred Care GoldAnywhere?
• Ready to join?  It's easy!
• Want to learn more about Preferred Care Goldanywhere?

1. How does a PPO differ from an HMO?

A Health Maintenance Organization (HMO) is a type of Medicare managed care plan where a group of doctors, hospitals, and other health care professionals agree to provide your health care for a set amount of money from Medicare every month.  Usually, you must get your care from the health care professionals in the plan.

A Preferred Provider Organization (PPO) is a Medicare managed care plan that gives you the flexibility to choose:

• doctors, hospitals, and health care professionals that belong to a health plan’s network, OR
• doctors, hospitals, and health care professionals outside of the health plan’s network, for an additional cost

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2. How is a Medicare PPO, such as Preferred Care GoldAnywhere, different from other Medicare plans?

• Hospitalization — Unlike Original Medicare, GoldAnywhere pays 100% of a medically necessary inpatient stay, if you use an in-network hospital.
• Monthly premiums — the monthly premium for GoldAnywhere is generally lower than a Medicare supplemental (Medigap) plan and may have richer benefits.
• Physician — with GoldAnywhere you are not required to have a primary care physician and you don’t need a referral to see another doctor, as is required with other Medicare Advantage plans (such as an HMO like Preferred Care Gold).
  

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3. What do I get with Preferred Care GoldAnywhere?

• Free health, exercise and wellness programs to help you improve your life.
• Free SilverSneakers® Fitness Program fitness center membership benefits.
• Worldwide coverage for emergency and urgent care.
• NEW for 2008 — a Nurse Advice Line for after-hours help, seven days a week.
• A network of more than 4,500 doctors and health care professionals to choose from.
• All hospitals in our service area.
• Coverage for preventive care such as annual physicals and mammograms.
• $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!*]

*Any unused portion of the HealthDollars benefit cannot carry over from one calendar year to the next

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4. How do I join Preferred Care GoldAnywhere?

You may join Preferred Care GoldAnywhere:

• When you first become eligible for Medicare benefits, which includes:

• the 3 months before your 65th birthday month
• the month in which you turn 65, and
• the 3 months after your 65th birthday month.

• Due to a disability that qualifies you for Medicare.
• During the annual enrollment period which runs from November 15 through        March 31.

• When you move into the Preferred Care GoldAnywhere 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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5. How do I sign up for Medicare Part D drug coverage?

Preferred Care GoldAnywhere also offers Medicare prescription drug coverage (Part D). If you wish to join our GoldAnywhere 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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6. What if I am currently enrolled in another Medicare managed care plan?

• Joining Preferred Care GoldAnywhere 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 GoldAnywhere takes the place of Medicare.  Keep your Medicare card for your records.
• If you sign up for Medicare prescription drug coverage (Part D) with Preferred Care GoldAnywhere, you will receive your Medicare prescription drug benefit through GoldAnywhere.  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 traveling, the same as when you are at home.  These services are NOT subject to the annual out-of-network deductible.

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 law does not allow you to enroll in Preferred Care GoldAnywhere unless you are a Preferred Care member or have had a successful kidney transplant. 

Some services require “prior authorization” by Preferred Care regardless of whether these services are given in-network or out-of-network.  Prior authorization refers to a process in which Preferred Care works with you and your doctors to make sure you receive medically necessary, high-quality medical treatment at a reasonable cost.  Some examples of services needing prior authorization include:

• Admissions to transitional care units, acute rehabilitation, skilled nursing facilities
• Durable medical equipment
• Home care services
• Implants and internal prosthetics
• Medically necessary dental services

Most often, your family doctor will begin the process and request authorization whenever it is needed.

If you need or want a medical service not available within the Preferred Care GoldAnywhere health care professional network, you may refer yourself to a doctor or service outside the network.  Remember that it may cost you more to receive medical services outside of the Preferred Care health care professional network.

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7. How can Preferred Care GoldAnywhere help me 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 offers a variety of programs and support services to help you take on life and live well.  You can 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 GoldAnywhere 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 Preferred Care GoldAnywhere member.

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8. Is Preferred Care GoldAnywhere simple and easy to use?

Yes!  As a Preferred Care GoldAnywhere member:

• You will have one membership card and one prescription drug card (if you join our prescription drug plan) with virtually no claim forms to complete unless you receive services outside of the Preferred Care GoldAnywhere network.
• Always carry and show your Preferred Care membership card when you visit your doctor, and pay your copayment or coinsurance.
• If you are hospitalized at a hospital that is part of Preferred Care’s health care professional network, you will pay only for personal charges (phone, TV, etc.).  You will pay more if you receive care other than emergency or urgently needed care in a hospital outside of the Preferred Care network.

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 GoldAnywhere 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 GoldAnywhere 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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9. What else should I know about Preferred Care GoldAnywhere?

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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10. Ready to join? It's easy!

• Complete, sign, and date a Preferred Care GoldAnywhere application.
• Each person must complete his or her own form.
• Choose Preferred Care GoldAnywhere with or without prescription drug coverage.

If you choose Preferred Care GoldAnywhere with prescription drug coverage

• You may be billed directly by Preferred Care GoldAnywhere.
• 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 GoldAnywhere without prescription drug coverage

• You may be billed directly by Preferred Care GoldAnywhere.
• You may include a check or money order to cover the first month’s premium for each person who is joining.

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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11.  Want to learn more about Preferred Care GoldAnywhere?

Call Preferred Care GoldAnywhere 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 – March 1, representatives also are available   

weekends from 8:00 a.m. to 8:00 p.m.) 

Visit us at www.preferredcare.org on the Web

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.

H3346 / PPO 459 (10/07)
GOLDANYWHERE DIRECT BILL

Last updated:  October 16, 2007