Medicare Advantage Plans - Frequently Asked Questions

IU Health Plans offers a variety of plans in 36 counties across Indiana. Review our plans by county to see if IU Health Plans is available in your area. To speak with a Member Advocate call 317.963.9700. If you would prefer an in-person consultation, call 866.308.2018 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. Those who qualify will not be subjected 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 Extra Help, 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.

Review the list of IU Health Plans covered yearly services, including preventative health services. There is also an app you can download on your phone called “What’s Covered”, the Official Medicare coverage app

IU Health Plans offers Medicare Advantage plan options. We recommend reviewing your plan options and then requesting an estimate of your potential costs by speaking with an agent at 317.963.9700 (option 1) now. If you would prefer an in-person consultation, call 866.308.2018 or request a consultation online.

Medicare beneficiaries can qualify for Extra Help with their Medicare prescription drug plan costs. Extra Help can reduce the plan premium and prescription drug costs. Many people are eligible for these savings and don’t even know it. For more information about Extra Help, contact your local Social Security office or call 800.MEDICARE (800.633.4227), 24 hours a day, 7 days a week. TTY users should call 877.486.2048. To qualify for the Extra Help, a person must be receiving Medicare, have limited resources and income, and reside in one of the 50 states or the District of Columbia.

If you would like help with this application or understanding your options, free counseling is available through the Senior Health Insurance Information Program (SHIP) at 800.452.4800; TTY 866.846.0139 or go to Medicare.in.gov.

Many people are eligible for these savings and don’t even know it. For more information about Extra Help, contact your local Social Security office or call 800.MEDICARE (800.633.4227), 24 hours a day, 7 days a week. TTY users should call 877.486.2048.

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.

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. The document will also address any new changes to your plan that were implemented at the start of the year. You can find your plan specific Evidence of Coverage document by logging into your member portal.

Each September, you will receive the Annual Notice of Changes to see what's 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.

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. See our Provider/Pharmacy Directory.

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.

To review the healthcare providers, facilities and pharmacies covered in our network, please view our provide/pharmacy directory where you can search our healthcare providers and facility locations.

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 your 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 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. Please review our Medicare Advantage forms for more details.

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 Provider/Pharmacy Directory for a complete list of network pharmacies.

Tip: Look for pharmacies marked as preferred retail pharmacies (including Costco, CVS, Kroger, Target, Walmart and IU Health retail pharmacies) Preferred pharmacies offer lower copayments for tier 1 and 3 prescriptions. To better understand pricing differences within the pharmacy benefit, view the 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*. Receiving an annual wellness visit could earn you a reward. Review the list of IU Health Plans covered yearly services, including preventive health services.

*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.

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 and ce

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); or

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.

Your provider is aware of the timelines in which prior authorization decisions are made. The prior authorization department can be reached at 866.492.5878 for immediate or routine needs. Routine after-hours calls will be answered by the departmental voicemail and returned the next business day; for urgent requests, please call the on-call nurse at 317.910.0499.

A prior authorization can be set up for a certain number of visits or for a particular device (like a hospital bed). The authorization is not really for a length of time but rather related specifically to the services you and your provider are requesting.

Services requiring prior authorization must be called in by the provider prior to any services being done. This excludes emergency services, which do not require services to be prior authorized; these services can be called for authorization after services are provided.