FREQUENTLY ASKED QUESTIONS

Below you will find the answers to common questions about our plans, Medicare and Medicare Advantage. Have more questions? Call us!

Prescription Drugs

Question: If a person has their part D thru a State retiree plan can they still sign up for our MA plan with no RX?
Answer: Yes - their state plan is not considered a PDP plan.

Question: Are my prescriptions covered?
Answer: Your drugs may be covered if you choose one of the plans with prescription drug coverage – Sound + Rx, Charter +Rx, Apex + Rx or Summit + Rx. Review the formulary to see which drugs are covered.

Question: What can I do if they are not?
Answer: Members have the right to request a formulary exception for coverage either of non-formulary drugs or formulary drugs at a less expensive Tier.

Question: Can you guarantee that a request for an exception will be approved?
Answer: We cannot guarantee an exception will be approved; it may depend on the prescription, quantities, if you have completed Step Therapy and other criteria. However your doctor can advise if there are other options available on the formulary that will work for you.

Question: I have a stand-alone PDP (Medicare Prescription Drug Plan). Can I keep this plan and choose one of your Medicare only plans, like Ascent or Alpine?
Answer: No, you cannot. If you want to have one of our Medicare Advantage plans and still want drug coverage you must choose a plan that includes drug coverage like, Sound +Rx, Charter + Rx, Apex +Rx or Summit +Rx.

Preventive Services

Question: Do I need a referral for a mammogram?
Answer: No, referrals are not necessary for mammograms.

Question: If I have a colonoscopy and the doctor finds polyps is there still no cost?
Answer: No, there will be additional costs. The doctor will remove the polyps at that time rather than having to bring you back in for a second procedure. Removing polyps changes the definition from a diagnostic or preventive screening to that of an outpatient surgery. In these cases, you will be responsible for the Outpatient Surgery copay of the plan you choose.

Question: Is the Shingles vaccine a free immunization?
Answer: No, it is a Part D drug and as such requires a prescription from your provider.

Diagnostic Tests

Question: How much is an echocardiogram?
Answer: There is no copay for diagnostic tests such as an echocardiogram.

Radiology Services

Question: How much does a full body scan cost?
Answer: A regular X-ray has no copay. An MRI/MRA, CT/CTA or PET/SPECT scan will have a copay between $130-$250 depending on the plan you choose.

Network/Referrals

Question: I have been seeing a Sports Medicine doctor for continuous care that is not in your network of physicians, will a referral be approved?
Answer: In general, referrals to providers outside of the Soundpath Health provider network will be only be approved when certain conditions are met, otherwise you will be redirected to an in-network provider.

Question: Can I see any Ophthalmologist that I want?
Answer: No, you will be required to see an Ophthalmologist that is in the Soundpath Health provider network unless certain conditions are met that would warrant an out of network referral to be authorized.

Dental

Question: Does the dental plan currently cover crowns?
Answer: Yes. They are covered under Class 3 Services at 50% or 40% depending on the status of your dentist in the network.

Alternative Health Care

Question: The supplement for Acupuncture/Chiropractor says "no referral needed", does that mean that I can go to any provider that I want to see?
Answer: No. While, you do not need a referral from your PCP for the services provided under this added benefit package, you are still required to see one of the contracted acupuncturists and chiropractors in the American Specialty Health Network (ASHN).

Question: How can I get my Chiropractor or Acupuncturist on the provider list?
Answer: Have your provider contact the American Specialty Health Network (ASHN) at 1-800-972-4226.

Cancer

Question: Are you contracted with the US Cancer Care Alliance or Fred Hutchinson?
Answer: No, Soundpath Health is not contracted with these providers, however, individual cases may be reviewed and referral authorized.

Question: Is in-patient chemotherapy covered under Part D or Part B?
Answer: It is covered under Part B and the co-insurances apply toward the Out of Pocket Maximum.

Medicare Advantage Plans

Question: What is the difference between an HMO and a PPO?
Answer: HMOs (Health Maintenance Organizations) and PPOs (Participating Provider Organizations) both have a contracted network of doctors which guarantees access to care for their members. PPO's differ in that they typically permit you to use non-contracted providers but at a higher out of pocket cost to you.

Health & Wellness

Question: Is Soundpath Health contracted with the YMCA for gym services?
Answer: Individual YMCAs may be contracted but not all are. Call your local YMCA to see if they are contracted with Silver & Fit.

VA/TRICARE for Life

Question: If I have VA benefits, do I need to sign up for Soundpath Health?
Answer: Some veterans choose to sign up for Soundpath Health as this allows them to see doctors off base and allows them access to more hospitals.

Enrollment/Disenrollment

Question: If I am unhappy with your plan, can I "opt" out of it at any time during the year?
Answer: If this is your first time on a Medicare Advantage Plan, you have a special opportunity to disenroll at any time during the first 12 months you are on a Medicare Advantage Plan. You may then go back to traditional Medicare but you may not enroll in a different Medicare Advantage plan. Otherwise you are confined to the enrollment periods defined by Medicare.

Question: I am not in the 12 month period following my first enrollment in a Medicare Advantage Plan. Can I disenroll before the Annual Enrollment Period (Oct. 15 – Dec. 7th) and change to another Medicare Advantage Plan?
Answer: No, you can only enroll or disenroll at certain times of the year during Medicare enrollment/disenrollment periods. You can disenroll and revert back to straight Medicare during the Annual Disenrollment Period from Dec. 8 to Feb. 14th otherwise you must wait for the next Annual Enrollment Period.

Question: When can I get Part D?
Answer: During your Initial Enrollment Period, or during the Medicare defined enrollment periods that happen annually, or if you qualify for a Special Enrollment Period.

Question: If I miss my Initial Enrollment Period with Part B when is my next chance to sign up?
Answer: Your next chance to sign up will be during the General Enrollment Period between January 1-March 31 each year with coverage starting July 1. You may have to pay a higher premium for late enrollment.

Question: If I miss my chance to enroll in Part B, will I have a penalty?
Answer: Yes, typically Medicare does apply a penalty to your monthly Part B premium.

Question: I just moved here – when can I change my coverage?
Answer: If you tell your current plan after you move, your chance to change includes the month you tell your plan plus two full months afterward.

Question: I just went to the doctor and found out he doesn't take the insurance I signed up with 4 months ago, what can I do?
Answer: Call the Centers for Medicare/Medicaid Services (CMS) at 1-800-MEDICARE (24 hours a day, seven days a week) to see if you qualify for a special enrollment period that allows you to choose a plan your doctor does accept.

Question: What are the Special Election Periods (SEPs) where I can make a change to my health coverage?
Answer: There are many reasons that a Special Election Period may be opened. If you move out of the service area of your current plan, you are on Medicaid or no longer eligible for Medicaid, you involuntarily lose coverage or your prescription drug coverage is no longer creditable are just a few reasons that a SEP may be opened. If you think that you should qualify for a SEP, contact Medicare at 1-800-MEDICARE (24 hours a day, seven days a week)  to find out what your options are.

Penalties

Question: What is a Part B enrollment penalty?
Answer: A penalty assessed by CMS if you delay enrollment in Part B beyond Initial Enrollment Period (IEP) or Special Election Period (SEP). The penalty equals 10% for each full year enrollment is delayed, based on a Part B premium.

Question: How do I avoid a Part B enrollment penalty?
Answer: You must enroll within the IEP for Part B which is the 7 month period that includes the 3 months before your birthday month, your birthday month, and the 3 months after your birthday month. There is Part B SEP for those who do not retire when they turn 65. Those people must get Part B within 8 months of retirement or when employee benefits end, whichever comes first.

Question: If I choose COBRA – can I wait to get Part B when my COBRA ends?
Answer: Only if you end your COBRA benefits within the 8 month period after retirement. If you go the full 18 months of COBRA, you will be beyond the 8 month SEP for Part B and will incur a penalty.

Page Last Updated: November 28, 2011