Most Commonly Asked Questions

Note: The date shown in parenthesis at the end the question represents the date the information was added or last verified. Some answers to previously asked questions may have changed to provide further clarification.

Enrollment

Q1. Will I receive an insurance card for the Pilot program? (February 2015)
A1. No. Beneficiaries will receive an enrollment letter from the Pilot program. The letter should be kept as proof of enrollment and can be shown to your medical providers/suppliers and pharmacies.

Q2. What if I do not live in Lincoln or Flathead County? (February 2015)
A2. Under the Affordable Care Act, the initial coverage area for the Pilot program was limited to the Libby area. The Libby area includes Lincoln and Flathead County. Those enrolled in Medicare under the Environmental Health Provision have the “usual” Medicare coverage no matter where they live. As of March 2014, the Pilot Program expanded to also include coverage in the following additional counties:

• Montana: Glacier, Lake, Mineral, Missoula, Sanders
• Idaho: Benewah, Bonner, Boundary, Clearwater, Kootenai, Latah, Shoshone
• Washington: Lincoln, Pend Oreille, Spokane, Stevens, Whitman

Q3. I would like to enroll in the Pilot program but I do not have Part B. What can I do? (February 2015)
A3. In order to enroll in the Pilot program, you must have Medicare Part B. Medicare is allowing a Special Enrollment Period (SEP) to enroll in Part B. This SEP ends May 30, 2015. If you do not enroll in Part B during the SEP, you may enroll during the General Enrollment Period (January through March of each year). In addition, a 10% late enrollment penalty will apply for each 12 month period you did not have Part B coverage, which starts from the time you were first eligible to enroll in Medicare.

Q4. How much is the Medicare Part B premium? (February 2015)
A4. The monthly premium for 2014 is generally $104.90, but could be higher depending on your income.

Q5. If I’m currently enrolled in Medicare and I enroll in the Pilot program, will my Medicare number change? (February 2015)
A5. No, your Medicare number will not change.

Q6. Is there a certain timeframe I need to enroll in the Pilot program? (February 2015)
A6. No, you may enroll in the Pilot program at any time during the year. If you meet the requirements for the Pilot program, you may contact Noridian to enroll after you have received notification from the Social Security office with your EHH designation. The effective date for the Pilot program will be the first of the month following which you call to enroll. For example, if you call us to enroll June 15th, your effective date in the Pilot will be July 1st.

Coverage

Q1. What services are covered under the Pilot program? (February 2015)
A1. Please refer to Potential Benefits of Pilot Program. Services are based on the individual needs of the beneficiary along with medical necessity. It is difficult to give a listing of all services covered as the individual needs of the beneficiaries vary greatly. If you have questions regarding coverage, please call 1-888-469-9464 for additional information and to obtain a prior authorization.

Q2. What types of home care assistance services are reimbursable? (February 2015))
A2. All services are based on the individual needs of each beneficiary. Examples of home care services that may be covered are general light housekeeping and meal preparation. The care coordinator will determine if home care services are reasonable and necessary for a beneficiary enrolled in the Pilot program.

Q3. What are the requirements to get reimbursed for travel costs to doctor appointments? (February 2015)
A3.The Pilot program reimburses for mileage to travel to medically necessary medical appointments such as doctor appointments, having lab work or other testing done, and hospitalization. You may submit a claim to the Pilot program which includes the name and phone number of the physician, facility or hospital, and number of miles traveled round trip. Please submit proof of attendance at that appointment with your claim. You will receive reimbursement for mileage once the claim is received and information is verified. If you have Medicaid coverage that reimburses for travel, the Pilot program will not provide reimbursement. The Pilot program does not reimburse for meals or overnight stays.

Q4. What is an acceptable form of proof of attendance for a medical appointment? (February 2015)
A4. A visit summary, co-payment receipt, explanation of benefits from insurance company, signed and dated letter from the doctor. The proof of attendance must show the appointment date, time, and facility. Please note that an appointment reminder card is not acceptable as proof of attendance.

Q5. Does the Pilot program reimburse the Medicare deductible and coinsurance? (February 2015)
A5. Deductible and coinsurance amounts are costs you may be required to pay as your share of the cost for an item or service. The Pilot program does not reimburse the Medicare deductible or coinsurance amounts.

Q6. Am I still eligible for services if I am not at my permanent residence during the winter months? (February 2015)
A6. Yes, as long as your permanent residence is located within the counties included in the Pilot program; however you must be present at your residence in order to receive reimbursement for services at this residence.

Q7. What types of nutrition supplements are reimbursable? (February 2015)
A7. Nutritional supplements must be prescribed by your physician in order to be considered for coverage under the Pilot program. Examples of nutritional supplements include liquid nutrition such as Ensure, Boost, or other brands.

Q8. Are medications covered under the Pilot program? (February 2015)
A8. In order to have prescription drug coverage under the Pilot program, you must have a Part D plan or other creditable coverage. As a reminder, co-payments are not reimbursable through the Pilot Program.

Q9. What is creditable coverage? (February 2015)
A9.Creditable coverage is drug coverage that is expected to pay; on average, at least as much as standard Medicare prescription drug coverage. Creditable prescription drug coverage  could include drug coverage from a current or former employer or union, TRICARE, Indian Health Service, the Department of Veterans Affairs, or health insurance coverage. Your plan must tell you each year if your drug coverage is creditable coverage. You may get this information in a letter or in a newsletter from the plan.
Please note: If your Pilot enrollment letter indicates you do not have creditable coverage, you may fax or mail your creditable coverage letter/certificate to us. Once coverage is verified, you will receive a new enrollment letter which reflects coverage for prescription drugs.

Q10. How can I obtain Medicare Part D coverage? (February 2015)
A10. If you did not enroll in a Medicare Part D plan when you  enrolled in Medicare, you will have to wait until the yearly General Enrollment Period to enroll in a Part D plan. A late enrollment penalty would apply, depending how long you went without creditable prescription drug coverage. This is generally 1% for each uncovered month without a Part D plan or other creditable coverage.
Please Note: If you reside in one of the 18 expansion counties, there is a one-time special enrollment period from March 1, 2014 to May 30, 2015. You must have Medicare Part A under EHH, must not currently have Part D coverage, must reside on one of the eighteen counties in the expanded area, and must express intent ot participate in the Medicare Pilot Program.

Q11. Is there any coverage for medications while I am in the coverage gap or “donut hole” in my Medicare Part D plan? (February 2015)
A11. There is a potential for reimbursement for medications during this coverage gap. Please contact the Pilot program at 1-888-469-9464 for further information.

Q12. Who will pay for my medications if I do not have Medicare Part D or other creditable coverage? (February 2015)
A12. If there is no Part D or other creditable coverage, the beneficiary is responsible for payment.

Q13. Is dental work, hearing services, or eye care covered under the Pilot program? (February 2015)
A13. No, routine dental, hearing services or eye care are not covered under the Pilot program. Subsequently, the Pilot program is unable to reimburse for mileage for travel for these types of appointments.

Claims

Q1.I received a check from Noridian and do not know what it is for. How can I find out? (February 2015)
A1. Payments made by the Pilot program have a corresponding Explanation of Benefits (EOB). Typically you will receive your reimbursement check first and your EOB will arrive shortly after. If you have questions regarding a check received for Pilot program services after you receive your EOB, please call 1-888-469-9464.

Q2. Will payments from the Pilot program affect any settlement we receive from the lawsuit against the mine? (February 2015)
A2. If Medicare records show the beneficiary has received a settlement, Medicare has the right to recover any payments which were made for services that are related to the settlement. Pilot benefits will not be available for any services that are related to the settlement as well. Medicare and Pilot benefits will remain available for all services not related to the settlement.

Q3. The allotted time to submit an appeal is 120 days. When does the 120 days start? (February 2015)
A3. The appeal must be submitted within 120 calendar days from the date on the Pilot Explanation of Benefits (EOB).

Q4. When should I submit my claims for reimbursement? (February 2015)
A4. Claims must be submitted within one year from the date of service. Please note that reimbursement cannot be made prior to a service being received.

Q5. How long will it take to receive reimbursement from Noridian once I have submitted my claim? (February 2015)
A5. Once the claim is received by Noridian, it can take 4-6 weeks to process for reimbursement.

Other

Q1. If the Affordable Care Act is changed or discontinued, will this eliminate the Pilot Program? (February 2015)
A1. At this time the Affordable Care Act is in place intact so it is premature to discuss what possible changes to the Act will mean to the Pilot program.