Medicare FAQs

March 31, 2018

Answers to the most frequently asked questions about Medicare

• Does the LAFRA PPO Medical Plan cover the Silver Sneakers program?
No, this is not a program currently offered by this Plan.

• Where can I find information about my LAFRA PPO medical benefits?
Call HealthSCOPE Benefits (HSB) at 1-866-995-2372 or visit www.lafra.org then select “MEDICAL AND PPO-SUMMARY-PLAN” from the dropdown. Login and you will find your Summary Plan Description (SPD).

• Where can I find a medical claim form so I can submit a request for reimbursement?
You can find a claim form at www.lafra.org. Select “Medical” and then “Medical Forms” from the dropdown. You can then select “Unprocessed Medical Expense Claim Form.”

• How do I find a provider who accepts Medicare and the LAFRA PPO Plan so benefits can be coordinated at the best rates?
Find a provider who contracts in-network with Anthem Blue Cross because if Medicare doesn’t pay your entire claim, or if they don’t cover a benefit at all, the PPO Plan may pay at least a portion of the claim. The Anthem site (www.anthem.com) will also indicate if the provider accepts Medicare.

 


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• Should I receive an Explanation of Benefits (EOB) from both Medicare and HealthSCOPE Benefits (HSB)?

Yes. When Medicare is primary, the provider must send the claim to Medicare first, regardless of whether they believe Medicare will pay or not. Medicare will pay most but not all charges. LAFRA, as your secondary plan, may cover benefits Medicare does not. The Medicare EOB must be sent to Anthem Blue Cross (see the back of the ID card for the address) to be priced because HSB needs to know how much was paid when processing the claim.

• How do I check the status of a Medicare Part A (Hospital Insurance) or Medicare Part B (Medical Insurance) claim?
Visit www.MyMedicare.gov and log into your account and access your personalized Medicare information. Note: Your Medicare Summary Notice (MSN) is a notice people with Original Medicare receive via the mail every three months. Receive a monthly statement electronically by choosing eMSN’s.

• Why does the EOB I received say I owe nothing but an invoice from the provider indicates there is patient liability?
Always open and read the information you receive from HSB because even if the ‘Patient Liability’ amount says you owe nothing, refer down to the bottom section under ‘Comment Codes’ to make certain the claim hasn’t been denied pending receipt of required information from your provider (i.e. proof of medical necessity). Please call 1-866-995-2372 with questions.

• Which medical ID card should be used when either the subscriber or the subscriber’s spouse turns 65?
When a subscriber or a subscriber’s spouse turns 65, they’re automatically rolled to the Employer Group Waiver Plan (EGWP). The spouse who hasn’t yet turned 65 will continue to use the current medical/pharmacy card. The spouse who turns 65 will be issued a new medical ID card which looks virtually the same, except it will not include pharmacy information. Express Scripts issues a separate pharmacy card, meaning once you turn 65, you will carry cards for Medicare, LAFRA’s PPO Medical Plan, and also an ESI pharmacy benefits card.

• Why does only the subscriber’s name appear on the medical/pharmacy ID card?
When dependents on the Plan go to the doctor, eligibility is confirmed by using the Alternate ID number which appears on the front of the card. Please note, LAFRA PPO members utilize the Anthem Blue Cross network, but providers must confirm eligibility by calling HSB, not Anthem, at 1-866-995-2372. This information can be found on the back of the card.

• If both spouses are 65+ but still working, will LAFRA still pay as primary?
Yes, but it’s very important to notify HSB so notes can be entered in the system. If this is not done, claims will be denied and you will be balance billed.

• If my doctor of 30 years doesn’t accept Medicare and I am about to turn 65, can I continue seeing this doctor and will LAFRA’s PPO Plan pay as primary?
The goal should be to see providers who contract in-network with Anthem Blue Cross because it saves the Plan and you money. We will accept a letter from the doctor telling us he/she is ‘opted out’ of Medicare and we will flag this in the system and pay as primary.

• I lost my purse/wallet and I’m afraid of identity theft. Do I need to get a new alternate ID number and medical ID card?
We will send a new ID card but you will not need a new alternate ID number. There isn’t any real risk since personal health information is not printed on the card.

• Why do I keep receiving a bill from my doctor (i.e. $11.00) when I have Medicare and the PPO Plan?
Check with your doctor’s billing office to make sure the claim and Medicare EOB made it to Anthem Blue Cross. The other possibility is that payment for multiple claims was sent to the provider via an electronic check. Call HSB so we can fax over proof of payment and the provider can post payment to the correct accounts.

• How do I find Durable Medical Equipment (DME) items? I will need a hospital bed when I get out of the hospital in a week.
If Medicare is primary, check the www.medicare.com website to find a DME provider using your zip code. All DME providers require a prescription from your doctor.

• My husband and I do not have long term care coverage. Will the PPO Plan cover any assisted living or nursing home costs?
Check to see if you have coverage through Unum. Nursing home and other assisted living facilities are not paid for through the Medical Plan. Respite care is also not a covered benefit.

• My spouse was released from the hospital and then moved to a Skilled Nursing Facility. How can I find a physical therapist to come into the home?
Whenever you or a family member stay in the hospital, be sure to request that an Anthem case manager be assigned. Call the case manager if they don’t call you first. A case manager is a registered nurse and can advise you on all kinds of issues, including finding a contracted physical therapist. Make sure the doctor orders physical therapy though before leaving the hospital.

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