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Medicare questions: Medicare FAQ

Applying for Medicare

Q. When should I apply for Medicare? How can I apply for it?

A. If you plan to retire at age 65 …

Apply for Medicare through your local Social Security office 3 months before your 65th birthday, unless you’re already receiving Social Security benefits. You may have to pay a late enrollment penalty if you delay signing up for Medicare when you turn 65.

If you’re already receiving Social Security benefits …

You do not need to apply for Medicare. You will automatically be enrolled. Social Security will send you a packet with your Medicare card approximately three months before you turn 65.

If you plan to continue working after age 65 …

If you or your spouse continue to work, and you or your spouse are covered under a group plan, take your Medicare questions to your local Social Security office or your group benefits administrator. It might not be in your best interest to sign up for Medicare Part B right now.

Learn more about Medicare enrollment periods.

Q. What is Medicare Part D? And how do I get it?

A. Medicare Part D is a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries. Anyone receiving Medicare is eligible for Medicare Part D and can receive this coverage by enrolling in a Medicare Advantage plan with Part D coverage, a Medicare Cost plan with Part D, or a stand-alone Medicare prescription drug plan (PDP).

Medicare Part D plans vary in cost and drugs covered.

Here are the basics:

  • Medicare Part D can only be purchased through private organizations, such as Kaiser Permanente, and each organization’s benefit must be equal to (or better than) the government’s standard benefit design.
  • There are some Medicare Part D plans that offer prescription coverage only and do not cover Part A/B services.
  • There is a limited Annual Enrollment Period for joining a prescription drug plan.
  • Medicare also has a program to provide extra help for drug plan costs. To determine if you are eligible for this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213 (toll free) or 1-800-325-0778 (toll free TTY for the hearing/speech impaired), Monday through Friday, 7 a.m. to 7 p.m.
  • Our Kaiser Permanente Senior Advantage (HMO) Individual Plan[s] and some Medicare Plus (Cost) plans include Part D coverage.

Learn more about our Medicare Advantage and Medicare Cost plans. Browse our Medicare health Plans & rates page now.

Q. What is the difference between Medicare vs. Medicaid?

A. Medicare is a federal program that provides health insurance to people over 65 years old, people with end-stage renal disease (ESRD), and people under 65 with certain disabilities.

Medicaid (Medi-Cal in California) is a joint venture between individual states (and sometimes counties within them) and the federal government to provide a wider variety of health care services to those with limited income, financial resources, or who otherwise meet eligibility criteria as specified by the State.

Medicare eligibility is largely determined by age (with the exceptions mentioned above) while Medicaid eligibility generally depends on income. Some people are eligible for both Medicare and Medicaid.

For more information on the difference between Medicare and Medicaid you can check out the Centers for Medicare & Medicaid Services (CMS).

Eligibility

Q. Who is eligible for Kaiser Permanente Medicare health plans?

A. You are eligible to enroll in one of our Medicare health plans if you meet 3 requirements:

  1. You are entitled to Medicare Part A (hospital insurance) and enrolled in Part B (medical insurance). (If you live in Maryland, Virginia, or Washington, D.C., you only have to be enrolled in Part B.)
  2. You reside in our Kaiser Permanente service area for the plan in which you are enrolling.
  3. You do not have end-stage renal disease (ESRD). There are limited exceptions to this, such as if you are already a member of our plan (in the same region in which you wish to enroll).

Q. How does a Kaiser Permanente Medicare health plan differ from Original Medicare?

A. Kaiser Permanente Medicare health plans offer more benefits than Original Medicare, including (in most cases) Part D prescription drug coverage, plus built-in wellness programs that promote your total health — mind, body, and spirit.

As a member of our plan, you may pay monthly premiums and copayments for the services you receive from Kaiser Permanente, in addition to your Medicare premiums. Premiums will vary depending on where you live, and in many areas, we have $0 premium options. You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s).

Learn more about our Medicare Advantage and Medicare Cost plans. Browse our Medicare health Plans & rates section now.

Benefits, formulary, pharmacy network, provider network, premiums and/or and co-payments/co-insurance may change on January 1 of each year. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party.

Q. How do I enroll in a Kaiser Permanente Medicare health plan?

A. We offer 5 easy ways to enroll in our Medicare health plans.

1. Online
Enroll now online. The simple step-by-step process guides you through the enrollment form.

2. Over the phone with a licensed sales specialist
Call 1-866-973-4588 (toll free) or TTY 711, 8 a.m. to 8 p.m., 7 days a week.

3. At a personal appointment with a local sales specialist…
Call 1-866-973-4588 (toll free) or TTY 711, 8 a.m. to 8 p.m., 7 days a week. Dialing this number will connect you with a licensed sales specialist.

4. At a Straight-Talk Seminar in your neighborhood*

5. By mail

California residents:
Download our enrollment form below, complete it, and mail it to us. After completing the enrollment form, be sure to make a copy for your records.

California enrollment form
Also available in Chinese [中文本]♦ and Spanish (en español)

Kaiser Permanente – Medicare Unit
P.O. Box 232400
San Diego, CA 92193-2400

Colorado residents:
Download our enrollment form below, complete it, and mail it to us.

Colorado enrollment form
Also available in Spanish (en español)

Southern Colorado residents: 
As you fill in the enrollment form, you will need to choose a primary care physician if you have not done so already. Download the Southern Colorado physician directory♦ for help in choosing a doctor. After completing the enrollment form, be sure to make a copy for your records.

Senior Advantage Sales Department
Kaiser Permanente
P.O. Box 378022
Denver, CO 80237-9933

Northern Colorado residents: 
As you fill in the enrollment form, you will need to choose a primary care physician if you have not done so already. Download the Northern Colorado physician directory♦ for help in choosing a doctor. After completing the enrollment form, be sure to make a copy for your records.

Senior Advantage Sales Department
Kaiser Permanente
P.O. Box 378022
Denver, CO 80237-9933

Georgia residents:
Download our enrollment form below, complete it, and mail it to us. After completing the enrollment form, be sure to make a copy for your records.

Georgia enrollment form
Also available in Spanish (en español)

Kaiser Permanente Senior Advantage
3495 Piedmont Road N.E.
Nine Piedmont Center
Atlanta, GA 30305-1736

Hawaii, Oregon, and Washington residents:
Download our enrollment form below, complete it, and mail it to us. After completing the enrollment form, be sure to make a copy for your records.

Hawaii enrollment form Oahu/Maui
Hawaii enrollment form Big Island

Oregon/Washington enrollment form

Kaiser Permanente—Medicare Unit
P.O. Box 232407
San Diego, CA 92193-9914

Maryland, Virginia, or Washington, D.C. residents:
Download our enrollment form below, complete it, and mail it to us. After completing the enrollment form, be sure to make a copy for your records.

Maryland, Virginia, or Washington, D.C. enrollment form

Kaiser Permanente Medicare Plus
Attn: Sales, 5E
2101 East Jefferson Street
Rockville, MD 20852


As you fill in the enrollment form, you will need to choose a primary care physician if you have not done so already. You can search for a doctor online or download the Maryland/Virginia/Washington, D.C. physician directory♦. After completing the enrollment form, be sure to make a copy for your records.

Medicare beneficiaries may also enroll in our Medicare health plans through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at www.medicare.gov.

Have more questions about how to enroll? Contact us by phone.

Q. When can I switch Medicare health plans?

A. The Annual Enrollment Period for Medicare Advantage and Cost plans with Part D prescription drug coverage is October 15 to December 7 each year. Your coverage will be effective January 1. During this time, you can switch from your current plan to any other plan.

For Kaiser Permanente Medicare Plus (Cost) members (available in Maryland, Virginia, and Washington, D.C.), if you have stand-alone prescription drug coverage and just need medical and hospital coverage, you can enroll anytime in a Kaiser Permanente Medicare Plus plan without Medicare Part D prescription drug coverage.

During the Medicare Advantage Disenrollment Period, from January 1 to February 14 every year, you can cancel your Medicare Advantage and switch to Original Medicare (Parts A and B only) or enroll in a Medicare Cost plan with or without Part D coverage. If you switch to Original Medicare or enroll in a Cost plan without Part D, you also may choose a separate Medicare prescription drug plan (PDP) at this time.

You may enroll in a Medicare Advantage Plan that has an overall 5-star rating during the year in which that plan has the 5-star overall rating, provided that you meet all Medicare health plan enrollment requirements. If you are enrolled in a plan with a 5-star overall rating, you may still switch to another plan that has a 5-star overall rating. You may use this SEP one time from December 8 through November 30 of the following year. The enrollment effective date is the first of the month following the month in which the plan receives the enrollment request.

Learn more about Medicare enrollment periods.

Q. Will I be turned down for membership in one of Kaiser Permanente’s Medicare health plans because of my age or medical condition?

A. No. Enrollment in a Kaiser Permanente Medicare health plan requires no health exam, and there is no age limit. However, if you have end-stage renal disease (ESRD) and require dialysis, you are not eligible for one of our Medicare health plans unless you are currently a member of the Kaiser Permanente region in which you wish to enroll, and were diagnosed with ESRD while a member. You may join our plan if you have had a kidney transplant and no longer require life-sustaining dialysis.

Q. If I join a Kaiser Permanente Medicare health plan, will I lose my Medicare coverage?

A. No. When you become a member of our plan, your Medicare benefits will be provided to you by Kaiser Permanente. You must maintain your Part B Medicare enrollment in order to keep your coverage in our Medicare health plan.

Getting started with Kaiser Permanente

Q. How do I start using my Kaiser Permanente plan benefits?

A. Visit our website for new members and start taking advantage of the many benefits of a Kaiser Permanente membership. Find facility locations near you, choose your doctor, try out our online health services, explore our built-in wellness programs, and more.*You should receive your Kaiser Permanente ID card and other information about your plan benefits within 10 days of your enrollment confirmation.

Q. Can I choose my own doctor?

A: Yes, you can choose your own personal Kaiser Permanente physician from our extensive network of doctors, with the freedom to select a new doctor within the network at any time. All of our available physicians accept Medicare health plan members. Simply visit kp.org/mydoctor.

When you join one of our Medicare health plans, you agree to receive all of your medical services through Kaiser Permanente, except for emergency care, urgently needed services, out-of-area renal dialysis, and referrals as authorized by Kaiser Permanente. If you receive other routine services from non-Kaiser Permanente practitioners without prior authorization, Kaiser Permanente and Original Medicare will not pay for these services.

For Kaiser Permanente Medicare Plus (Cost) members (available in Maryland, Virginia, and Washington, D.C.):

You may use your Original Medicare benefits and go to any non-Kaiser Permanente health care provider who accepts Medicare. You will have to pay Original Medicare deductibles and coinsurance for the care you receive from non-Kaiser Permanente providers.

For Kaiser Permanente Senior Advantage (HMO-POS) members:

Kaiser Permanente Senior Advantage Plus Choice (HMO-POS) has formed a network of doctors, specialists, and hospitals, You can use any doctor who is part of our network. In some cases, you may also go to doctors outside of our network. Generally, you are restricted to a doctor who is part of our 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 and /or out of network.

Q. What about coverage while I'm traveling?

A. With most of our Medicare health plans, you don’t have to worry when you’re traveling—even if you’re traveling outside the U.S. Wherever you go, you can have peace of mind knowing that you’ll be covered worldwide for medically necessary emergencies or urgently needed care for a maximum of three to twelve consecutive months, depending on your plan. You will need to submit claim forms to be reimbursed for these services.

For more detailed information on coverage while traveling, please refer to your Evidence of Coverage or contact Member Services.

Note: Kaiser Permanente Medicare Plus Basic Option plan (MD, VA, and DC) does not include urgent or emergency care outside the United States except under limited circumstances.

Q: Does Medicare cover dental?

A: Original Medicare does not provide dental coverage, but many of our Medicare health plans offer dental services through Advantage Plus, an optional, supplemental benefit package. With Advantage Plus, you can add more coverage such as dental, vision, and hearing benefits for an additional premium each month.

For more information, visit our plans and rates section or call us.

Q: How do I ask for a coverage decision?

A: When a coverage decision involves your medical care or asking us to pay you back or pay a bill you have received, it is called an organization determination. To request for a coverage decision on medical care or service you want but have not received, or to pay a bill, you may call, write or fax Member Services. If your health requires a quick response, you should ask us to make a "fast coverage decision". You, your doctor, or your representative can make the request for medical care. We will provide a response for a fast coverage decision within 72 hours. A response for a standard request for care or services can take up to 14 calendar days. A response for a request for payment can take up to 30 days. If we say no to your request for coverage for medical care or payment, you may seek an appeal. (See "How do I make an appeal?"). For additional details, refer to Chapter 9 in your Evidence of Coverage.

Q: How do I make an appeal?

A: If we say no to your request for coverage for medical care or payment of a bill you have the right to ask us to reconsider, and perhaps change the decision by making a Level 1 Appeal. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage or payment decision.

  • For a standard appeal, write to Member Services to make your appeal. If your health requires a quick response, you must ask for a "fast appeal" (also called an expedited reconsideration) by writing or calling Member Services. You, your doctor, or your representative can do this. If your representative is appealing our decision for you, your appeal must include an Appointment of Representative form authorizing this person to represent you.
  • We consider your appeal and we give you our answer. A response for a fast appeal request will be within 72 hours. A response for a standard appeal request for medical care you have not received can take up to 30 calendar days. A response for a standard appeal request for payment of a bill can take up to 60 calendar days.
  • If our plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process. To make sure we were following all the rules when we said no to your appeal, we are required to send your appeal to the Independent Review Organization. This means your appeal has gone to Level 2. The Independent Review Organization reviews your appeal carefully and gives you its decision in writing and explains the reasons for it.

For additional details, refer to Chapter 9 in your Evidence of Coverage.

Q: How do I make a complaint about Kaiser Permanente’s process or services?

A: If you are unhappy with the medical care or services you are receiving, or if you are unhappy with our processes, you can make a complaint, also known as filing a grievance. Contact Member Services within 60 days of the event or incident, by phone or in writing. If there is anything else you need to do, Member Services will let you know. We look into your complaint and give you our answer within 30 calendar days. For additional details, refer to Chapter 9 in your Evidence of Coverage.

You may obtain a summary of information about the appeals and grievances that plan members have filed with Kaiser Permanente. To get this information, please contact Member Services.

 


 

Benefits, formulary, pharmacy network, premiums, and copayments/coinsurance may change on January 1 of each year.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply.

 

 

*The products and services described above are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Kaiser Permanente grievance process.

Q. Can I be disenrolled from a Kaiser Permanente Medicare health plan?

A. You cannot be disenrolled because of your health status. Your membership can be terminated for other reasons, which may include, but are not limited to, the following:

  • failing to pay your Kaiser Permanente premium, if one is required under your plan
  • living temporarily out of the service area for more than 90 consecutive days if you are in a Kaiser Permanente Medicare Plus (Cost) plan without Part D, 12 months if you are in a Kaiser Permanente Medicare Plus plan with Part D, or for more than 6 months if you are in a Kaiser Permanente Senior Advantage (HMO) plan
  • moving permanently out of the service area
  • not maintaining your enrollment in Medicare

There are a few other causes for disenrollment, which are explained in the Evidence of Coverage.

Q. What happens if I move out of the service area?

A. While temporarily outside the Kaiser Permanente service area, coverage is limited to medically necessary emergencies, urgent care, and, for Kaiser Permanente Senior Advantage (HMO) members, renal dialysis services.

Note: if you are outside of the service area for more than 3 to 12 months, depending on your plan, or move permanently outside of our service area, Medicare requires us to disenroll you from our plan. Call us, and we can help you with coverage when you travel or move.


Kaiser Permanente is not responsible for the content or policies of external Internet sites.



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Call 1-877-852-5081
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Schedule a personal appointment with a local sales specialist

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