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Federal Consumer Information Center Medicare Questions and Federal Consumer Information Center: Medicare - Questions and Answers

Section 2: Other Medicare Health Plans (continued)

Q: Is there any other time when I may be guaranteed issuance of a Medigap policy?

A: You are guaranteed issuance of ANY Medigap policy if:

• When you first become eligible for Medicare at age 65, you joined a Medicare health plan other than the Original Medicare Plan, and

• You then disenroll from that plan within 12 months of the effective date of when you joined.

You must apply for the Medigap policy within 63 calendar days of disenrolling from the health plan. If you are denied Medigap coverage, you should call your state insurance department.

* * You can find phone numbers for your area in your copy of Medicare & You or on the Internet at under Important Contacts.

Q: What is a medical emergency? How do I get emergency care if I am in a Medicare managed care plan?

A: A medical emergency includes severe pain, an injury, sudden illness, or suddenly worsening illness that you believe may cause serious danger to your health if you do not get immediate medical care. Your plan is required to provide access to emergency and urgently needed care services 24 hours a day, 7 days a week. Your plan must pay for your emergency care and cannot require prior authorization for emergency care you receive from any provider. You can receive emergency care anywhere in the United States. When you receive emergency care, the doctor or hospital that provides the service will bill either you or your plan. If you receive the bill, give it to your plan, and keep a copy for your own record. Following a medical emergency, your plan must also pay for care you need before your condition is stable enough for you to return to your plan’s provider. If your condition lets you return to the plan service area, you will need to get follow- up care from your Medicare managed care plan. You should let your plan know of emergencies as soon as medically possible. If what you believed was an emergency turns out not to be, the plan must still pay. Your plan can require that you pay the entire cost of care received in an emergency room for a problem that you knew was not an emergency. You can appeal a denial of payment for emergency services.

Q: What is “urgently needed care”? How do I get urgently needed care if I am in a Medicare managed care plan?

A: Unexpected illness or injury that needs immediate medical attention, but is not life threatening, is urgently needed care. Your primary care doctor generally provides urgently needed care. If you are temporarily out of the plan’s service area and cannot wait until you return home, the health plan must pay for urgently needed care.

Q: Does travel affect my health care? How does the Medicare managed care plan handle coverage when I’m not in the service area?

A: If you travel a lot or live in another State part of the year, you should contact the plan and ask if the plan provides coverage for services when you are out of the service area. The Original Medicare Plan does not cover care outside the United States. Some Medicare managed care plans, as well as some of the more expensive Supplemental Insurance (Medigap) policies, cover care outside of the U. S.

Railroad retirees have different rules. Call the Railroad Retirement Board at 1- 800- 808- 0772 for information.

Q: Will Medicare managed care plans pay for services under a private contract?

A: No. See the information on private contracts.

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