Whether you’re new to Medicare or have been enrolled for a while, it can be complicated. At our Medicare events and in their day-to-day work, our representatives field a variety of Medicare-related questions from members and the public. Here’s a random sampling along with answers and resources to help you understand how it all works.

Do I have to submit claims with Medicare?

If you have Original Medicare, your doctor or healthcare provider will typically file Medicare claims for your covered services and supplies. (They are required by law to do so.) On rare occasions, you may need to file a claim yourself.

Similarly, if you have a Medicare Advantage plan, you will rarely need to file claims. With these plans, the healthcare provider bills the insurance company instead of Medicare directly, and the insurer pays for covered services on behalf of Medicare.

More info: Medicare.gov/claims-and-appeals/file-a-claim/file-a-claim.html

What is the difference between HMO, HMO-POS, and PPO plans?

When shopping for a Medicare Advantage plan, you may see these acronyms used in plan names or descriptions. Here’s what they mean and how they differ:

  • HMO = health maintenance organization. With this type of plan, you can only see providers within the plan’s provider network. Premiums are typically lower with this type of plan.
  • POS = Point of service plans. These are sometimes referred to as HMO-POS. They are similar to an HMO, but more flexible in allowing plan members to seek care outside of the provider network.
  • PPO = Preferred provider organizations. With this type of plan, you have the flexibility to see any healthcare provider. Depending on the insurer, you may have lower out-of-pocket costs when seeing an in-network doctor. Premiums and deductibles are usually higher with PPO plans.

How does Medicare work with other insurance?

If you have Medicare and other health insurance or coverage, there are rules to determine which plan pays for services first. This is known as “coordination of benefits.” If you have a group health plan, coverage through a spouse, veterans’ benefits, or other coverage, it’s important to understand which plan is primary and which is secondary. More info: Medicare.gov/supplement-other-insurance/how-medicare-works-with-other-insurance/who-pays-first/which-insurance-pays.html.

Can I enroll in Medicare if I have a pre-existing condition?

  • You can enroll in Original Medicare regardless of your health status. In fact, if you have certain disabilities, you may be able to enroll before you turn 65.
  • Insurance companies are prohibited from denying you a Medigap policy based on pre-existing condition.
  • You can join a Medicare Advantage Plan even if you have a pre-existing condition, except for End-Stage Renal Disease (ESRD)

Can Medicare drop your coverage?

There are only a few reasons you can lose your Medicare coverage. Here are the more common scenarios:

  • You don’t pay your premium.
  • You become ineligible for Medicare.
  • You move outside the plan’s service area.
  • The insurance company becomes bankrupt or insolvent.

Attend a Free Class or Seminar to Learn More

To help you understand and get the most from Medicare, we offer free classes, seminars, and events. Nonmembers welcome!

Medicare classes: These casual meetings outline how Medicare works, what it does and doesn’t cover, and more. Visit medicare.pacificsource.com/Events for dates and locations.

Plan seminars: These presentations are an opportunity to learn more about which Medicare Advantage is right for you. You’ll have access to a company representative with information and applications. Visit medicare.pacificsource.com/Events for dates and locations.

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PacificSource Community Health Plans is an HMO/PPO plan with a Medicare contract. Enrollment in PacificSource Medicare depends on contract renewal. For accommodation of persons with special needs at sales meetings call (888) 863-3637 or TTY (800) 735-2900.