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Frequently Asked Questions

To help you better understand your options, here are some Frequently Asked Questions and Answers (FAQs) about Medicare and our HealthMarkets Care AssuredSM Plans.

HOW THE PLAN WORKS

1. What is a PFFS Plan?
2. How do the benefits of a PFFS Plan compare to Original Medicare?
3. How do the benefits of a PFFS Plan compare to a Medicare Supplement (Medigap) Plan?
4. How is a PFFS Plan different from a Medicare HMO?
5. How is a PFFS Plan different from a Medicare PPO?
6. Am I protected against catastrophic expense with a PFFS Plan?
7. Does a PFFS Plan include prescription drug coverage?
8. What is not covered by a PFFS Plan?
9. Do I need to continue to pay my Part B premium if I enroll in a PFFS Plan?

ADVANTAGES OF THE HEALTHMARKETS CARE ASSURED PLAN (referred to in these FAQs as “Care Assured” or the “Plan”)

10. Who is HealthMarkets and who is Chesapeake?
11. What advantages do I get by joining Care Assured?
12. Is there a copay for all covered services with Care Assured?
13. How is hospitalization covered under Care Assured?
14. How is preventive care covered under Care Assured?
15. How is vision covered under Care Assured?
16. How is hearing covered under Care Assured?
17. Are dental discounts offered under Care Assured?
18. How is emergency or urgent care covered under Care Assured?
19. What if I spend part of the year in another location?

PRESCRIPTION BENEFITS

20. Why should I choose a Care Assured Plan that includes prescription drug coverage?
21. How do I get my prescriptions filled with Care Assured?
22. What is a formulary?
23. Who decides which prescription drugs will be covered by the Care Assured Formulary?
24. What happens if one of my medications is not on the Care Assured Formulary?
25. How do I save money using the mail order service?
26. What is the coverage gap or “donut hole?”
27. Can I request an exception to the Care Assured Formulary?

YOUR RELATIONSHIP WITH YOUR PROVIDERS

28. Can I use the same doctors and hospitals I use now with Care Assured?
29. Am I limited to using providers from a network with Care Assured?
30. What is a “deemed” provider?
31. Do I need to coordinate care through a Primary Care Physician with Care Assured?
32. Do I need to get referrals with Care Assured?
33. What if my provider does not accept Care Assured?
34. What if my provider is not familiar with Care Assured?
35. Suppose I want to pay out-of-pocket to see a provider that does not accept Care Assured?

ENROLLMENT

36. Who is eligible to join Care Assured?
37. When can I join Care Assured?
38. How can I decide which Care Assured Plan is best for me?
39. What happens if I am already in enrolled in a Medicare Advantage or Medigap Plan and I want to join Care Assured?
40. What happens if I move out of the Plan’s service area?
41. Suppose I am covered by Original Medicare and a standalone Part D prescription drug plan and I want to join Care Assured?
42. What should I do if I want to join Care Assured and I already have retiree coverage though an employer or union plan?
43. What are my options for paying my monthly premium?

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HOW THE PLAN WORKS

1. What is a PFFS Plan??

The HealthMarkets Care Assured Plan is a Medicare Advantage Private-Fee-For-Service plan (PFFS), and is subject to the terms of a contract with the Centers for Medicare and Medicaid Services (CMS). PFFS plans are offered to Medicare beneficiaries by private insurance companies. With a PFFS plan such as the HealthMarkets Care Assured Plan, you can go to any Medicare-eligible provider who is willing to accept the Plan’s terms and conditions of payment — you are not restricted to providers on a list.

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2. How do the benefits of a PFFS Plan compare to Original Medicare?

A PFFS plan covers all of the benefits covered under Original Medicare. In addition, a PFFS plan may cover some of the cost sharing under Original Medicare and additional benefits not covered under Original Medicare. For example, Care Assured plans cover an unlimited number of days in the hospital whereas Original Medicare does not.

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3. How do the benefits of a PFFS Plan compare to a Medicare Supplement (Medigap) Plan?

Whether the benefits are better depend on which Medigap plan and which Care Assured plan you are comparing. Care Assured premiums are generally lower than Medigap premiums and some of the Care Assured plans offer more coverage than some Medigap plans. You should also compare the cost sharing under a Care Assured plan and a Medigap plan.

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4. How is a PFFS Plan different from a Medicare HMO?

With a PFFS Plan, you are not required to use a set list of providers. You can go to any Medicare-eligible provider willing to accept the Plan’s terms and conditions of payment without prior approvals. If your doctor or hospital does not agree to accept our payment terms and conditions, they may not provide healthcare services to you, except in emergencies.

In addition, you are not required to coordinate your care through a Primary Care Physician or get referrals to see specialists.

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5. How is a PFFS Plan different from a Medicare PPO?

With a PFFS Plan, because there are no network restrictions, you can go to any Medicare-eligible provider willing to accept the Plan’s terms and conditions. Your out-of-pocket expenses do not change based on whether or not a provider is in the network. You do not have to worry about unanticipated bills because you used “non-participating” providers.

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6. Am I protected against catastrophic expenses with a PFFS Plan?

PFFS Plans typically have an annual out-of-pocket maximum, but after you have met your annual maximum, you are protected against additional costs for covered services. The annual out-of-pocket maximums are: $1,500 for the HealthMarkets Care Assured Premier and HealthMarkets Care Assured Premier Plus Plans and $3,500 for the HealthMarkets Care Assured Value and HealthMarkets Care Assured Value Plus Plans.

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7. Does a PFFS Plan include prescription drug coverage?

Many PFFS Plans offer options that do include prescription drug coverage. Care Assured has two plan options that cover prescription drugs: HealthMarkets Care Assured Premier Plus and HealthMarkets Care Assured Value Plus.

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8. What is not covered by a PFFS Plan?

A PFFS Plan covers all medically necessary services outlined in Medicare Parts A and B. Many PFFS Plans, such as Care Assured, cover additional services not covered by Original Medicare, although not every service is covered.

Examples of services typically not covered by the Plan, include but are not limited to: experimental procedures, private hospital room, custodial care and travel immunizations.

We recommend that you check your Evidence of Coverage for details on which services are not covered by the Plan.

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9. Do I need to continue to pay my Part B premium if I enroll in a PFFS Plan?

Yes. You must continue to pay your Part B premium every month when you enroll in a PFFS Plan.

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ADVANTAGES OF A HEALTHMARKETS CARE ASSURED PLAN

10. Who is HealthMarkets and who is Chesapeake?

HealthMarkets is a family of companies with 25 years of experience in individual health insurance, currently serving 650,000 members through its subsidiaries and affiliates. At HealthMarkets, we are committed to keeping affordable insurance a part of the American dream and to giving you the personal service you deserve.

The HealthMarkets Care Assured Plan is underwritten and issued by The Chesapeake Life Insurance Company, an indirect subsidiary of HealthMarkets, Inc. and one of the HealthMarkets’ Companies.

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11. What advantages do I get by joining Care Assured?

HealthMarkets is a company dedicated to providing benefits to individuals and small business entities, not to large corporations. Our Care Assured Plans have been designed by the HealthMarkets Companies to deliver what Americans need and expect from their health insurance.

You can stretch your health care dollars with Care Assured Plans that feature:

  • Four plan options including one that does not require any additional monthly premium over the basic Medicare premium!
  • No deductibles so you receive first dollar coverage (although there may still be a copayment).
  • $0 copays for Medicare-approved preventive care services. (However if you obtain services from a Medicare provider who does not accept assignment, you may be balance billed up to 9% of the plan payment.)
  • No limits on the number of days you can stay in the hospital.
  • Generous discounts for routine vision, hearing and dental services for all Plan options, although some plans have insured benefits and other plans have services that are eligible for discounted rates using a discount card.
  • Full benefits while traveling anywhere in the USA.
  • A broad prescription drug list so you save on the medications you need.

Best of all, Care Assured Plans are easy-to-use. There are NO referrals, LESS paperwork to complete and NO network restrictions — you can use any provider who agrees to accept Care Assured’s terms and conditions.

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12. Is there a copay for all covered services with Care Assured?

There is no copay for all Medicare-approved preventive care services with Care Assured. In addition, the HealthMarkets Care Assured Premier and HealthMarkets Care Assured Premier Plus Plans do not require a copay for Primary Care Physician office visits, and many x-rays and lab services.

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13. How is hospitalization covered under Care Assured?

You are covered with Care Assured for every day you need to be in the hospital — there are NO limits on the number of days you are covered and there are no deductibles. However, you will pay a copayment for hospitalizations. Refer to the Care Assured Summary of Benefits for details on the applicable copayments.

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14. How is preventive care covered under Care Assured?

Early detection is the key to successful treatment of many medical conditions. Care Assured takes the worry out of paying for preventive care with no copays for a number of preventive services:

  • Annual physical exams
  • Medicare-covered immunizations
  • Colorectal screening per the Medicare guidelines
  • Annual GYN exams
  • Annual screening mammograms
  • Annual bone mass measurements
  • Annual prostate screening

However if you obtain services from a Medicare provider who does not accept Medicare assignment, you may be balance billed up to 9% of the plan payment.

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15. How is vision covered under Care Assured?

On a clear day, you can see much better with Care Assured’s routine vision savings.

All Plan options include a discount card that allows you to use your vision discounts over and over again for additional pairs of regular glasses or for prescription sunglasses. Locate a convenient discount vision provider in your area.

The HealthMarkets Care Assured Premier and Premier Plus Plans have additional coverage as set forth below.

Vision savings by Plan type include:

Premier/Premier Plus Plans

  • $50 allowance each year towards routine eye exams as part of the insured benefit under the Plan
  • $75 allowance each year towards glasses or contacts as part of the insured benefit under the Plan
  • Discounts on additional eyewear through a discount card*

    • Value/Value Plus Plans

  • Discounts on routine eye exams, frames and lenses through a discount card*

* The products and services described above are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products or services may be subject to the Careington International Corporation’s or its third party vendors’ grievance processes.

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16. How is hearing covered under Care Assured?

All Plan options include a discount card that allows you to take advantage of the latest advances in hearing technology with generous savings on hearing services. Locate a convenient discount hearing provider in your area.

The HealthMarkets Care Assured Premier and Premier Plus Plans have additional coverage as set forth below.

Hearing savings by plan type include:

Premier/Premier Plus Plans

  • $50 allowance each year towards routine hearing exams as part of the insured benefit under the Plan
  • $500 allowance each year towards hearing aids as part of the insured benefit under the Plan
  • Discounts on additional hearing aids through a discount card*

    • Value/Value Plus Plans

  • Discounts on routine hearing exams through a discount card*
  • Discounts on hearing aids through a discount card*

* The products and services described above are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products or services may be subject to the Careington International Corporation’s or its third party vendors’ grievance processes.

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17. Are dental discounts offered under Care Assured?

All Plan options include a discount card that allows you to enjoy improved dental health with deep discounts on a range of dental services*. Locate a convenient discount dental provider in your area.

Discounts vary by procedure but among those included are:

  • Routine oral exams
  • Unlimited cleanings
  • Fillings
  • Dentures
  • Root canals
  • Crowns

* The products and services described above are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products or services may be subject to the Careington International Corporation’s or its third party vendors’ grievance processes.

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18. How is emergency care covered under Care Assured?

You are covered for full emergency benefits anywhere in the world — you do not need to worry about whether or not the provider accepts the Plan.

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19. What if I spend part of the year in another location?

You are covered for full benefits anywhere in the U.S. — not just emergency care — from any Medicare-eligible provider who is willing to accept the Plan’s terms and conditions of payment. Just follow the same guidelines that you do when seeking care at home.

Advise your providers that you are a Care Assured member when you make your appointment and present your ID card at the time of service. There is no need to inform us in advance or obtain any pre-authorizations.

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PRESCRIPTION BENEFITS

20. Why should I choose a Care Assured Plan that includes prescription drug coverage?

You can save hundreds of dollars each year when you elect Care Assured Part D prescription drug coverage. The Plans feature no deductible so you can start saving with your very first prescription.

Our pharmacy network includes more than 62,000 participating drug stores including many national and regional chains and neighborhood pharmacies.

Benefit from extra savings on medications you take every day — a three-month supply for the cost of two — when you use our convenient mail order service.

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21. How do I get my prescriptions filled with Care Assured?

Care Assured Plan prescription benefits are easy to use:

  1. Get your prescription from your doctor.
  2. Check the Care Assured Formulary to see how the drug is covered.
  3. Take your prescription to one of more than 62,000 participating drug stores including many national and regional chains and neighborhood pharmacies. Or you can choose to have your medications delivered right to your door with our convenient mail order service and save 33% on a three-month supply.

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22. What is a formulary?

The Care Assured Formulary is the Plan’s preferred drug list of thousands of brand name, generic and specialty drugs. The Care Assured Plan offers one of the broadest formularies available including the drugs used by many Medicare beneficiaries to treat cholesterol, arthritis, high blood pressure, diabetes and acid reflux. Refer to the Care Assured Formulary to check your current medications.

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23. Who decides which prescription drugs will be covered by the Care Assured Formulary?

Our Formulary is developed by Care Assured, in consultation with a team of health care providers, and represents the prescription therapies such providers believed to be a necessary part of a quality treatment program.

The Care Assured Formulary has been approved by the CMS and covers all medications required by Medicare Part D as well as some additional medications that are not covered by Medicare Part D.

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24. What happens if one of my medications is not on the Care Assured Formulary?

If your medication is not on the formulary, call Care Assured Member Services to check if your medication is covered. If Care Assured does not cover your medication:

  • You can ask Member Services for a list of similar drugs that are covered by Care Assured. Show the list to your doctor to see if one of these drugs will work for you.
  • You can ask Care Assured to make an exception and cover your drug.

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25. How do I save money using the mail order service?

You can order a three-month supply of maintenance medications via our convenient mail order service. The drugs are delivered right to your door and you save 33% on your copayments.

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26. What is the coverage gap or “donut hole?”

In 2008, under the standard Medicare Part D benefit, there is no coverage after costs incurred for your covered drugs reaches $2,510 until your out-of-pocket costs reach $4,050 (or your total drug costs hit $5,726.25).

While you are in the “donut hole” gap, your cost for drugs is the discounted price that the plan negotiates with the pharmacy.

If you purchase the HealthMarkets Care Assured Premier Plus Plan, the Plan does cover generic drugs in the gap subject to a $5 copayment for a one month (31 day) supply.

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27. Can I request an exception to the Care Assured Formulary?

There are two types of exceptions you can request: 1) You can ask us to cover your drug even if it is not on our formulary; or 2) You can ask us to waive coverage restrictions or limits on your drug.

Generally, Care Assured will only approve an exception if the alternative drugs included on the Plan’s formulary, the low-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. When requesting a Preferred Medication, tiering or a utilization restriction exception, submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of your request.

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YOUR RELATIONSHIP WITH YOUR PROVIDERS

28. Can I use the same doctors and hospitals I use now with Care Assured?

You can continue to use any Medicare-eligible provider as long as that provider is willing to accept the Plan’s terms and conditions of payment. You should contact your doctor and see if your doctor is willing to accept Care Assured.

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29. Am I limited to using providers from a network with Care Assured?

No. You can use any Medicare-eligible provider who is willing to accept the Plan’s terms and conditions of payment.

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30. What is a “deemed” provider?

A provider is considered a deemed provider if: 1) The provider is aware in advance of furnishing services that you are enrolled in a Care Assured Plan; 2) The provider has information about or reasonable access to the Care Assured Plan’s terms and conditions of payment (which we make available on our website and by the telephone number listed on your membership card); and 3) The provider subsequently renders covered services to you.

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31. Do I need to coordinate care through a Primary Care Physician with Care Assured?

No. Although it is a good idea to have a Primary Care Physician, you do not need referrals for specialty care, diagnostic tests or hospitalization with the Care Assured Plan.

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32. Do I need to get referrals with Care Assured?

The Care Assured Plan does not require referrals. You can go directly to any Medicare-eligible provider who accepts the Plan’s terms and conditions of payment.

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33. What if my provider does not accept Care Assured?

If a provider does not accept Care Assured’s terms and conditions, the provider may not provide care to you, except in emergencies. Call us at the numbers on your ID card and we will be happy to assist you in finding providers who will accept the Plan.

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34. What if my provider is not familiar with Care Assured?

Call us at the numbers on your ID card and we will send your provider an information packet about Care Assured. Your provider can also call us directly and we will give them all the information they need about the Plan.

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35. Suppose I want to pay out-of-pocket to see a provider that does not accept Care Assured?

If your doctor or hospital does not agree to accept our payment terms and conditions, they may not provide healthcare services to you, except in emergencies. If they provide services to you in non-emergency situations and are aware that you are a Care Assured member, they are deemed to be a Care Assured provider and must accept the plan’s terms and conditions. The provider may NOT accept out-of-pocket payments from you.

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ENROLLMENT

36. Who is eligible to join Care Assured?

You are eligible to join Care Assured if you are:

  • Entitled to Medicare Part A; and
  • Enrolled in Medicare Part B; and
  • Live in the Plan’s service area; and
  • Do not have end stage renal disease.*

Medicare-eligible beneficiaries with limited income and resources may qualify for special assistance. People under age 65 with certain disabilities may also be eligible to join Care Assured. Call your local Social Security Office for more information.

* If you developed ESRD while you were a member of a health plan offered by Chesapeake Life and have been continuously enrolled in a Chesapeake Life plan you may be eligible to enroll in Care Assured.

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37. When can I join Care Assured?

When you can join Care Assured depends on whether or not you are already Medicare-eligible. If you already have Medicare Parts A and B, you can:

  • Enroll in a new plan between 11/15/07 and 12/31/07 for the 2008 calendar year; or
  • Enroll during the open enrollment period between January 1 and March 31 (certain restrictions apply with regard to adding or dropping drug coverage during this period); or
  • Switch plans anytime if you move out of your plan’s service area or if you lose your group coverage.

If you are just turning 65, you can:

  • Sign up three months before or after your 65th birthday. Your enrollment will be effective the first of the next month after you turn 65.

There may be other limited special enrollment periods when you can join. If you are interested in joining please call Care Assured at 1-877-219-5458 and we will tell you whether any of these periods applies.

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38. How can I decide which Care Assured Plan is best for me?

To help decide which care Plan is best for you, consider:

  • Do you have numerous doctor visits and tests each month? The HealthMarkets Care Assured Premier Plan features no copays for Primary Care Physician visits and low copays for specialist visits.
  • Are you in good health with few monthly medical visits? The HealthMarkets Care Assured Value Plan (with no prescription drug coverage) is available to you without any additional monthly premium above your Medicare Part B premium.
  • Do you need prescription drug coverage? Both the HealthMarkets Care Assured Premier Plus and HealthMarkets Care Assured Value Plus Plans offer the convenience of one source for all of your health care and prescription needs.

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39. What happens if I am already in enrolled in a Medicare Advantage or Medigap Plan and I want to join Care Assured?

You can only enroll in one Medicare Advantage Plan at a time. If you are enrolled in a Medicare Advantage Plan that offers prescription drug coverage, and you want to join Care Assured, then you should select either the HealthMarkets Care Assured Premier Plus or HealthMarkets Care Assured Value Plus Plan. Your other Medicare Advantage coverage will be cancelled when your Care Assured Plan goes into effect.

If you are enrolled in a Medicare Supplement (Medigap) Plan, you should be aware that Medicare Supplemental policies will not work with Medicare Advantage Plans. Medicare Supplemental Plans coordinate with Original Medicare. If you enroll in Care Assured, you will no longer receive your benefits through Original Medicare. Care Assured will provide coverage of your Medicare benefits. Further, in addition to paying for your Medicare benefits, Care Assured covers some of the Medicare cost sharing amounts.

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40. What happens if I move out of the Plan’s service area?

If you move out of the Plan’s service area, you can join another Medicare Advantage Plan that does offer coverage in your new location, you can switch to a Medicare Supplement Plan, or go back to Original Medicare.

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41. Suppose I am covered by Original Medicare and also by a standalone Part D Prescription Drug Plan, how do I join Care Assured?

If you wish to get your medical and prescription drug coverage from one source, you may enroll in a Care Assured Plan that includes prescription drug coverage. You will be automatically disenrolled from your Prescription Drug Plan.

If you wish to remain enrolled in your current Prescription Drug Plan, you must choose a Care Assured plan that does not include a drug benefit.

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42. What should I do if I want to join Care Assured and I already have retiree coverage though an employer or union plan?

Before canceling any other coverage you may have, you should speak to your benefits representative to determine which is the best choice for you. Once you drop employer or union coverage, you may not be able to rejoin it later.

Also, there are certain rules that Medicare has established about creditable coverage for prescription drugs that may affect your decision. Be sure you have all the facts before you make a change.

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43. What are my options for paying my monthly premium?

You can have the monthly premium for your HealthMarkets Care Assured Plan automatically deducted from your Social Security check. If you don’t choose this option, we will send you a bill each month which you can pay by mail or by Electronic Funds Transfer (EFT). Generally, you must stay with the payment option you choose for the rest of the year.

If you elect EFT, you must complete the Optional Automatic Monthly Payment Agreement and attach a voided check or deposit slip. Debits will be drawn on the 5th day of the month for which the premium is due.

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CMS APPROVAL 11/24/2007
H7845_MM_NA_E_4006_3_ALL

Underwritten by

The Chesapeake Life Insurance CompanySM