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.

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

The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums. Y ou 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.  The late enrollment penalty is not determined by the Johns Hopkins Advantage MD 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)
3. Another Medicare health plan that offers Medicare prescription drug coverage
4. Creditable prescription drug coverage.

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.

Certain medical services and supplies may require approval before they will be covered by your plan, such as specialty medical care, inpatient mental health treatment or inpatient substance-abuse treatment. Your Evidence of Coverage indicates which services, supplies or medications require prior authorization. For Advantage MD PPO, Plus PPO and Premier PPO plans, no prior authorization is required for out-of-network providers eligible to participate in Medicare and most services and supplies as long as the services are covered benefits and medically necessary. All prior authorization requests are coordinated through your primary care physician (PCP), so your provider must ask for and receive approval before you receive care. Johns Hopkins Advantage MD will review the service, drug or equipment to determine the necessity or appropriateness of the services being authorized. If prior authorization is not given, then coverage for care, services or supplies may be limited or denied. For more information on prior authorization guidelines specific to your Advantage MD plan, refer to your Advantage MD Evidence of Coverage.

A referral is a written order from your PCP giving you permission to see a specialist or receive certain medical services. For Advantage MD HMO and D-SNP plans, you will need a referral from your PCP before you can see a specialist and be covered for that care. For information on getting a referral for care specific to your Advantage MD plan, refer to your Advantage MD Evidence of Coverage.

Yes, our HMO plan requires referrals for specialist visits. Your PCP will help coordinate your care with any
specialists you may require. Johns Hopkins Advantage MD is a Medicare Advantage Plan with a Medicare contract offering HMO and PPO products. Enrollment in Johns Hopkins Advantage MD HMO or PPO depends on contract renewal.

Site of service is a term used to indicate the facility in which you receive care. Many surgical procedures can be performed safely in an outpatient hospital setting, such as an ambulatory surgery center (ASC). Certain procedures require prior authorization when performed in an outpatient hospital setting. For information on covered outpatient services specific to your Advantage MD plan, refer to your Advantage MD Evidence of Coverage.

Some medications require prior authorization from your plan before they can be dispensed by your in-network pharmacy. This helps us ensure that your prescriptions are medically necessary. To determine if a medication requires prior authorization, refer to the Pharmacy Formulary specific to your Advantage MD plan. Your physician can request these medications by submitting a prior authorization request. Information about covered medications, medication prior authorization requirements and pharmacy plan benefits are available here.

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 $4,660 for the 2023 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 25% for generics and brand name drugs. Discounts vary depending on the drug and your plan’s Formulary.

If your total out-of-pocket spending on prescriptions reaches $7,400, and the year’s 2023 not over, you move into the catastrophic phase for the rest of the calendar year. You pay very little for your prescriptions — 5% of the cost of the drug or $4.15 per generic and $10.35 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. You can review your “Monthly Prescription Drug Summary” that Advantage MD sends to you in the mail if you have filled a prescription. This will help you determine which stage you are in and when you will move to the next stage. Or you can log onto Caremark.com to check your current out-of-pocket spending.

To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in the plan’s service area. The Johns Hopkins Advantage MD (HMO) service area includes the following counties in Maryland: Anne Arundel, Baltimore, Carroll, Frederick, Howard, Montgomery, Somerset, Washington, Wicomico, and Worcester.

The Johns Hopkins Advantage MD (PPO) and Johns Hopkins Advantage MD Plus (PPO) service area include the following counties in Maryland: Anne Arundel, Baltimore, Carroll, Frederick, Howard, Somerset, Washington, Wicomico, and Worcester. (Not available in Montgomery County.)

The Johns Hopkins Advantage MD Premier (PPO) service area includes Montgomery County only.

You must contact Social Security Administration at 800-772-1213, Monday through Friday, 8 a.m. – 5:30 p.m. In addition, you must contact Johns Hopkins Advantage MD Customer Service at 877-293-4998 (HMO) or 877-293-5325 (PPO). From October 1 – March 31, our Customer Service hours are Monday through Sunday 8 a.m. – 8 p.m. From April 1 – September 30, our hours are Monday through Friday 8 a.m. – 8 p.m.

D-SNP stands for Dual Eligible Special Needs Plan. These plans enroll individuals who are entitled to both Medicare and Medicaid. These plans must cover the same Medicare services that all Medicare Advantage plans cover and may also cover extra services. To join a D-SNP plan you must meet the eligibility requirements. To find out more about Johns Hopkins Advantage MD D-SNP (HMO) see your 2023 Summary of Benefits or 2022 Summary of Benefits. To see if you qualify for Medicaid visit www.marylandhealthconnection.gov.