Important plan documents

What does Medicare include?

Original or traditional Medicare includes Part A and Part B.

Medicare Part A is hospital insurance and helps cover:

• Inpatient hospital care
• Skilled nursing facility (SNF) care
• Hospice care
• Home health services

Medicare Part B is medical insurance and helps cover:

• Services from doctors and other healthcare providers
• Outpatient care
• Durable Medical Equipment (DME)
• Preventive services

How does Medicare work?

Original Medicare beneficiaries usually don’t pay a monthly premium for Medicare Part A (hospital insurance) coverage if either they or their spouse paid Medicare taxes while working. However, those who don’t qualify for Part A at no cost can still buy Part A.

Part B (medical insurance) does require that Medicare beneficiaries pay a monthly premium. This amount can vary, depending on income level, and is often deducted from your Social Security check.

You can contact Social Security for more information about Part A and Part B premiums. Also, there are deductibles and co-payments for Medicare Parts A and B.

What about prescription drugs?

For prescription drug coverage, you may join a stand-alone Prescription Drug Plan (PDP) or a Medicare Advantage Part C (MAPD) plan such as Aspire Health Plan that includes Part D.

In a stand-alone plan, participants pay a monthly premium for Part D coverage. But with Aspire Health Plan, your prescription drug coverage is included in one combined premium — it’s all-in-one.

What is a Medicare Advantage plan?

Medicare Advantage plans are referred to as Medicare Part C. They are offered by private
companies who have a contract with the Centers for Medicare and Medicaid Services (CMS) to cover all of your Medicare Part A and Part B benefits. Medicare Advantage plans cover everything that Original Medicare covers, and they typically cover more.

Why choose a Medicare Advantage plan instead of Original Medicare?

One third of Medicare beneficiaries are on Medicare Advantage plans. Medicare Advantage plans cover everything that Original Medicare covers, plus more. Many Medicare Advantage plans, including Aspire Health plans, cover Part D prescription drugs, transportation, acupuncture, and chiropractic. What’s more, our plans do not have an annual medical or hospital deductible — so you are covered from the start. Our low co-pays and co-insurance make your healthcare costs predictable and often save you substantial amounts of money when compared to Original Medicare.

What is a coordinated care plan?

A coordinated care plan provides the right care in the right place at the right time. Aspire works directly with members and their care providers (doctors, hospitals, pharmacies, and wellness centers) to keep our members healthier. Consider people who struggle to manage their diabetes and, as a result, sometimes end up in the emergency department with high or low blood sugar. We coordinate with the member’s doctor to ensure that diabetes monitoring and education services are provided. In addition, we can assign members with high-risk diabetes to their own care manager, who can assist and guide them.

Why choose our Aspire Health Plan over a Medicare supplement (Medigap) plan?

Insurance companies offer Medicare Supplement insurance. Aspire Medicare Advantage, however, is more than that.

1. Our plans include prescription drug coverage, making them a one-stop shop for all your healthcare needs, so you get an all-in-one plan with just one card
2. Aspire is a coordinated care plan designed by leading local doctors and medical specialists to maintain and/or improve the health of our members. It’s a community plan just for you
3. We don’t just fill in the gaps of what Medicare doesn’t cover, like deductibles and co-insurance. Instead, our coordinated team of healthcare providers administers all of your care including hospital, medical, and prescription drug coverage

Finally, Medicare supplement premiums can vary widely and typically do not cover prescription drugs or other additional benefits, such as transportation, gym membership, chiropractic, and acupuncture. With a Medicare Advantage plan such as ours, premiums remain the same regardless of your age and health history.

Can I continue to see my doctor?

Aspire partners with all four hospitals and more than 700 doctors and other providers in Monterey County. Our network of primary care physicians and specialists accepts our Medicare Advantage plans. If your doctor is among the list of providers, you may continue to see him or her. If not, you may choose another doctor or stay with your current plan.

Find out if your provider is part of our network by checking out our Provider and Pharmacy Directory.

How is Aspire’s HMO-POS plan different than the two HMO plans that Aspire offers?

All of our Medicare Advantage plans use an HMO network of doctors, specialists, hospitals, and other medical service providers. With any Aspire Health plan, you will first select a network primary care provider (PCP) here in Monterey County, who will help coordinate your care.

All of our plans provide nationwide coverage for urgent and emergent care situations, so don’t worry about emergencies or sudden illnesses that may arise when traveling. You are covered the same way you are in-network — anywhere in the country.

In our two HMO plans (Advantage and Value), when receiving non-urgent or non-emergent care, you must use the providers who are in our network.

When using our HMO Point of Service (POS) Plan (Plus Plan) in Monterey County, you must access the network of providers for your healthcare services. If you use providers who are in Monterey County but not in the plan’s network, you are fully responsible for the cost of those services. When you are outside of Monterey County and anywhere in the U.S. or its territories, the plan’s Point of Service component provides coverage for you to access Medicare-eligible providers and Medicare-covered services.

What is a Medicare Advantage “trial right?”

The Medicare Advantage “trial right” is designed to take some of the pressure out of choosing between a Medigap policy and a Medicare Advantage plan.

This trial right allows you to apply for a Medigap policy on a guaranteed issue basis if you join a Medicare Advantage plan for the first time and, within the first year of joining, decide to return to Original Medicare and purchase a Medicare supplement. You may qualify for a “trial right” under other circumstances. For more information, please visit www.medicare.gov.

How do I sign up for the optional Enhanced Benefits?

It’s easy. But please note that it will cost you an extra monthly premium. If you’re signing up for one of our health plans for the first time, you can elect the Enhanced Benefits option at the same time you choose your health plan.

If you don’t elect coverage at that time, you will have a short grace period in which you may still add the Enhanced Benefits, but you must apply for them within 90 days of your health plan effective date. After the 90-day window has passed, you will have to wait until the next Annual Election Period (AEP) to add them.

What if I sign up for the Enhanced Benefits and then decide I don’t want them?

No problem. You may drop your Enhanced Benefits coverage at any time throughout the year, and it will not affect your health plan coverage. If you choose to drop the coverage, you must provide a written request to the plan. Your Enhanced Benefits will end effective the first of the month following the month in which you notified the plan of your intent to disenroll.

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