National Medicare Member Information
Medicare is health insurance for people 65 or older. You’re first eligible to sign up for Medicare 3 months before you turn 65. You may be eligible to get Medicare benefits earlier if you have a disability, End-Stage Renal Disease (ESRD) or ALS (also called Lou Gehrig’s disease).
1. Create your secure Medicare account — Access your information anytime. You can also:
- Add your prescriptions to help you better compare health and drug plans in your area.
- View your Original Medicare claims as soon as they're processed.
- Print a copy of your official Medicare card.
- Review a list of preventive services you're eligible to get in Original Medicare.
- Learn about your Medicare premiums, and pay them online if you get a bill from Medicare.
You’ll need your Medicare Number to create an account. If you don’t have your Medicare card yet, you can log into your secure Social Security account to get your Medicare Number, or call us at 1-800-MEDICARE (1-800-633-4227) for help. TTY users can call 1-877-486-2048.
If you join a Medicare health or drug plan, your plan may offer an online account to track your claims.
2. Give Medicare permission to talk to someone you trust — We can’t share any information about your Medicare account, like claims or billing, unless you give us written permission first. Fill out and mail us an authorization form or log into your Medicare account to give us permission to talk to a person you trust (like a spouse, family member, or caregiver).
3. Find out if you qualify for help with costs — If you have limited income, you may qualify for help paying costs, like your premiums or for drugs.
4. Go digital — You can save and print information anytime for your records. Log into your account to get these items electronically: “Medicare & You” handbook — We’ll send you an email with a link to the PDF version. With the PDF version, you can enter search words to quickly find what you want, and print the pages you need. Original Medicare claims statements — You’ll get these statements, called Medicare Summary Notices, every month instead of waiting 3 months for them to arrive by mail. Access them anytime in your Medicare account.
5. Get your free "Welcome to Medicare" visit — Schedule this free preventive visit with your doctor during your first year with Medicare benefits. You’ll talk with your doctor about your medical history, your health needs, and preventive services that may be right for you.
State your health care preferences.
Decisions about end of life medical care can be much easier when advance directives are used. An Advance directive is a written instruction, such as a living will or durable power of attorney for health care, made while you are competent, about the medical treatment you want when you consciously cannot make decisions. By stating your health care preferences in writing about end of life care, your decisions are legally valid and will be respected by medical professionals, the health care decision-makers designated by you, and your family.
A Health Care Power of Attorney is a document that allows you to name a person who will act on your behalf to make health care decisions for you if you become unable to make them for yourself.
A Living Will is a document that allows you to establish, in advance, the type of medical care you would want to receive if you become permanently unconscious or terminally ill and unable to tell your physician or family what kind of life-sustaining treatments you want to receive.
If you want to use an advance directive, we recommend that you:
- Get the form. If you want an advance directive, you can get the form that complies with state law from your lawyer, from a social worker, from some office supply stores and from organizations that provide information about Medicare. You can also contact Member Services to ask for the forms (phone numbers are listed on the back of your member ID card).
- Complete the form and sign as directed. Regardless of where you get the advance directive form, keep in mind that it is a legal document. Consider asking a lawyer help you prepare it.
- Give copies of the signed forms to appropriate people. We recommend that you give a copy of the form to your physician, your lawyer, and to the person you name on the form to make decisions for you. You may also give copies to close friends or family members. Be sure to keep a copy at home.
If you know ahead of time that you are going to be hospitalized, and you have an advance directive, take a copy with you to the hospital.
- If you are admitted to the hospital, a hospital staff member will ask whether you have an advance directive and whether you have it with you.
- If you have not signed an advance directive, the hospital has forms available and a staff member will ask if you want to sign one.
Remember, it is your choice of whether you want to complete an advance directive (including whether you want to sign one if you are in hospital). Under the law, no one can deny you care or discriminate against you based on whether or not you signed an advance directive. Advance directives should be reviewed on a periodic basis so they can be updated as necessary.
Getting Medical Care and Prescription Drugs in a Disaster or Emergency Area
When the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic service area and PrimeTime Health Plan determines the disaster or emergency has caused a disruption to our member’s ability to access health care or covered Part D drugs, we will temporarily change our rules for affected member’s medical care and prescription drugs during the disaster or emergency or as described below:
- Cover Medicare Parts A and B services and supplemental Part C plan benefits furnished at non-contracted facilities (note: Part A/B benefits must be furnished at Medicare-certified facilities)
- Waive, in full, requirements for referrals where applicable.
- Provide the same cost-sharing for the member as if the service or benefit had been furnished at a plan-contracted facility.
- Make changes that benefit the member effective immediately without the 30-day notification requirement.
We will continue to provide access to health care benefits for 30 days after whichever of the following occurs first:
- All sources that declared a disaster or emergency that include the service area have ended.
- No end date was identified and all applicable emergencies or disasters declared for the area have ended, including through expiration of the declaration or any renewal of such declaration.
- There is no longer a disruption of access to health care.
Pharmacy Access (Plans with Part D coverage)
- Lift the “refill-too-soon” edits on Part D drugs if you had to leave your home without them or they were lost or damaged due to the emergency or disaster.
- Allow affected members to obtain the maximum extended-day supply, if requested and available at the time of refill, at one of our extended-day supply pharmacies.
- Allow access to covered Part D drugs dispensed at out-of-network pharmacies when you cannot obtain your covered drugs at a network pharmacy. You may have to pay more at an out-of-network pharmacy. If you pay the full cost for your medications at an out-of-network pharmacy, you may submit your receipt for reimbursement consideration.
We will continue to lift these edits until the end of a public health emergency or the end of a declared disaster or emergency. In the case of a public health emergency, it ends when the emergency no longer exists or the expiration of the 90-day period beginning from the initial declaration, whichever occurs first.
For major disasters declared by the President, we will review the disaster incident periods listed on the Federal Emergency Management Agency (FEMA) website. If the incident period has not officially closed 30 days from the initial Presidential declaration, we may consider extending the implementation of the edits but are not required to do so. We will work with our members who inform us they are still displaced or impacted by the disaster or emergency.
Replacing your Member ID card
Contact our Service Center at the phone numbers listed below to replace a lost or damaged member identification card.
Paying your plan premium
If your plan has a monthly plan premium and you pay us directly, you can sign up for premium withholding from your Social Security check or pay by electronic funds transfer through your bank. Contact our Service Center at the phone numbers listed below for additional information.
To get more information about getting care from doctors or other providers and prescription drugs during an emergency or disaster, please call: 330-363-7407 or 1-800-577-5084 TTY users: 711. Call Center Hours: Monday through Friday 8:00 a.m. to 8:00 p.m. (October 1st – March 31st, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.).
Throughout the year, the Centers for Medicare & Medicaid Services (CMS) may issue notifications of new coverage rules and Medicare benefits for additional services covered by the Medicare program or clarifications of existing covered services. These notifications are called National Coverage Determinations (NCDs). NCDs expand coverage for a specific service or set of services to Medicare beneficiaries. Services addressed by NCDs may be covered by PrimeTime Health Plan. The CMS requires PrimeTime Health Plan to notify members when NCDs are issued.
What does this mean to me?
This is an announcement of new coverage rules. The new rules may not affect all members. See below for a list of NCDs for the current plan year.
What are the new coverage rules?
The Centers for Medicare & Medicaid Services (CMS) will cover acupuncture for chronic low back pain under section 1862(a)(1)(A) of the Social Security Act. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances: (effective January 21, 2020)
- For the purpose of this decision, chronic low back pain (cLBP) is defined as:
- Lasting 12 weeks or longer;
- Nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease); v
- Not associated with surgery; and
- Not associated with pregnancy.
- An additional eight sessions will be covered for those patients demonstrating an improvement.
- No more than 20 acupuncture treatments many be administered annually.
- Treatment must be discontinued if the patient is not improving or is regressing.
NCD for Acupuncture for Chronic Low Back Pain (cLBP) released 05.13.2020
The Centers for Medicare & Medicaid Service (CMS) has determined that the evidence is sufficient to cover ambulatory blood pressure monitoring (ABPM) for the diagnosis of hypertension in Medicare beneficiaries under certain circumstances.
ABPM devices must be:
- Capable of recording and plotting blood pressure measurements for 24 hours.
- Provided to patients with oral and written instructions and a test run in the physician's office must be performed; and
- Interpreted by the treating physician or treating non-physician practitioner.
For eligible patients, ABPM is covered once per year.
NCD for Ambulatory Blood Pressure Monitoring (ABPM) released 07.02.19
Medicare covers leadless pacemakers through Coverage with Evidence Development(CED) when procedures are performed in CMS-approved CED studies effective January 18, 2017.
NCD for Screening for Leadless Pacemakers_released 07.28.2017
Medicare has concluded that implanted permanent cardiac pacemakers, single chamber or dual chamber, are reasonable and necessary for the treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and secondand/or third degree atrioventricular block.
NCD for Single Chamber and Dual Chamber Permanent Cardiac pacemakers_update released 10.26.2015
Medicare will cover a lung cancer screening with Low Dose Computed Tomography (LDCT) once per year for Medicare beneficiaries who meet specific criteria.
NCD for Lung Cancer Screening with Low Dose Computed Tomography (LDCT)_released 02.05.2015
What should I do if I have questions?
If you would like help understanding these new rules, call PrimeTime Health Plan at (330) 363-7407 or 1-800-577-5084. (TTY only call 711) We are available for phone calls Monday through Friday 8:00 a.m. to 8:00 p.m. From October 1st - March 31st the Service Center is open 7 days a week from 8:00 a.m. to 8:00 p.m.