HMO Guide for Seniors - Office of the Patient Advocate - State of ...

13
Questions & Answers
What do I pay for
prescription drugs?
There are several costs to
know about. See page 14. You
may have a separate deductible
and yearly out-of-pocket limit
for prescription drugs.
Are all co-pays the same?
No. Plans have different
co-pays for different services.
For example, you may pay $15
to see a primary care doctor
and $30 to see a specialist.
Some co-pays are high. You
may pay $200 a day for a
hospital stay. Or you may pay
$500 per hospital stay regardless
of the number of days.
What is a deductible?
It is what you pay each year
before your plan starts to
pay. Not all plans have a
deductible.
things you can do
Keep Your Costs Down
Know what your HMO does and does not pay for.
Ask your HMO for a Summary of Benefits.
If You Get a Bill
You may be billed for your premium, co-pay,
co-insurance, or deductible. In most other cases,
providers in your HMO’s network should not bill
you for their services.
If your letter says, “This is not a bill,” you don’t
have to pay anything.
Before you pay a bill, you can call your plan to
make sure it is correct.
Keep copies of all bills you pay, in case you
have a problem.
If your HMO will not pay your bill, but you think
it should, see page 59.
You Usually Have to Pay the Whole Bill If:
You get services that are not part of your
benefit package.
You see a specialist without a referral from
your primary care doctor.
You see a provider who is not in your HMO’s
network.
You get care outside your HMO’s service area,
unless it is emergency or urgent care.
where to find help
Medicare HMO Member or Customer Services
The number to call when you have a question about
your plan. It is listed on your membership card.