Medicare is the Federal government health care program designed for people ages 65 and over. Most U.S. citizens earn the right to enroll in Medicare by working and paying their taxes for a minimum of 10 years. The earliest someone who is turning age 65 can sign up for Original Medicare Parts A and B is three months before the month they will turn age 65. Under certain circumstances, people under age 65 may be eligible for Medicare. There are four parts of Medicare related to specific services: 

Part A — Hospital coverage.
Part B — Medical coverage.
Part C — Medicare Advantage Plans (private insurers like Blue Cross and Blue Shield of Texas that contract with the government to provide Medicare coverage through a variety of insurance products).
Part D — Prescription drug coverage.

IMPORTANT: To participate in a group retiree Medicare plan, you will need to enroll in both Parts A and B. If you do not enroll in Medicare Parts A, B and D when you are first eligible, you may be subject to late enrollment penalties.

The following web sites may be helpful: www.medicare.gov; www.ssa.gov; www.cms.gov.

Enrollment is done through the Social Security Administration (SSA). Most people should enroll in Medicare Part A (hospital coverage) during the Initial Enrollment Period. SSA will send you enrollment instructions at the beginning of your IEP. This is the period during which you can enroll in Medicare for the first time. It is a 7-month period that begins three months before the month you turn 65, includes the month you turn 65 and runs for three months after the month you turned 65. For example, if you were born in June, your window to enroll is March 1 through September 30.

If you are already receiving Social Security benefits, you will be automatically enrolled in Medicare Part A at the start of your Initial Enrollment Period. However, you will need to contact SSA to sign up for Part B.

Visit SSA online at www.ssa.gov, or
Visit in person at your local SSA office, or                         
Call SSA at 1-800-772-1213 (TTY 1-800-325-0778)

Because enrollment takes time to process, if you plan to retire at 65, we recommend enrolling three months prior to your 65th birthday.

IMPORTANT: If you plan to enroll in the City of Austin retiree MAPD Open Access PPO plan, you will need to enroll in both Parts A and B. And if you do not enroll in Medicare Parts A and  B when you are first eligible, you can be subject to late enrollment penalties.

Coverage is effective on the first day of the month following the date the application was processed or the Medicare Parts A and B effective date, whichever is later.

You have two separate enrollments: Original Medicare and the City of Austin retiree MAPD Open Access PPO plan. Enrollment in Medicare Part A and Part B through the Federal government is required for retirees to be eligible for any retiree Medicare plans, including this plan. To have full coverage, you must sign up for Medicare Parts A and B and continue to pay any required Part A or Part B premiums. You will need to do this first and get your 11-character Medicare Beneficiary Identifier before you can enroll in the City of Austin retiree MAPD Open Access PPO plan.

When enrolling in the retiree plan, you will provide your MBI located on your red, white and blue Medicare card, along with your effective date.  

You can call the dedicated City of Austin enrollment support line at 1-855-380-8542 to learn how the retiree plan will work with Medicare.

You can only be enrolled in one Medicare plan at a time. While Medicare usually cancels your previous Medicare Insurance plan coverage automatically when you enroll in a new plan, we recommend that you contact your current carrier to cancel your coverage. Be sure to continue coverage until the new plan’s effective date to avoid any gaps in coverage. We can offer support as you go through this change by calling 1-855-380-8542. 

You have an Initial Enrollment Period (IEP) of 7 months to sign up: the 3 months leading up to the month you turn age 65, the month you turn 65, and 3 months following the month you turn 65. We strongly encourage you to start the enrollment process 3 months prior to turning age 65 so that there will be less chance of any gaps in coverage with the City of Austin retiree MAPD Open Access PPO plan.

You should receive it within 10-14 days after Medicare approves your enrollment. You will receive three mailings: an acknowledgment letter, followed by a confirmation letter and then your new card.

Part A will not cost you anything if you or your spouse paid into Social Security for a minimum of 10 years. You pay a premium each month for Part B. Your Part B premium will be automatically deducted from your benefit payment if you get benefits from one of these: 

• Social Security.
• Railroad Retirement Board.
• Office of Personnel Management.

Non-payment of Part B and/or IRMAA premiums will result in termination of coverage.

Medicare Advantage plans bundle your Part A, Part B and usually Part D coverage into one plan. Medicare Advantage, also known as ‘Medicare Part C’, must cover all emergency and urgent care and all medically necessary services Original Medicare covers. Your rights and protections are the same.

Medicare Advantage plans like this one may offer some extra benefits such as a fitness membership, 24-hour nurse advice line or discount program. Plans also coordinate care and offer disease prevention and management resources. The plan takes care of all claims and coordinates Original Medicare benefits for you. You will not need your Medicare card to receive services or prescription drugs, just your BCBSTX member ID card. Costs for monthly premiums and the services you receive vary depending on your group retiree plan. You must continue to pay your Part B premium.

For more information about Medicare Advantage plans, visit Medicare.gov.

All Medicare-based plans are individual plans. A retiree and their eligible spouse/partner each enroll as individuals, even if they choose the same plan.

If you have a pre-existing condition, you cannot be refused coverage, your coverage cannot be canceled and your claims for covered services cannot be denied.

As a rule, group retiree Medicare plans have richer benefits than individual plans. And, because many employers or pension funds offer a defined contribution plan or subsidy (paying part of the cost you would pay wholly on your own with an individual plan), the cost may be less as well.

Yes. Spouses and/or dependents who are eligible for Medicare are eligible for this plan. They must join the City of Austin retiree MAPD Open Access PPO plan if the primary policyholder joins the plan. 

If a spouse and/or dependent are not Medicare-eligible, they have the option to remain on the City’s active coverage.

Blue Cross and Blue Shield Global Core program gives members traveling outside of the United States and its territories access to urgent and emergency medical assistance services and doctors and hospitals in more than 200 countries around the world. If you have questions about what medical care is covered when you travel, please call the member services at 1-855-380-8542 or access information at www.bcbsglobalcore.com.

This plan is available to retirees who live in the United States and its territories. If you reside full time outside of the country, you are not eligible for this Medicare Advantage Open Access PPO. Your coverage may be continued through the current City of Austin active health care plan.

The City of Austin retiree MAPD Open Access PPO plan was designed to match or provide better benefits than your current plan. Based on the specific procedure or service, there could be some differences, but those are rare. In many cases, the City of Austin retiree MAPD Open Access PPO plan has additional benefits outside of what Medicare allows. Please see the plan overview and summary of benefits for coverage details. You can also call the pre-enrollment help line at 1-855-380-8542.

Prior Authorization is when a contracted provider needs to get approval from the health plan to deliver a service. The goal is to make sure the treatment or service is covered by Medicare, the best for the member, medically necessary and safe. Among the procedures a PA is needed for are (not a complete list):

• Advanced Imaging (MRI, MRA, CT scans and PET scans).
• Lab Management Solutions – molecular and genomic lab testing.
• Musculoskeletal – pain/joint/spine services – excludes exams, physical therapy and occupational therapy.
• Inpatient stay that is not the result of an emergency.
• Outpatient medical oncology, radiation therapy, sleep study and specialty drugs.
• Select Durable Medical Equipment.
• Some procedures that are performed as part of an inpatient stay.

Twenty-three hour observation or emergency room visits do not need PA. Your provider will work with the plan to get any PA you may need and may talk with you about other options if necessary. If you have a PA in place when you enroll in the City of Austin retiree MAPD Open Access PPO plan, that PA continues for the first three months of coverage.

Your provider is responsible for getting a PA for you. If they fail to get a PA before providing a service, the plan may not pay the claim and the provider would have to absorb the cost of the service. You are not required to pay for the service if the provider fails to get a required PA. Providers can request a PA by calling the customer service number listed on your member ID card or via fax. They may also use our provider service through Availity^® Essentials.*

* Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.

No, however the City of Austin and Blue Cross and Blue Shield of Texas are proud to partner in providing a coverage option dedicated to retirees. City of Austin retirees have the option to join this Medicare plan which features a low monthly premium and $0 out of pocket costs for medical services. This plan is designed to improve your experience, lower out of pocket costs, and provide a dedicated team with training and experience supporting retirees participating in Medicare. This is a highly customized option, designed for City of Austin retirees and their eligible spouses/dependents, which includes additional benefits above and beyond Original Medicare. 

To enroll, view your existing coverages or make changes follow these steps:

• Go to: https://www.benselect.com/coa.
• Enter your username: Your unique username (printed on your Open enrollment packet from City of Austin)
• Enter your PIN: Your PIN is the last 4 digits of your Social Security  Number and the 2-digit year of your birth. For example, if the last 4 digits of your SSN are 3214 and you were born on September 21, 1968, your PIN would be “321468.”
• Click Log in.
• You will be prompted to create a new PIN.
• Login using your newly created User ID and Password.
• You can begin enrollment by clicking NEXT in the top or bottom right-hand corner of the welcome page.

Coverage is effective on the first day of the month following the date your application was processed or your Medicare Part A and Part B effective date, whichever is later.

Most likely, yes. Under the City of Austin retiree MAPD Open Access PPO plan which is a ‘non-differential’ or ‘passive’ PPO, you can go to any providers who: 1) accept Medicare; 2) agree to see you as a patient; and 3) agree to submit claims to the plan. They do not need to be part of any Blue Cross and Blue Shield network.

Coverage levels and costs are the same inside and outside the plan service area nationwide for covered benefits. Referrals are not required for office visits. Prior authorization may be required for certain services from providers who are Medicare Advantage-contracted with BCBSTX.

Please note: Even providers who accept Medicare can decide which patients they want to see, except in an emergency. We recommend that you confirm that yours will accept and submit claims to this Open Access plan.

Please inform your providers that your plan has changed when you call for an appointment and when you arrive for your visit. Be sure to show your new member ID card to your providers or their office staff. Remind them that your old ID is no longer valid. If your provider does not use your new number, care may be delayed. Your enrollment and welcome kits will also have a notice to bring with you when you see your provider.

Yes We make the claims process simple. Instead of submitting claims to Medicare, providers submit directly to the plan. Providers outside of Texas can file claims with their local BCBS plan. They are familiar with how to do this. The plan takes care of any interactions with Medicare on behalf of the provider and you. The customer service number listed on the back of your member ID card is for you or your provider to call with any questions.

This is an Open Access PPO plan. Any provider who accepts Medicare assignment and agrees to bill BCBS, will be paid. Providers who have contracted to be in the BCBS network will be paid their contracted rate. Providers who are not in the BCBS network will be paid the Medicare allowable rate for your care. You can see providers inside and outside of the BCBS network who agree to the rules stated above. Providers outside of Texas can file claims with their local BCBS plan and are familiar with this process.

To request an appeal, you, your representative, or your doctor can mail or fax a written request as well as contact customer service. Appeals must be submitted within 60 days of receiving your Explanation of Benefits (EOB) for the visit in question.

If you submit a written request for appeal, you must include the following information:

Your name, member number, address, reasons for appealing, and any evidence you want us to review such as medical records, doctor’s letters or other information that explains why you need the item or service.

Requests can be mailed to:

Blue Cross Medicare Advantage    
Attention: Appeals Department
P.O. Box 663099
Dallas, TX 75266

For a standard appeal we will provide a written decision within 60 days.

Yes. If a member goes to a provider who does NOT accept Medicare assignment and is not in the national BCBS Medicare Advantage PPO network, the member may be expected to pay the billed amount directly to the provider at the time of service. The member can submit the claim to BCBSTX. We would then pay the claim to the member at the Medicare limiting charge of 115% of the Medicare fee schedule for professional providers. If the provider has charged more than the 115% limiting charge, the member would not be reimbursed the difference of the billed amount they paid to the provider for services and 115% Medicare rates paid. The member would need to pursue a refund from the provider directly.

Example: Robert sees Dr. Smith, a non-participating provider and pays him $200 after the visit. The Medicare allowed amount for the visit is $80. Because Medicare limits what the provider can charge for covered services to 115% of the allowed amount for the service, Robert will be reimbursed $92. The remaining $108 will not be reimbursed.

$  80    Medicare allowed amount for the service
$  92    115% of the allowed amount

$200    Robert pays Dr. Smith
$  92    Robert is reimbursed this amount by BCBS
$108    Robert would need to seek this refund from the provider on his own

Less than 2% of providers opt out of Medicare. Providers who have opted out are unable to be reimbursed for services rendered. A member may see a provider who has opted out of Medicare; however, the visit will not be paid for by the plan or Medicare. A listing of providers that have opted out of Medicare can be found here on the CMS website.

If the provider does not accept Medicare assignment and refuses to bill BCBS, the member may need to pay the billed amount of the services directly to the provider at the time of service and submit the bill to BCBSTX for reimbursement. There is no reimbursement form to complete, however you can submit a claim for reimbursement in writing to:

Blue Cross Medicare Advantage (Claims)
PO Box 4195
Scranton, PA 18505

Please include the following documentation:

• Copy of receipt showing payment was made
• Member name and ID number including the alpha prefix listed on ID card, and
• An invoice showing services rendered OR another form of documentation that includes:
  • Diagnosis (or DX codes if available)
  • Procedure (or CPT codes if available)
  • Name and address of servicing provider

Yes, the plan includes Medicare Part D coverage for 30-, 60-, and 90-day retail and mail order prescriptions.

Before you enroll, you can search your medicines online at www.myprime.com:

• Select ‘Medicines,’ then ‘Find a Medicine,’ followed by ‘Continue  without sign in.’
• Under ‘Select Your Health Plan,’ select ‘BCBS Texas,’ then answer ‘Yes,’ select ‘Blue Cross Group Medicare Advantage (PPO) 3T Complete (your plan’s formulary),’ and click ‘continue.’ 
• Type your medicine and dosage. Review the drug tier requirements. Refer to the Summary of Benefits for your costs.

After enrollment, use your Blue Access for Members (BAM) account or visit www.myprime.com.

MyPrime.com is a pharmacy benefit website owned and operated by Prime Therapeutics LLC, a separate company providing pharmacy benefit management services for your plan.

If you are transitioning from another plan, you are eligible for a one-time 30-day supply of non-formulary drugs or drugs with utilization management requirements during the first 90 days of enrollment. You should then talk to your doctor to decide if there is another option available on the formulary. You can also call us to find out if we cover another drug that is used to treat your condition. Or you or your doctor may ask for an exception. We will work with your doctor to help make sure you are getting the right medicine to meet your needs.

Federal law forbids people who have Medicare from using coupons or other discounts with their Part D plan. These may only be used outside of your Part D benefit. 

Financial assistance to help with the costs of prescription drugs, like deductibles and copays, may be available through the government’s Low Income Subsidy program, also called Extra Help. You can apply for it any time. Visit the Social Security website at www.ssa.gov and click ‘Medicare,’ then ‘Apply for Part D Extra Help.’

The City of Austin retiree MAPD Open Access PPO plan covers a routine hearing exam, a hearing aid allowance of $2,500 for both ears over 36 months, and routine chiropractic care and acupuncture.

Routine chiropractic visits are covered at a $0 copay (20 visits per year).

Your supplemental benefits include:

• Hearing Care
• Wellness Solutions
• SilverSneakers® Fitness Program*
• 24/7 Nurseline 
• Virtual Visits
• Post-Hospital Discharge Meals
• Routine Chiropractic Care
• Non-Emergency Transportation
• Chronic Disease Prevention and Support
• Hypertension and Diabetes Programs 
• Musculoskeletal and Chronic Pain Programs 
• Weight Management Program
• Over the Counter Discount Program
• Routine Acupuncture

Please check your summary of benefits for coverage levels.

* Classes and amenities vary by location.

You can still participate but you will not be eligible for free medication.

You should receive it within 10-14 days after Medicare approves your enrollment. You will receive three mailings: an acknowledgment letter, followed by a confirmation letter and then your new card.

Here are the items you can expect, in order. You will receive an acknowledgment letter, followed by a confirmation letter and then your new member ID card. You may use your confirmation letter as proof of insurance until your card arrives. Your member ID card is for use with hospital and medical providers and pharmacies. You will not need your red, white and blue Medicare card to receive services.

Be sure to show your new member ID card to your providers or their office staff. Remind them that your old ID is no longer valid. If the provider does not use your new number, your benefits cannot be confirmed and there may be delays processing your claims. 

You will receive your Explanation of Benefits (EOB) from BCBSTX. How often you receive it depends on how often you see your provider. The EOB statement is not a bill. It simply details what you have paid and indicates the level of benefits you have used.