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FAQ

What is Medicare?

Medicare is a federal government program, run by the Center for Medicare & Medicare services (CMS), which provides health insurance coverage to individuals who are eligible for Medicare through age or disability.

Medicare provides four coverage options:

• Part A: provides help with hospital costs
• Part B: provides help with doctor and other outpatient costs
• Part C: also known as Medicare Advantage. allows you to receive your Medicare Part A & part B benefits from a private health plan like Carilion Clinic Medicare Health Plan.
• Part D: Prescription drug benefit added to Medicare as part of the 2003 Medicare Modernization Act (MMA). Drug coverage is limited to drugs on a plan's formulary.

For more information about Medicare, please visit our Resources page.

What is Medicare Advantage?

Medicare Advantage is the newest program of private health plans within the Medicare system. It enables those who qualify for Medicare to enjoy an unprecedented level of personal freedom in choosing the healthcare options that they believe are best for them. Instead of receiving benefits from the government, beneficiaries can choose to receive them from a health plan that contracts with Medicare, like Carilion Clinic Medicare Health Plan. These plans provide all the Part A and Part B covered services and may offer extra coverage for other medical services. Many plans, including Carilion Clinic Medicare Health Plan also include Medicare Prescription Drug coverage (Part D).

What is a Medicare Advantage Health Maintenance Organization (HMO)?

These plans offer a set of pre-determined and pre-paid services provided by a network of physicians and hospitals which have a contract with the Medicare Advantage Plan. When you enroll in an HMO, you must use network providers except in emergent or urgent situations. If you obtain routine care from out-of-network providers neither Medicare nor Carilion Clinic Medicare Health Plan will be responsible for the costs.

What is a Medicare Point of Service (POS) Plan?

This plan gives you the option of using providers in or out of the plan’s network. With Point of Service (POS) plans, you can choose to reduce your out-of-pocket costs by choosing providers in the plan’s network – or you can seek services outside the network and you will usually pay more.

Why choose Carilion Clinic Medicare Health Plan?

Sponsored by Carilion Clinic, the Carilion Clinic Medicare Health Plan offers more benefits than Original Medicare, affordable coverage, a range of benefit options and prescription drug coverage. Carilion Clinic Medicare Health Plan is a local health plan, sponsored by Carilion Clinic and served by seven Carilion Clinic hospitals and more than 600 physicians, including 131 non-Carilion physicians in the network.

Which Medicare Advantage plans does Carilion Clinic Medicare Health Plan offer?

The Carilion Clinic Medicare Health Plan offers four Medicare Advantage HMO plans:

• Bronze (HMO-POS)*: A $0 monthly premium plan that allows members to determine – at the point of service – whether they want to receive certain designated services within the Health Plan Provider Network, or seek such services outside the Plan’s network. Network primary care visits are $10 and services available outside of the Plan’s provider network are specified. If you choose to use out-of-network providers, deductible and co-insurance apply..
• Silver (HMO-POS)*: A $35 monthly premium plan that allows members to determine – at the point of service – whether they want to receive certain designated services within the Health Plan Provider Network, or seek such services outside the Plan’s network. Network primary care visits are $10 and services available outside of the Plan’s provider network are specified. If you choose to use out-of-network providers, deductible and co-insurance apply.
• Gold (HMO-POS)*: A $70 monthly premium plan that also allows members to determine whether they want to receive certain designated services within the Health Plan Provider Network, or seek such services outside the Plan’s network. This product provides additional coverage for inpatient hospital care, lower copayments for specialty care office visits as well as lower copayments and additional coverage for some ancillary services. Network primary care visits are $0 and services available outside of the Plan’s provider network are specified. If you choose to use out-of-network providers, deductible and co-insurance apply.
• Platinum (HMO-POS)*: A $149 monthly premium plan that allows members the choice of using in or out-of-network providers. Provides coverage similar to Medicare Supplement plans and includes prescription drug coverage. There are no copays for network primary care and specialist office visits as well as in-patient hospital stays.

*You must continue to pay your Medicare Part B premium. For full information on Carilion Clinic Medicare Health Plan benefits, call our Customer Service Department at 800-779-2285, TTY 877-225-3157, Monday through Friday, 8 am to 8 pm.

If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for it to take effect and you will remain responsible for those premiums.

Where is the Carilion Clinic Medicare Health Plan available?

The service area for this plan includes Bedford, Buena Vista, Lexington, Radford, Roanoke and Salem, and the counties of Bedford, Botetourt, Craig, Floyd, Franklin, Giles, Montgomery and Roanoke. You must live in one of these areas to join the plan.

Who is eligible to join Carilion Clinic Medicare Health Plan?

You can join a Carilion Clinic Medicare Health Plan if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease are generally not eligible to enroll in Carilion Clinic Medicare Health Plan unless they are members of our organization and have been since their dialysis began. More information is available by clicking here.

What happens if I go to a doctor who is not in the Carilion Clinic Medicare Health Plan’s network?

You can go to primary care doctors, specialists, or hospitals in or out of network. You may have to pay more for the services you receive outside the network, and you may have to follow special rules prior to getting services in or out of network.

Do the Carilion Clinic Medicare Health Plans include prescription drug coverage?

Yes, your Carilion Clinic Medicare Health Plan covers both Medicare Part B prescription drugs and Medicare Part D prescription drugs.

More information can be found in our Part D Coverage Section.

Where can I get my prescriptions if I join this plan?

Carilion Clinic Medicare Health Plan has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits, except under non-routine circumstances when you cannot reasonable use network pharmacies. The plan may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time.

For additional network pharmacy information please call our Customer Service Department at 866-544-6981, TTY 800-716-3231, 24 hours, 7 days a week

Can I get extra help with my prescription drug costs?

Yes, if you qualify you may be able to get extra help to pay for your prescription drug premiums and costs. See more information for low-income individuals.

When can I enroll?