Medicare Advantage Plans - Frequently Asked Questions

IU Health Plans offers a variety of plans in 38 counties across Indiana. Review our plans by county to see if IU Health Plans is available in your area. To speak with a Medicare Expert call 317.963.9700 or request a consultation online.

From Oct. 1–Mar. 31, a representative will be available to speak to you 8 am – 8 pm, seven days a week. Beginning Apr. 1 through Sept. 30, a representative will be available from 8 am – 8 pm, Monday through Friday. Outside of normal business hours, you may leave a voicemail or send an inquiry to IUHPMedicare@IUHealth.org which will be responded to within 1 business day.

A copay or copayment is an amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount (for example $10), rather than a percentage.

A deductible is the amount you must pay for health care or prescriptions before our plan pays. After you have met your plan’s deductible amount, you usually pay only a copayment or coinsurance for covered services.

Coinsurance is an amount you may be required to pay, expressed as a percentage (for example 20%) as your share of the cost for services or prescription drugs.

A Maximum Out-of-Pocket is the most that you pay out-of-pocket during the calendar year for in-network covered Part A and Part B services. Amounts you pay for your Medicare Part A and Part B premiums, and prescription drugs do not count toward the maximum out-of-pocket amount.

We know that choosing or using your policy can result in many questions—most of which are related to the terms used. Review the Medicare glossary for more information around commonly used insurance terms and definitions.

People with limited incomes may qualify for “Extra Help” to pay for their prescription drug costs. If you qualify, Medicare could pay up to 75% or more of your drug costs including monthly prescription drug premiums, yearly deductibles, and coinsurance. Additionally, those who qualify will not have a late enrollment penalty. To see if you qualify, call 800.633.4227 or TTY/TDD 711 24 hours a day, seven days a week. You can also contact your local Social Security office, or your local State Medicaid office for help. Click here to apply online.

Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Original Medicare covers things like inpatient hospital care, doctors’ services and tests, and preventive services. You pay for services and items as you get them. IU Health Plans covers the same benefits as Original Medicare; however, our plans also offer some extra benefits that Original Medicare does not cover such as vision, hearing and dental services.

IU Health Plans offer Medicare Advantage plan options. We recommend reviewing your plan options and then requesting an estimate of your potential costs by speaking with a licensed Medicare Expert at 866.308.2018 or requesting a consultation online.

The Summary of Benefits will detail what costs your plan will cover, what you will pay and how it varies for different types of care. The Summary of Benefits also lists your monthly premium, deductibles and protection limits for out-of-pocket costs and is available in your member portal or on the Tools & Resources page if you're not a member.

Your Evidence of Coverage will go into deeper detail about the benefits offered by your plan, including what your plan will cover and how it works. You can find your plan specific Evidence of Coverage document by logging into your member portal.

In late September each year, you will receive the Annual Notice of Changes to see what is new or changing in your Evidence of Coverage benefit package for the next year.

Once your application has been approved, your IU Health Plans Medicare Advantage welcome kit will be mailed within 10 days. Your membership card will be mailed separately. If you do not receive your information after 14 days, please contact a Member Advocate at 800.455.9776, to verify your address. You can also request a replacement membership card on your IU Health Plans Member portal at iuhealthplans.org. After logging in (first time users must register first), go to "My Health Plan", then "Member Information." Choose the link "Request ID Card". A replacement card will be mailed to you.

IU Health Plans Medicare Advantage is not allowed to ask you to leave our plan for any health-related reason. If you feel that you are being asked to leave our plan because of a health-related reason, call Medicare at 1.800.MEDICARE (1.800.633.4227) 24 hours a day, 7 days a week. (TTY/TDD 1.877.486.2048). If you choose to end your membership in our plan, you may continue to get your medical services, items and prescription drugs through our plan until your membership ends, and your new Medicare coverage begins. This means:

1. You may continue to use our network providers to receive medical care.
2. You may continue to use our network pharmacies or mail order to get your prescriptions filled.
3. If you are hospitalized on the day your membership ends, your hospital stay will be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins).

Yes. You will have your choice of a wide variety of highly skilled doctors located in your community. You may choose to see a physician, without a referral, as long as the physician is in the IU Health Plans network. See our directory of doctors and facilities.

HMO – You will have your choice of a wide variety of highly skilled doctors in the IU Health Plans provider networks. You may choose to see any primary care or specialist who is in our network without a referral.

HMO-POS – If you are enrolled in one of our HMO-POS plans, you may receive your care from a network or out-of-network provider (a provider who is not part of our plan’s network) for covered services. However, please note that Providers who do not contract with us are under no obligation to treat you, except in emergency situations. Some costs may be higher if you use out-of-network providers. If you need emergency or urgently needed services, you pay the same price in network or out of network.

If you need help locating a provider in the IU Health Plans network, please contact a Member Advocate at 800.455.9776 to assist you in finding a provider that meets your needs.

At IU Health Plans, we understand the importance of finding and managing your health with a provider you trust. If your provider is no longer part of the IU Health Plans network, or you are new to IU Health Plans, we can help you find a provider that meets your needs. IU Health Plans offers a Transition of Care period during which you can continue to see and receive coverage with your current provider. This period allows time for you to explore our network of leading healthcare providers and helps to create a seamless transition to a new provider.

We may make changes to the hospitals, doctors, and specialists (providers) that are part of your plan during the year. If your doctor or specialist leaves your plan you have certain rights and protections that are summarized below:

• Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists.
• We will make a good faith effort to provide you with at least 30 days’ notice that your provider is leaving our plan so that you have time to select a new provider.
• We will assist you in selecting a new qualified provider to continue managing your health care needs.

You can find healthcare providers and facilities using Find a doctor or facility and choose Medicare Advantage in the network drop down menu. You can search by distance from your zip code or county and by type of provider (Primary Care Physician, Specialist, etc.).

IU Health Plans network includes many doctors and hospitals that are part of other healthcare systems and conveniently located in your community. Find healthcare providers in your neighborhood.

If you are enrolled in the IU Health Plans Flex Network HMO-POS or IU Health Plans Choice HMO-POS, we will cover certain out-of-network care. If you are enrolled in any other IU Health Plans option, there is no coverage for out-of-network doctors or hospitals, with the exception of emergency care or urgent care services. IU Health Plans covers emergency care services at any hospital when services are needed to treat, evaluate or stabilize an emergency medical condition, such as a vehicle accident or when there is difficulty breathing or severe bleeding.

More information about emergency care can be found in your Evidence of Coverage. You can find your Evidence of Coverage by selecting your plan on our Tools & Resources and downloading the Evidence of Coverage or by logging into the member portal.

HMO plan options - There is no coverage for out-of-network doctors or hospitals, with the exception of urgent and emergency care services. IU Health Plans covers emergency care services at any hospital when services are needed to treat, evaluate or stabilize an emergency medical condition, such as a vehicle accident or when there is difficulty breathing or severe bleeding.

HMO-POS plan options - As a member of our plan, you can choose to receive care from in-network or out-of-network providers. However, please note that providers who are out-of-network and do not contract with us are under no obligation to treat you, except in emergency situations. We suggest that you ask an out-of-network provider if they will accept you as a patient with your Flex Network (HMO-POS) or Choice (HMO-POS) plan before scheduling an appointment.

More information about emergency care can be found in your Evidence of Coverage. You can find your plan specific Evidence of Coverage document by logging into your member portal.

If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you may request an authorization from the health plan to see an out-of-network provider. Once authorized by the health plan, you will pay the same as you would pay if you got the care from a network provider. Contact our Member Appeals Department at 866.823.1016  (TTY/TDD 711) to make a request.

No. However, some physicians could require a referral to see them. Coverage does depend on applicable copayments and coinsurance. Remember to advise your primary care doctor about services received or prescriptions ordered by a specialist so your doctor can maintain your complete medical record.

To find out if your current medications are covered, please search our Comprehensive Formulary (list of covered drugs).

If you learn that your prescriptions are not covered under your plan, you still have options. Review the Evidence of Coverage, Chapter 5 to find out how IU Health Plans can help.

To find an in-network pharmacy in your community, view the Pharmacy Directory for a complete list of network pharmacies.

To better understand pricing differences within the pharmacy benefit, view the Comprehensive Formulary (list of covered drugs/costs).

No. As an IU Health Plans Medicare Advantage member, you are not required to pay for Medicare-covered annual preventive and wellness services*. Review the list of IU Health Plans covered yearly services, including preventive health services.

You will earn a $50 reward if you get your an Annual Wellness Visit to identify your health risks and create a care plan personalized for you.

*Additional tests or services during the same visit may have a copay.

To learn more about the services provided at no cost through your plan, please refer to your Evidence of Coverage or visit Medicare.gov. You can find your plan specific Evidence of Coverage by logging into your member portal.

This is a very real concern for many of our members. To better understand what you may have to pay, first refer to your Summary of Benefits document and your Evidence of Coverage document on our Tools & Resources page. Both of these documents contain information about what your plan covers and what you may be responsible for. These documents can be found on your member portal. Because you are enrolled in a Medicare Advantage Plan, there is a limit on the total amount you have to pay out-of-pocket each year for medical services that are covered under Medicare Part A and Part B. This limit is called the maximum out-of-pocket (MOOP) amount for medical services.

Many doctors’ offices have after-hours care or a doctor on call. If you have an urgent question, contact your doctor first. You also have access to urgent care centers, should your doctor be unavailable. Find the nearest urgent care center to you.

If you have a true emergency, call 911 or go to the nearest emergency room.

IU Health Virtual Visits (telehealth) - A faster, easier way to see a physician when your medical condition is not life threatening and does not need in-person treatment. Download the IU Health Virtual Visits app to register for 24/7 virtual access. For more information, visit iuhealthvirtualvisits.org.

Urgent care – Your medical condition is not life threatening but needs urgent attention. Care may be furnished by network providers or by out-of-network providers when your providers are temporarily unavailable or inaccessible.

Emergency room – Your medical condition is life threatening or could result in loss of life or permanent disability (examples: difficulty breathing, heart attack, heavy bleeding, loss of consciousness, poisoning, seizures, severe chest pain, severe head trauma, stroke, sudden paralysis or slurred speech, visibly broken bones). Call 911 immediately or go to the nearest emergency room. You do not need to get prior approval or a referral from your PCP.

Check your Evidence of Coverage to see if your plan provides in-network coverage when you visit any Medicare-approved provider within the United States (no network limitations). Some restrictions apply.

Part B drugs are covered under Part B of original Medicare and include certain oral anti-cancer drugs, some drugs that usually aren’t self-administered by the patient and are injected or infused while you are getting physician hospital outpatient services.

Part D plans vary widely; some have deductibles, some have copays and some charge a percentage of the cost.

In 2024, most Part D plans also have a coverage gap (or “donut hole”) during which the health plan may not cover some of the drug cost.

In 2025, there will be a new program called the Medicare Prescription Payment Plan (M3P) program, and the coverage gap (or “donut hole”) will be eliminated. This program will help some people manage drug costs by capping their out-of-pocket covered prescription cost at $2,000 per year and allowing them to pay that cost to their health plan in monthly payments. M3P is not a good option for everyone.

Because there is no deductible for our health plans, you begin in the Initial Coverage Stage when you fill your first prescription of the year.

During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription. You stay in this stage until your total out-of-pocket costs reach $2,000. You then move on to the Catastrophic Coverage Stage.

Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year. During this payment stage, you pay nothing for your covered Part D drugs.

To learn more about the M3P program, visit Tools & Resources.

There is a secure way for members to easily access their health records through third-party apps of their choice downloaded on a smartphone or tablet. These health records include health insurance claims and other information submitted to IU Health Plans by healthcare providers and may include cost and other clinical information.

For more information, visit iuhealthplans.org/health-records or contact a Member Advocate.

A drug coverage determination is any decision (an approval or denial) that IU Health Plans makes when you ask for coverage or payment of a drug that you believe IU Health Plans does not cover but you think it should.

You or your doctor and other prescribers can ask for a coverage determination. You can also appoint someone (such as a relative) to request a coverage determination for you. You can ask for a standard coverage determination; IU Health Plans will give you a decision in 72 hours.

You can also ask for an expedited (fast) coverage determination if you or your doctor or other prescriber believes that starting the drug is important for treatment and cannot wait up to 72 hours for a normal coverage decision. IU Health Plans will give you an answer in 24 hours.

If IU Health Plans denies your coverage determination, you have the right to request a redetermination appeal. Please see our section on Appeals and Grievances for information about your appeal rights or contact our Member Appeals Department at 866.823.1016 (TTY/TDD 711).

For some problems, you will need to use the process for coverage decisions and appeals or the process for making complaints; also called grievances.

Both of these processes have been approved by Medicare. Each process has a set of rules, procedures, and deadlines that must be followed by us and by you.

More information is available in the Evidence of Coverage (reference the chapter: What to do if you have a problem or complaint) for your plan option. The guide in Section 3 will help you identify the right process to use and what you should do.

An organization determination is any decision (an approval or denial) that IU Health Plans makes when you ask for authorization or payment for a healthcare item or service.

An appeal or reconsideration is the first step in the process requesting a re-evaluation after an adverse organization determination.

A grievance is an expression of dissatisfaction with the manner in which IU Health Plans behaves, provides health care services, operations, or activities regardless of whether remedial action is requested or can be taken.

Time frames – resolution time frames (not coverage determinations)

• Standard Organization Determination
  • 14 days from receipt of the request
• Standard Coverage Determination (Part D)
  • Standard: Within 72 hours of receipt of the request
  • Expedited: Within 24 hours of the receipt of the request
  • Request for payment: A decision, notification and reimbursement for approvals 14 calendar days of receipt of request
• Standard MA Grievance
  • 30 days from receipt

Standard MA Appeals/Reconsiderations (Part C)

• Pre-Service: no later than 30 calendar days from receipt of request
• Expedited Pre-Services: no later than 72 hours from receipt of request
• Post Service (Payment Appeals): no later than 60 calendar days from receipt of request
• Standard MA Appeals/Redeterminations (Part D): Pharmacy Team Reviews

• Standard: Within 7 calendar days from receipt of request
• Expedited: Within 72 hours of receipt of the request
• Direct Member Reimbursement Redetermination: 14 calendar days from receipt of the request

Types of appeals

Pre-Service (prior to service taking place): usually related to a denied authorization request

• Post-Service/Payment: after service or benefit has been received (claim payment or denial of claim)
• Expedited (pre- service only): request for appeal when enrollee or physician feel using standard timeframe could seriously jeopardize the life or functionality of the enrollee.
• Redetermination: Related to Part D denials. ALL Redeterminations are handled by the pharmacy team.

How to submit – written, email, fax, verbal – call, portal

You or your doctor and other prescribers can ask for an organization determination. You can also appoint someone (such as a relative) to request a coverage determination for you. You can ask for a standard coverage determination; IU Health Plans will give you a decision in 72 hours.

You can also ask for an expedited (fast) coverage determination if you or your doctor or other prescriber believes that starting the drug is important for treatment and cannot wait up to 72 hours for a normal coverage decision. IU Health Plans will give you an answer in 24 hours.

If IU Health Plans denies your request, you have the right to request a redetermination appeal. Please see our section on Appeals and Grievances for information about your appeal rights or contact our Member Appeals Department at 866.823.1016 (TTY/TDD 711).

For some problems, you will need to use the process for coverage decisions and appeals or the process for making complaints; also called grievances.

Both of these processes have been approved by Medicare. Each process has a set of rules, procedures, and deadlines that must be followed by us and by you.

More information is available in the Evidence of Coverage (reference the chapter: What to do if you have a problem or complaint) for your plan option. The guide in Section 3 will help you identify the right process to use and what you should do.

It is important to remember that your premium payment is due to IU Health Plans every month. See options below:

• Get a bill – Pay by check or call 800.455.9776, option 3 to speak to a Member Advocate (single payment)
• Electronic funds transfer (EFT) from your bank account on the 3rd of each month
• Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check
• The EFT from your bank account or automatic deduction from your Social Security or RRB check may take up to 3 months.
• Paying by Credit Card (Single Payment): Call 317.963.9700 / 800.455.9776 (TTY/TDD 711, option 3 to speak with a Member Advocate.

IU Health Plans does not accept payment for providers. If you owe a payment for medical services to a provider, please contact the provider billing office using the phone number on the billing statement.

Please Note: IU Health does not process premium payments for IU Health Plans.

Yes. If you have limited income and resources, you may be able to get extra help to pay your Part B premium. To see if you qualify for getting “Extra Help,” call:

• 1-800-MEDICARE (1.800.633.4227). TTY/TDD users should call 1.877.486.2048, 24 hours a day/7 days a week
• The Social Security Office at 800.772.1213, between 8 am to 7 pm, Monday through Friday. TTY/TDD users should call 800.325.0778 (applications)

A Prior Authorization is approval from a health plan that is required before you get some services or fill some prescriptions. This approval is needed in order for the service or prescription to be covered by your plan.

Some services, like surgeries, hospitalizations or durable medical equipment, can be done or purchased at different types of places. IU Health Plans wants to ensure that you are using the appropriate services, at the appropriate place, and at the best time for your care plan. With the Prior Authorization process, we have nurses and other clinicians that review your plan of care to make sure you are receiving the best quality of care. Prior authorization rules may still apply for services received using the out-of-network options with our Flex Network and Choice HMO-POS plans. Some prescriptions also require a prior authorization.

A prior authorization can be set up for a certain number of visits or days for a particular device (like a hospital bed). The authorization is specifically related to the dates of service you and your provider are requesting.

Services requiring prior authorization must be called in by the provider prior to any services being done. Any non-emergent after-hour requests can be submitted using the Provider Portal. This excludes emergency services, which do not require services to be prior authorized; these services can be called for authorization after services are provided.