California PHP

1. 1. What is PHP (HMO SNP)?
   2. Who qualifies?
   3. Is it mandatory to enroll in PHP?
   4. Does a Medicare beneficiary get less health benefits if they choose to enroll in PHP?
   5. Can a Medicare beneficiary enroll or disenroll at any time?
   6. How does one enroll in PHP?
   7. Is PHP a Medicare Part D Prescription Plan only?
   8. How does PHP work?
   9. What if a member needs urgent care?
   10. What if a member has a life threatening emergency?
   11. What happens if a member gets sick outside of the services area?
   12. What happens if a member is traveling outside of the plan’s service area and he/she needs to fill a prescription?
   13. What does “Extra Help” mean?
   14. What would happen if PHP were to leave the Medicare program?
   15. What is the monthly premium for PHP?
   16. What happens when a Medicare beneficiary chooses not to enroll in a Part D prescription drug plan or choose a Medicare Advantage plan without prescription drug coverage?
   17. Does PHP issue member identification cards?
   18. Can members see any doctor they wish?
   19. Can members use any pharmacy they wish?

PHP is a Medicare Advantage special needs health plan that includes prescription drug coverage. The plan is an HMO and is for Medicare beneficiaries who have a prior HIV diagnosis and live in Los Angeles County, California. The plan is offered by AIDS Healthcare Foundation and is approved by Medicare.

Medicare beneficiaries who have an HIV/AIDS diagnosis and live in Los Angeles County, California. To be eligible to enroll, applicants must have Medicare Part A and Part B and not have end-stage renal disease (kidney failure).

No. Enrolling is entirely voluntary. Medicare beneficiaries have many other options to get their health care such as other Medicare Advantage plans, Medicare Advantage plans with prescription drug coverage, and Original Medicare with a prescription drug plan. Beneficiaries can choose plan options on Medicare’s website (By clicking on this link, you will be taken to the Medicare website).

No. Members receive all the medical benefits that Original Medicare offers, plus prescription drug coverage and added benefits that Original Medicare doesn’t offer.

Eligible Medicare beneficiaries may join or leave the plan at certain times. Eligible beneficiaries with Original Medicare or those enrolled in a general Medicare Advantage plan can join at any time and may disenroll during the Annual Enrollment Period or Medicare Advantage Annual Disenrollment Period. There may be other circumstances when a beneficiary may disenroll from the plan. For more information, conatact Member Services.

Beneficiaires with Medicare and Medicaid benefits (dual-eligible) and those with Medicare who are receiving “Extra Help” from Medicare can join the plan at any time and disenroll at any time. (See more information about disenrolling.)

See “How to Enroll.”

No. PHP covers medical services (Medicare Part A and Part B), such as doctor visits and hospitalization, and prescription drugs (Part D).

The plan has a contracts with doctors, hospitals, ancillary providers and pharmacies to provide members with all of their medical care and prescription drugs. Members must choose a primary care physician (PCP) who is responsible for the coordination of their care. The PCP will refer members to specialists when necessary. Members may self-refer to plan providers for certain services like emergency services, urgently needed care, routine women health care, flu shots, vaccinations and dialysis when outside plan’s area. To have PHP cover members’ care, they must get it from network providers except in limited circumstances, such as when emergency care or urgently needed care is necessary and the provider network is not available.

During business hours, he/she should contact his/her primary care provider (PCP) for help. If the PCP is unavailable, he/she should go to a network urgent care center. If there is no network urgent care center available, he/she should go to the closest Urgent Care Center or hospital emergency room. Members can also call the After Hours Nurse Advice Line for help from a Registered Nurse when their PCP’s office is closed.

He/she should call 911 or go to the nearest hospital with an emergency room.

Go to the nearest urgent care center or hospital with an emergency room. Members should contact their primary care provider or RN Care Manager as soon as possible (usually within 48 hours), as well as tell Member Services.

Members can go to any network pharmacy, which includes the big national chain pharmacies, such as Walgreens, CVS, Rite Aid, etc.

“Extra Help” is a subsidy that Medicare offers to certain beneficiaries to help pay for prescription drug costs. People with limited income and resources may qualify for “Extra Help.” You may be able to get “Extra Help” to pay for your prescription drug premiums and costs. To see if you qualify for getting “Extra Help,” call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week;
• The Social Security Office at 1-800-772-1213, between 7 a.m. to 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or
• Your State Medicaid Office.

Some people automatically qualify for “Extra Help” and don’t need to apply. Medicare mails a letter to people who automatically qualify for “Extra Help.”

Eligible Medicare beneficiaries will not lose Medicare coverage. If the plan were to leave, current plan members would receive a letter at least 90 days before coverage ends in the plan that explains available options.

There is no premium for PHP in 2021.  You must continue to pay your Medicare Part B premium.

The beneficiary will have to pay 100% of the cost of prescription drugs. He or she may be subject to Medicare’s late enrollment penalty should he or she later decide to join a prescription drug plan or Medicare Advantage plan with prescription drug coverage. The beneficiary will not be eligible to for the California AIDS Drug Assistance Program (ADAP) either.

Yes. Members should carry their PHP member ID card and use it when they get medical care and prescription drugs. While enrolled in PHP, members must not use their red, white and blue Medicare card for services. They should put the Medicare card away for safekeeping should they ever leave the plan and choose Original Medicare coverage.

No. PHP is an HMO with a provider network. You generally must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. There are exceptions like emergency or urgent care, which are covered by the plan when you use out-of-network providers; if you need covered medical care and there is no appropriate provider in our network (you must have an authorization from the plan before you seek care from an out-of-network provider; and kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

No. PHP is an HMO and has a pharmacy network that includes many of the large national chain pharmacies like Walgreens, Rite Aid and CVS. In most cases, prescriptions are covered only if they are filled at the plan’s network pharmacies.