Positive Healthcare Partners - Florida Medicare


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		Frequently Asked Questions
		What is Positive Healthcare Partners (PHP)? Who qualifies? Is it mandatory to enroll in PHP? Does the member get less health benefits if they choose to enroll in PHP? Can a member enroll or disenroll at any time? How can potential members enroll in PHP? Is PHP a Medicare Part D Prescription Plan only? How does the PHP plan work? What if the member needs urgent care? What if it is a life threatening emergency? What happens if the member gets sick outside of the services area? What happens if the member is traveling outside of the services area and he/she needs urgent prescription drugs? What are the responsibilities of the RN care manager? What are the responsibilities of Member Services What is a drug formulary? What is an exception? What is a PHP preferred pharmacy? What does extra help mean? What would happen if PHP leaves the Medicare Program? What is the monthly premiums for PHP Plans? What happens when a Medicare beneficiary chooses not to enroll in te Part D prescription drug program? Does the member get a PHP identification card? 1. What is Positive Healthcare Partners (PHP)? A Medicare Advantage Health Plan. Offered by AIDS Healthcare Foundation, MCO of Florida, Inc. a Medicare Advantage Health Plan. Approved by Medicare for the State of Florida, October 2007. Among the 40+ plans offered by Medicare, PHP is the first one designed for people with HIV or AIDS and the only one in the State of Florida. 2. Who qualifies? People with HIV. Must have Medicare Part A and Part B (Hospital & Medical). Must live in Broward or Miami-Dade County. No renal Failure (not on dialysis treatment). 3. Is it mandatory to enroll in PHP? No. This is a voluntarily Special Needs Plan. Medicare beneficiaries have other options. Must live in Broward or Miami-Dade County. If you choose to enroll in PHP, you are still in the Medicare Program. 4. Does the member get less health benefits if they choose to enroll in PHP? Members receive all of the benefits that the original Medicare Plan offers. We offer more benefits which may change from year to year. 5. Can a member enroll or disenroll at any time? Members may join or leave the plan at certain times. People with Medicare only, can join at any time and may disenroll during the annual open enrollment period. People with Medicare and Medicaid benefits (Medi Medi), or people with Medicare and LIS (Low income Subsidy) can join on a monthly basis. 6. How can potential members enroll in PHP? Members can enroll by contacting a PHP representative by calling (888) 456-4715. 7. Is PHP a Medicare Part D Prescription Plan only? PHP covers Part B and Part D prescription drugs for a small co-payment. PHP also covers 100%, for all Part A and Part B medical and hospital services. 8. How does the PHP plan work? PHP has a contracts with doctors, hospitals, ancillary health providers and pharmacies to provide their members with all of their medical and prescription drug care services. PHP offers their members extra benefits such as basic coverage for dental and vision services. These benefits have small co-payments. PHP also offers their members with a health and wellness benefit such as a health club membership or nutritional supplements. Members must choose from the PHP network a Primary Care Physician, who would be responsible for the coordination of all their medical care. Members can change PCP provider at any time. Members can only self refer themselves through plan providers for emergency services, urgently needed care, routine women health care, flu shots, vaccinations and dialysis when outside plan’s area. When a member joins PHP they must get all their medical care within the network of providers that the plan has to offer. PHP is a prepaid Medicare Plan. Medicare reimburses PHP on a monthly basis. 9. What if the member needs urgent care? During business hours he/she should contact their PCP providers healthcenter immediately or their PHP Personal Care Manager if the provider is not available. After hours, call the nursing advice line at (866) 228-8714. Go to a hospital that is in the network if possible, if not he/she should go to the nearest hospital for care. 10. What if it is a life threatening emergency? Call 911 for an ambulance. Go to the nearest hospital with an emergency room. 11. What happens if the member gets sick outside of the services area? Go to the nearest hospital with an emergency room. If traveling outside of the services area for more than two weeks, member should contact their PCP provider and RN care manager, to be provided with enough medication supplies. 12. What happens if the member is traveling outside of the services area and he/she needs urgent prescription drugs? Member could go to any participating pharmacy in the network. We have over 55,000 pharmacies in our nationwide network. 13. What are the responsibilities of the RN care manager? To answer medical questions when PCP is not available. To coordinate medical care in conjunction with your provider. After hours nursing advice line is (866) 228-8714. 14. What are the responsibilities of Member Services? To answer questions on how the plans works. To assist members with any complaints. To handle disenrollments. To coordinate the Health & Wellness program. To guide members. 15. What is a drug formulary? A list of drugs covered by the Plan to meet patient needs. The formulary may change periodically by adding, changing or removing drugs. PHP reviews formulary monthly. Member can request an exception, when drug is not in the formulary or switch to an alternative drug that is listed. 16. What is an exception? Members have the right to request coverage determination, when they believe a drug should be covered under Part D or it is not in the PHP drug formulary. 17. What is a PHP preferred pharmacy? A preferred pharmacy is one of the AHF pharmacies. Member could receive up to 90 days supply by mail order. 18. What does extra help mean? Members can contact Medicare by calling 1-800-Medicare or for TTY users 1-877-486-2088, to see if they qualify for extra help to pay for Plan Premiums and prescription drugs. Call PHP member services for information on how to get help. 19. What would happen if PHP leaves the Medicare Program? Medicare beneficiary will not lose Medicare coverage. Members would receive a letter at least 90 days before their coverage ends explaining options. 20. What is the monthly premiums for PHP Plans? $15. 00 for the Standard PHP Plan and $82.90 for the Enhanced PHP plan. Not all members have to pay out of their pocket. Members may qualify for extra help. 21. What happens when a Medicare beneficiary chooses not to enroll in te Part D prescription drug program? He/she would not be covered by ADAP. Medicare beneficiary would have to pay 100% for prescription drug coverage. 22. Does the member get a PHP identification card? Yes. Members should carry their PHP membership services card and put away their white, red and blue Medicare card.