SeniorCare Frequently Asked Questions - Scott & White Health Plan

SeniorCare and SeniorCare Rx
Frequently Asked Questions

Senior Select, Senior Preferred and Senior Preferred Plus Frequently Asked Questions

SeniorCare Rx Frequently Asked Questions

How do I select a Primary Care Physician (PCP)?
You may select a PCP online or call a Customer Service Coordinator at a SWHP office near you. A Customer Service Coordinator can assist you in selecting a PCP or provide specific information about a PCP. You can select your PCP from the following physicians:
- Family Medicine physicians - treats all age groups from newborns to the elderly. Family Medicine physicians provide routine medical care, obstetrics/gynecology services, some minor surgical procedures and referrals to specialist.
- Community Internal Medicine physicians - treat patients 18 years and older. Community Internal Medicine physicians provide routine medical care, gynecology services, and referrals to specialists.
  
  In selecting a PCP, consider which clinic would be most convenient to meet your medical needs. After you designate a PCP, you may make an appointment with your PCP. If your PCP is not available, you may make an appointment with any other physician in the same specialty in the same clinic.
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After selecting my PCP, what happens if I do not like him/her?
You can change your PCP online or call a Customer Service Coordinator at a SWHP office near you.
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I am currently seeing a non-SWHP physician. Can I continue to see that doctor?
SWHP is a Health Maintenance Organization (HMO) and your care has been prepaid and prearranged within the Scott & White network. If you would like SWHP to pay for the doctor visit, you must see a SWHP physician. You may continue to see the non-SWHP physician, but SWHP will not pay for the visit. If the service received is Medicare covered, then you will be responsible for the Medicare deductible and coinsurance amounts same as the traditional fee for service Medicare program. You may want to get copies of your medical care records from the non-SWHP physician so your Scott & White PCP can continue care.
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When Scott & White cannot provide the services I need, how do I get a referral?
Scott & White Clinic is a large multi-specialty facility and, in most cases, can meet the majority of your medical needs. If you develop a medical condition that your PCP and a specialists at Scott & White cannot care for, you will need:
a. A recommendation from your Scott & White treating physician and
b. The approval of the SWHP Medical Director(s) before any out-of-plan services can be covered. A formal review of your case will be provided and you will receive a letter outlining clearly what SWHP will or will not cover with the non-SWHP physician. As a Member of the SWHP, you have the right to appeal any decision about our payment for, failure to arrange or continue to arrange what you believe are Covered Services (including non Medicare covered Benefits) under the Health Plan.
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What happens if I disagree with the treatment that my PCP prescribes? What are my options then?
If you disagree with your PCP, you have the ability to change your PCP or see another physician within the clinic for another opinion. When seeing a specialist at Scott & White, you must ask your PCP for a second opinion within the system.
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What happens if I am hospitalized outside the service area?
If you are out of the service area, SWHP will provide benefits for medically necessary emergency or urgent care. Please have someone call SWHP within 48 hours or as soon as possible so we can begin coordinating your care. The instructions for reporting an out-of-area admission are printed on the back of your member identification card. If you are hospitalized while traveling with others, we suggest that you have someone else within your group know what to do in case you are unable to speak for yourself.
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What should I do if I get a bill that should have been paid by SWHP?
As soon as you receive the bill, please contact a Customer Service Coordinator at a SWHP office near you. The Claims Department will research the bill to determine if payment has been made and will work with the provider to resolve the situation.
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What if I need additional identification cards, a copy of my policy, or any other materials?
You can receive an additional identification card, Evidence of Coverage, Summary of Benefits, or any other material from your local SWHP office. To request the needed materials, contact a Customer Service Coordinator at a SWHP office near you.
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SeniorCare Rx Frequently Asked Questions

How much will SeniorCare Rx cost?
SeniorCare Rx offers affordable monthly premiums.
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Why should I sign up for Medicare prescription drug coverage?
Medical practice has come to rely more and more on new drug therapies to treat chronic conditions, and out-of-pocket spending on drugs has steadily increased. As we age, most people need prescription drugs to stay healthy. Medicare prescription drug coverage will protect you from future high out-of-pocket costs. For most people, joining when you are first eligible means that you will pay a lower monthly premium than if you wait to join until later. There will be a penalty for those who sign up for a prescription plan outside of an enrollment period.
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When should I join?
The annual enrollment period is November 15th through December 31st of each year. You can join during your Initial Enrollment Period or during a Special Enrollment Period.

Initial Enrollment is a seven month period -
- Three months before eligibility for Medicare prescription coverage
- The month of eligibility
- Three months after eligibility for Medicare prescription coverage

Special Enrollment Period - a person may be in a special enrollment period
- when they move permanently into the plan's service area
- when they enter, reside in, or leave a long-term care facility
- Involuntary loss, or reduction of coverage.
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When will my drug coverage begin?
If you enroll between November 15 to December 31 your coverage will begin January 1. If you are eligible and enroll after December 31st, your coverage will begin on the first day of the following month.
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How do I pay plan premiums?
You can have plan premiums deducted from your Social Security checks or you may pay your premiums directly to Scott & White Health Plan. Your employer can also pay plan premiums for Medicare-eligible retirees directly.
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What if I need help paying for prescription drugs?
Medicare helps pay for prescription drugs for those who qualify for extra help. Eligibility is based on guidelines set by the federal government. You can apply for extra help through the Social Security Administration by calling 800-772-1213 (TTY 800-325-0778) or visiting www.socialsecurity.gov.
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What is creditable coverage?
This is coverage that is on average at least as good as the basic Medicare prescription drug coverage the government has outlined.
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What is a formulary?
It is a list of covered drugs that has been approved by the federal government. It provides you and your doctor with a choice of quality, cost-effective generic and name brand medications approved by the U.S. Food and Drug Administration (FDA).
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Are all Medicare drug plans the same?
No. However, all drug plans will have to provide coverage at least as good as the Medicare standard coverage.
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Who do I call for more information or when I am ready to enroll?
Call a SWHP office near you.
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What happens if I sign up late?
You may pay a government penalty later. This penalty may increase for each month you do not have Medicare prescription drug coverage (or coverage that is creditable). You will not pay a penalty if you have prescription coverage from either TRICARE, The Federal Employee Health Benefits Program (FEHBP), The Department of Veteran's Affairs (VA) or your (or your spouse's) former or current employer who has furnished you a notice stating that the prescription coverage the coverage year will be, on average, at least as good as the Medicare standard prescription drug coverage.
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Can SeniorCare Rx plans help me save on the costs of medications?
Yes. Scott & White Health Plan negotiates discounts for medications with our participating network pharmacies.
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What happens if I go to a pharmacy that's not in your network?
If you go to a pharmacy that is not in our network, you might have to pay more for your prescriptions. You also might have to follow special rules before getting your prescription in order for the prescription to be covered under our plan.
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Is there special help for me if I have a limited income and resources?
People with limited income and resources may quality for extra help paying their Medicare prescription drug coverage costs. If you automatically qualify for extra help, Medicare will send you a letter to let you know. You don't need to apply for extra help if you get this letter.

If you don't automatically qualify for extra help, you can call Social Security at 1-800-772-1213 to apply by phone or to get a paper application. You can also visit www.socialsecurity.gov on the web to apply on line.
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How often will I be able to change plans?
You can choose to switch your current plan from November 15 through December 31 of every year. In certain cases, such as if you move or enter a nursing home, you can switch your plan at other times.
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I am healthy and don't use many medications, so why should I join a Medicare drug plan?
Medicare prescription drug coverage will protect you from future out-of-pocket costs. For most people, joining when you are first eligible means that you will pay a lower monthly premium than if you wait to join until later. There will be a penalty for those who sign up for a prescription plan outside of an enrollment period.
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How does the plan protect people on Medicare against high out-of-pocket drug costs?
You pay co-payments and the amount depends upon which plan you take, until the total cost of your prescription drugs in a year totals $2,510. Then you pay a total of $4,050 out of pocket for your drugs. After that, you pay only $2.25, $5.60 or 5% for the rest of the calendar year.
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What happens if I currently have employer-provided drug coverage?
If you have drug coverage from your (or your spouse's) employer or former employer or union, check with your benefits administrator before considering if you want a Medicare prescription drug plan. Medicare will help employers and unions continue to provide retiree drug coverage that meets Medicare's standards. You should receive a notice from your current plan telling you if your current coverage, on average, is at least as good as the Medicare standard prescription coverage (called "creditable prescription drug coverage").
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