FAQs About Medical Plans

Click on any question to read the answer, below. You will also find answers to questions about the drug plan portion of your coverage under the Prescription Plan FAQs.


What should I do if I have other insurance in addition to Medicare?

What are my protections if I enroll in a PriorityMedicare plan?

How can I compare your plans to my other Medicare options?

Where are PriorityMedicare plans available?

Can I choose my doctors?

What happens if I go to a doctor who's not in the PriorityMedicare network?

Can I disenroll from my plan?


Q: What should I do if I have other insurance in addition to Medicare?
If you have Medicare supplemental insurance that fills gaps in the original Medicare plan, you may not need it if you join PriorityMedicare^SM or PriorityMedicarePlus^SM. If you drop your supplemental policy, you may not be able to get the same one back. You should check into this carefully before you drop your supplemental policy to make sure you have all of the coverage you need. You or your spouse may have, or be able to get, employer group health coverage. If so, you should talk to the employer to find out how your benefits will be affected if you join a PriorityMedicare plan. Get this information before you decide.


Q: What are my protections if I enroll in a PriorityMedicare plan?
1.  One-Year Coverage Guarantee. All medical plans in the Medicare program (including PriorityMedicare and PriorityMedicarePlus) agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare health plan leaves the program, you will not lose Medicare prescription drug coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

2. Requests for Exceptions, Appealing Our Decisions, and Filing Grievances (complaints). As a member of our plans, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination; you may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception rquest. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or with one of our network pharmacies that does not involve coverage for a prescription drug.
Read more about the exceptions, appeals and complaints process.


Q: How can I compare your plans to my other Medicare options?
Our members receive all of the benefits that the original Medicare plan offers. We also offer more benefits, which may change from year to year. Look in the Summary of Benefits brochure for any PriorityMedicare^SM medical plan to see a chart comparing its benefits to the original Medicare plan.
Go to the Summary of Benefits for PriorityMedicare and PriorityMedicarePlus medical + prescription plans
Go to the Summary of Benefits for PriorityMedicareRx prescriptions-only plan


Q: Where are PriorityMedicare plans available?
PriorityMedicare and PriorityMedicarePlus medical + prescription plans are available in all of Allegan, Antrim, Benzie, Crawford, Grand Traverse, Kalkaska, Kent, Leelanau, Manistee, Montcalm, Muskegon, Oceana, Osceola, and Ottawa counties in Michigan. If you are covered by an employer that offers PriorityMedicare but you do not live in one of these counties, contact the employer group representative to see if you are eligible. PriorityMedicareRx^SM, a Medicare prescription drug plan, is offered everywhere in the state of Michigan.


Q: Can I choose my doctors?
PriorityMedicare and PriorityMedicarePlus medical plans have a network of doctors, specialists and hospitals. You can use any doctor or other health care provider who is part of our network. You may also go to doctors outside our network, but you costs may be higher. The health care providers in our network can change at any time. Check the Provider Directory for a list. (You can also search our online interactive Find a Doctor tool for doctors who participate in these plans, but you will be leaving the PriorityMedicare section of this website.)


Q: What happens if I go to a doctor who's not in the PriorityMedicare network?
You can go to doctors, specialists, pharmacies or hospitals out of the network, but you may have to pay more for the services you receive, and you may have to follow special rules prior to getting services.  Learn more about using out-of-network health care providers.


Q: Can I disenroll from my plan?
There are limits to when you may leave, how often you can make changes, and what type of plan you can join after you leave. You may only enroll in or disenroll from a plan during specific times of the year, unless newly eligible for Medicare. For 2007 coverage, you must sign up between November 15 and December 31, 2006. Your next opportunity to change plans won't be until November 15, 2007 (for 2008 coverage).

There are also a few situations where you would be required to leave. For example, we will disenroll you from your PriorityMedicare plan if you move permanently out of our geographic service area. We are not allowed to ask you to leave the plan because of your health.

If you disenroll from your PriorityMedicare plan, it may take some time for your membership to end and your new way of getting Medicare to take effect. Until your membership ends, you must keep getting your Medicare services through PriorityMedicare or you will have to pay for them yourself.

For more information about your rights and responsibilities, or the disenrollment process, see your plan's Evidence of Coverage document.