Frequently Asked Questions

It covers hospital services such as those received by the patient at the hospital, care centers and certain types of specialized home care.

1. It is an optional coverage for outpatient medical services and other services not covered by Medicare Part A. These services include primary care provider visits and some preventive services such as routine tests and vaccines, among others.

1. It is a private plan that administers and manages Parts A and B of Medicare. This plan, also known as Medicare Advantage, is available for members with Parts A and B. Private Plans offer additional benefits and, in many cases, Part D option. A Medicare Advantage plan may offer: • Access to physicians and specialists • Deductibles and coinsurance covers for Medicare Parts A and B • Hearing, vision, and dental services coverage • Emergency and urgency coverage anywhere in the world • Routine service coverage in the U.S.

It is a prescription drug coverage that offers Medicare beneficiaries a cost-effective and accessible alternative to purchase their drugs through a private plan. This coverage is optional and is only offered by private plans. If the beneficiary does not enroll when they are eligible for the first time and enroll later, they may have to pay a penalty.

1. For Medicare Advantage plans with Part D prescription drug coverage, Medicare sets a limit on the total spending of drugs they cover during the year. This figure includes the amount paid by the beneficiary, as well as the amount paid by the plan. After this amount is reached, the beneficiary reaches what is called a coverage gap stage. From there, the beneficiary will receive limited coverage and/or discounts on certain drugs and must pay for the remaining him/herself.  When the beneficiary reaches the new top amount for that stage, he/she then enters the next stage known as catastrophic coverage.  From that moment on, the plan will pay for most of the costs of their prescription drugs.  For more detailed information on payment stages, please refer to your plan’s Evidence of Coverage (EOC).

Persons who are eligible for Medicare and Medicaid coverage have “dual eligibility.” A large part of their medical expenses is covered if they have complete Medicare and Medicaid coverage. If you have dual eligibility, you may qualify for a Dual-Special Needs Plan (D-SNP).

If the enrollment process for Part B is delayed or not completed, the beneficiary may face severe economic penalties imposed by Medicare.

There are specific periods each year to enroll or make changes to Medicare: October 15 – December 7 This is known as the Annual Open Enrollment Period. During this time, members may make changes to their Medicare and Medicare Advantage coverage.   January 1st to March 31st During this period, better known as Medicare Advantage Open Enrollment Period, a beneficiary can make a one-time election to go to another Medicare Advantage plan or switch to Original Medicare. Should this be the case, the beneficiary may simultaneously choose a separate Medicare prescription drug coverage plan.   Special Enrollment Period To qualify for this period of change, you should have met at least one of the following circumstances: • You just turned 65 years of age. • Your current plan has been cancelled. • You have moved to/from Puerto Rico. • You are eligible for Platino benefits. • You have moved to a nursing home. • You receive “additional support” to cover the cost of medicine. • The Original Medicare or Medicare Advantage contract has been violated

Yes. Residents of nursing homes may enjoy the benefits of a Special Needs Plan (SNP). Medicare SNPs are a type of Medicare Advantage plan. Medicare SNPs are limited to people who have specific needs and characteristics, and identify the benefits, providers, medication forms, and other options that best address their healthcare needs.

Medicare Original was not created to cover all your medical expenses. This plan covers close to 80% of medical and hospital costs. A Medicare Original plan does not cover prescription drugs. The beneficiary is responsible for all expenses that Medicare does not cover. Medicare Advantage is a viable option to cover those expenses not covered by Original Medicare and receive additional services and benefits.

If you are under the age of 65 and have a disability, you are eligible for Medicare Advantage and may be privy to the same benefits that a person aged 65 or older receives. If you have been receiving Social Security benefits for at least the past two years, you may apply to enroll in a Medicare Advantage plan as soon as today.

The Centers for Medicare and Medicaid Services (CMS) assess the relative quality of Medicare Advantage plans. CMS evaluates the plans on a scale of one to five stars, with a five-star rating representing the highest quality. The score provides a general measure and is a cumulative indicator of the quality and access to care, responsiveness, and satisfaction of the beneficiary with the plan. Valuations of plans are posted on the Medicare website to provide beneficiaries with additional information to help them select among Medicare Advantage plans in their area.