About Medicare Products

The Medicare program is a federally managed health insurance program for people age 65 or older, people under age 65 who have certain disabilities, and people of all ages who have permanent kidney failure requiring dialysis or a kidney transplant (a condition referred to as End-Stage Renal Disease).

Medicare now offers four kinds of insurance: hospital (Part A), medical (Part B), Medicare Advantage ( formerly Medicare+Choice ), (Part C), and prescription drug (Part D).

Part A: Hospital Coverage

Medicare Part A helps cover inpatient care services received in hospitals (includes critical access hospitals and inpatient rehabilitation facilities), as well as intermittent inpatient care received in skilled nursing facilities. For those who meet certain eligibility requirements, Part A also covers hospice care and some home health care services. Part A does not cover custodial or long-term care.

Most people are eligible for Part A automatically when they turn 65. Part A is available at no cost to people who have worked, or whose spouses have worked, for at least 10 years and have paid Medicare taxes through their employers.

Part B: Medical Coverage

Medicare Part B helps cover medically necessary providers’ services, outpatient care, some preventive services, and some additional services not covered by Part A (such as physical or occupational therapy). It also may cover medically required home health care services.

Medicare Part B is optional coverage. If you are interested in receiving Part B, you will need to sign up during your initial enrollment period, which occurs between three months prior to and three months after you meet the eligibility requirements. Part B requires a monthly payment, or premium, for coverage. Generally, this payment is deducted from your Social Security check. The premium amount is set when a person first becomes eligible to enroll in Part B. In most cases, premium rates will increase by 10% annually for those who do not enroll when they become eligible. Therefore, it is a good idea to consider enrolling in Part B as soon as you become eligible.

Part C: Medicare-approved Health Plans

These plans are approved by Medicare and are run by private health insurance companies. When you join one of these plans (such as AmeriHealth 65 NJ HMO), you are still in Medicare. Some of these plans require referrals to see specialists. They provide all of your Part A (hospital) and Part B (medical) coverage. They generally offer extra benefits and many include prescription drug coverage. These plans often have networks, which means you may have to see providers are in the plan’s network or go to certain hospitals to get covered services. In many cases, your costs for services may be lower than in the Original Medicare Plan, but it is important to check with the plan because the costs for services will vary.

Part D: Medicare Prescription Drug Plans

Anyone who is eligible for Medicare is also eligible for Part D. Like Medicare Part C, Medicare Prescription Drug Plans are offered by health insurance companies. Other private companies may be approved by Medicare to offer a Prescription Drug Plan, also.

With a Medicare Prescription Drug Plan:

Generally, you pay less for your prescriptions.
You will get a plan member card after you enroll. You use this card when you go to the pharmacy to get your prescriptions filled.
You will pay the copayment, coinsurance, and/or deductible, if any.

If you have limited income and resources, you may get extra help to pay for your Medicare drug plan costs. Learn more about low-income subsidy.

You must continue to pay your Medicare Part B premium.

The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions.

Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.

You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor AmeriHealth 65 NJ HMO will be responsible for the costs.

Please contact AmeriHealth 65 HMO for more information.

In lots of cases, your prescriptions are covered under AmeriHealth 65 NJ HMO, AmeriHealth Rx PDP if they are filled at a network pharmacy or through our mail-order pharmacy service. There are thousands of network pharmacies, including:

national chain and independent retail pharmacies
long-term care and home-infusion pharmacies
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Program pharmacies

Website last updated: 12/30/11
Y0041_HNS_12_301a Pending CMS Approval