Frequently Asked Questions
Click on a question below to get answers to some of the most frequently asked questions regarding Advantage Medicare Plan.
What is Advantage Medicare Plan (HMO)?
Advantage Medicare Plan is an HMO with a Medicare contract. This means that when you join Advantage Medicare Plan, CommunityCare administers your Medicare Parts A & B benefits. Advantage Medicare Plan is contracted with Saint Francis Health System and Ascension St. John (other providers are available in our network). We offer plans with affordable premiums and low copays to help you manage your medical costs. We have three levels of coverage to choose from – two of our plans include your Part D coverage.
How does Advantage Medicare Plan operate in the Medicare system?
Advantage Medicare Plan has a contract with the Federal government to provide Medicare services. Under this contract, the government pays us a fixed monthly amount of money for each Medicare member we serve. CommunityCare handles virtually all paperwork and medical services for our members. Advantage Medicare Plan's contract with CMS is renewed annually. As a result, the availability of coverage beyond the end of the current contract year is not guaranteed. Benefits, limitations, service areas and premiums are subject to change on January 1 of each year.
Do I lose my Medicare when I join?
No. You must be enrolled in both Medicare Parts A & B in order to join our plan. However, while you are a member of Advantage Medicare Plan you will only show your Member ID card. Keep your red, white, and blue Medicare card in a safe place in case you need it later.
When can I enroll?
Most people are eligible to enroll in Medicare when they turn 65, although some people are eligible before age 65 due to a disability. You can submit an application for our plan beginning 3 months prior to your Medicare A & B effective date and your plan will begin on the same day as your Medicare.
There may be other times when you can change your plan - for example, if you move out of your plan's service area, you would have a special election period to choose a plan in your new area.
You can also change plans each year during the Annual Election Period. The Annual Election Period is October 15 through December 7 - any plan changes you make during this time go into effect January 1.
There is also a Medicare Advantage Open Enrollment Period from January 1 through March 31. During this time, you may enroll in another Medicare Advantage plan or disenroll from your Medicare Advantage plan and return to Original Medicare – you may make only one election during this period.
For more information on when and how to enroll, please call us.
Do I choose my own doctor?
Yes. You choose your own primary care physician from a long list of physicians affiliated with Advantage Medicare Plan. You may choose any primary care physician (PCP) you wish, but we recommend that you select one close to home. This will give you the chance to build a stronger doctor-patient relationship.
Can I change doctors?
Yes. You may change doctors for any reason, as long as the new doctor you select is a Advantage Medicare Plan provider. Simply call Customer Service and we will help you select another doctor.
What do I do in an emergency?
Advantage Medicare Plan gives you worldwide coverage for medical emergencies. If you find yourself in an emergency, whether inside or outside Advantage Medicare Plan's
service area, go to the nearest doctor or hospital or call 911. Your safety is what counts!
We ask that you notify your doctor within 48 hours or as soon as reasonably possible to arrange follow-up care.
A copayment of $90 for Choice Plus and Premier and $120.00 for Choice is required for emergency treatment, but is waived upon admission to a hospital.
What constitutes an emergency or urgent need for care?
Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent
layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child;
- serious impairment to bodily functions; or
- serious dysfunction of any bodily organ or part.
Emergency services means covered inpatient and outpatient services that are:
- furnished by a provider qualified to furnish emergency services; or
- needed to evaluate or stabilize an emergency medical condition.
These services are considered to be emergency services, and continue to be emergency services, as long as transfer to a Advantage Medicare Plan participating provider would be a risk to your health, or because transfer would be unreasonable, given the distance involved in the transfer and/or the nature of your medical condition.
Urgently needed services means covered services provided when an enrollee is temporarily absent from Advantage Medicare Plan's service area (or, under unusual and extraordinary circumstances, provided when the enrollee is in the service area but Advantage Medicare Plan's provider network is temporarily unavailable or inaccessible) when such services are medically necessary and immediately required:
- as a result of an unforeseen illness, injury, or condition; or
- it was not reasonable given the circumstances to obtain the services through Advantage Medicare Plan.
If an urgent medical need arises, seek care from a local doctor. Should this prove to be difficult, you may seek care from a hospital emergency room. Follow-up care is expected to be provided by your Advantage Medicare Plan primary care physician.
What about pharmacy benefits?
Advantage Medicare Plans Choice Plus and Premier include Medicare Part D prescription drug coverage. Call us for more information, or you may also refer to the Summary of Benefits or Evidence of Coverage.
What are my disenrollment rights and responsibilities?
You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period and during the Medicare Advantage Open Enrollment Period. In certain situations, you may also be eligible to leave the plan at other times of the year. Until your membership ends, you must keep getting your medical services and drugs through our plan. Chapter 10 of the 2020 Evidence of Coverage provides information about ending your membership. Click here for more information regarding Disenrollment.