Frequently Asked Questions (FAQs)

No. You will not lose Original Medicare coverage if you enroll in our plan. You’re just choosing to allow a private company to administer your benefits instead of the federal government. You do not lose your Medicare benefits and you must continue to pay your Part B premium.

Your premium will stay the same every month during the calendar year unless you receive a Part D Late Enrollment Penalty (LEP) from the Social Security Administration. If you choose to enroll in the Optional Supplement Benefits during the year, this will be an additional monthly premium.

You can pay your premium by using electronic funds transfer (EFT) from your bank account or automatically deducted from your Social Security or Railroad Retirement Board (RRB) benefit check. You can also receive a monthly bill.

If you enroll in EFT, Social Security or RRB you don’t have to wait on a monthly bill or write checks. The EFT enrollment process usually takes 4-5 weeks. Enrolling in automatic withdraw from Social Security takes a minimum of 90 days. While you are waiting for EFT or Social Security withdraw to start, you will receive a monthly bill. You must pay your premium directly to Advantage MD.

Failure to pay your Advantage MD premium will result in being dis-enrolled from the plan. The plan encourages all members to make timely payments, by the first of every month. If a payment is not received for 3 consecutive months you will be dis-enrolled from the plan.

An LEP is an additional charge for not previously being enrolled in a Part D Plan. This penalty is determined by Medicare for the number of months not enrolled in a Part D Plan, if for any continuous period of 63 days or more after your Initial Enrollment Period is over, you go without one of these:

1. A Medicare Prescription Drug Plan (Part D)
2. A Medicare Advantage Plan (Part C) (like an HMO or PPO) or another Medicare health plan that offers Medicare prescription drug coverage.
3. Creditable prescription drug coverage (For example, prescription drug coverage from an employer or a union that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.)

Members can have a $0 premium and may still have a responsibility to pay a monthly LEP. Failure to pay the monthly LEP can result in being dis-enrolled from the Johns Hopkins Advantage MD plan by Medicare.

Advantage MD offers both HMO and PPO products. With an HMO plan, you must select a primary care provider (PCP) from our network who will coordinate your care. Your PCP will refer you to specialists or hospitals if you require additional care. You must get your care from providers that are in the Advantage MD network; if you go to a provider outside of our network for non-emergency care, you will be responsible for the entire cost.

With a PPO plan, you have the freedom to choose physicians and specialists from within our network, or seek care out of network. If you choose to see a provider that is not in the Advantage MD network, your out-of-pocket costs will be higher.

If you use providers that are not in our network, the plan may not pay for these services. For more information, review your Evidence of Coverage.

Yes, our HMO plan requires referrals for specialist visits. Your primary care provider will help to coordinate your care with any specialists you may require.

Advantage MD recommends verifying your provider’s network status regularly and especially before receiving services. It is important to verify because providers can opt out of the plan at any time throughout the year. To check our Provider Directory, please visit www.hopkinsmedicare.com/find-a-provider.

No, it is always best to verify the network status of your specific provider. Providers may have permission to practice at a facility, but may not be contracted with Advantage MD, which can impact the use of your benefits and your out-of-pocket costs. To check our Provider Directory, please visit www.hopkinsmedicare.com/find-a-provider.

If you meet certain income and resource limits, you may qualify for Extra Help from Medicare to pay the costs of Medicare prescription drug coverage. Visit the Social Security Administration’s website (www.ssa.gov) to see if you qualify. Maryland residents may also be eligible for The Senior Prescription Drug Assistance Program (SPDAP).
For more information, visit www.marylandspdap.com.

The donut hole, or coverage gap, starts when your total drug costs — including what you and your plan have paid for drugs — reaches $3,820 for the calendar year. When you enter the donut hole, the amount you pay for your prescriptions will increase. Because of this, you are eligible for discounts to help you pay for your drugs. You will pay 37% for generics drugs and 25% for brand name drugs. Discounts vary depending on the drug and your plan’s Formulary.

If your total out-of-pocket spending on prescriptions reaches $5,100, and the year’s not over, you move into the catastrophic phase for the rest of the calendar year. You pay very little for your prescriptions — either 5% or $3.40 per generic or $8.50 per brand — whichever is higher. The costs that help you reach catastrophic coverage also include most of the discounts on brand-name drugs that you received in the coverage gap. The amount your drug plan paid for your drugs in your initial coverage period also does not count. If someone else pays for your drugs on your behalf (i.e. family members, most charities, State Pharmaceutical Assistance Programs, AIDS Drug Assistance Programs and the Indian Health Service), this will also count toward getting you out of the coverage gap. You must continue to pay your drug plan’s monthly premium during the gap, but the premium does not count toward the out-of-pocket limit.