Member

• The Enrollment/Disenrollment Process
• Member ID Cards
• Determining Eligibility Through Gateway Health Plan Medicare Assured^®
• Primary Care Practitioner’s Role in Determining Eligibility
• Members’ Rights and Responsibilities
  • Member Responsibilities

The Enrollment/Disenrollment Process

Gateway Health Plan Medicare Assured^® Medicare Advantage Prescription Drug Plan (MA-PD) is for people with Medicare Part A, Medicare Part B and Medicaid (Full and QMB). The Centers for Medicare and Medicaid (CMS) have periods when beneficiaries can enroll or disenroll with/from Medicare plans throughout the year. These times are known as election periods. There are multiple election periods when beneficiaries are entitled to enroll with Gateway Health Plan Medicare Assured^SM which is a Special Needs Plan (SNP).This means that all of our members have both Medicare and Medicaid and because of this, they qualify for the Special Election Period (SEP) every month. The SEP permits our members to enroll and disenroll at any time throughout the year.Members can enroll into our plan by using these methods: 

• A paper enrollment form
• On-line forms through Medicare’s website
• Gateway’s website at www.gatewayhealthplan.com - click on the link for Medicare Assured^®.
• By calling Gateway Health Plan Medicare Assured^® 1-877-GATEWAY(TTY users should call 1-800-654-5988); 8:00am – 6:00pm, 7 days a week.
• By contacting Medicare at: 1-800-MEDICARE or www.medicare.com.

Members can disenroll from our plan by completing a paper disenrollment form, sending a letter/fax to Gateway Health Plan Medicare Assured^®.Members may also contact Medicare at 1-800-MEDICARE (TTY: 1-877-486-2048) or www.medicare.com. Members may also disenroll from Gateway Health Plan Medicare Assured^SM by simply enrolling in another HMO or Part D plan. Members should call Gateway Health Plan® or visit www.gatewayhealthplan.com for additional information.

Member enrollments are made effective the first day of the calendar month, and member disenrollments are made effective the last day of the calendar month.

Member ID Cards

Each Medicare Assured^® member will receive an ID card.  Each card is issued once, unless cards are requested or reissued due to a demographic or PCP change. ID Cards are good for as long as the person is a member of Gateway Health Plan Medicare Assured^®.  (Sample ID cards below).

Pennsylvania

Ohio

Pennsylvania members age 21 and over will need to use their Gateway Health Plan Medicare Assured^® ID card and keep their Medicaid Access card to use for services covered under Medical Assistance and to cover Medicare deductibles and coinsurance, as long as the provider also participates with Medicaid.

Pennsylvania members under the age of 21 will use their Gateway Health Plan Medicare Assured^® ID card and their Medicaid HMO plan ID card. These members will need to keep their Medicaid Access card for non-Medical assistance services, such as transportation through the Medical Assistance Transportation Program (MATP) or cash assistance.

Ohio Medicare members will use their Gateway Health Plan Medicare Assured^SM ID card. They will keep their Ohio Medicaid card to use for services covered under Medicaid and to cover their Medicare deductibles and coinsurance, as long as the provider also participates with Medicaid.

Determining Eligibility Through Gateway Health Plan Medicare Assured^®

Because of potential changes in a member’s eligibility, each participating practitioner is responsible to verify a member’s eligibility with Gateway Health Plan Medicare Assured^® BEFORE providing services.  Verifying a member’s eligibility will ensure proper reimbursement for services.  To verify a member’s eligibility, the following methods are available to all practitioners:

1. Gateway Health Plan Medicare Assured^® Identification Card
   • The card itself does NOT guarantee that a person is currently enrolled in Gateway Health Plan Medicare Assured^®.    Members are NOT required to return their identification cards when they are no longer eligible for Gateway Health Plan Medicare Assured^®.
2. Gateway Digital Voice Assistant (DIVA)
   • The Gateway DIVA System (1-800-642-3515) is available 24 hours a day, 7 days a week.  To verify member eligibility at each visit, practitioners follow a few simple steps, which are listed below:

Press 1 if calling for a member who resides in Pennsylvania

Press 2 if calling for a member who resides in Ohio

Press 1 to verify eligibility

Member Identification Number?

Press 1 to verify eligibility using the patient’s social security number, when prompted enter the patient’s 9-digit social security number

Press 2 to verify eligibility using the patient’s Gateway member identification number, when prompted enter the patient’s 8-digit Gateway Health Plan Medicare Assured^® identification number

Press 3 to verify eligibility using the patient’s Medical Assistance recipient identification number, when prompted enter the patient’s Medical Assistance recipient number  (Note: This option can not be used for Gateway Health Plan Medicare Assured^® members.)

Press 4 to verify eligibility using the patient’s Medicare Health Insurance Claim (HIC) number, when prompted enter the patient’s HIC number, followed by the # sign.  (For letters press the corresponding key on your touch tone phone.  For example:  To enter an A, B, or C, press the 2 key.  For Q, press the 7 key.  For Z, press the 9 key.)

Press 0 to speak to a Provider Services Representative

Press 9 to repeat the menu

Verification of Date?

Press 1 to verify whether the patient is eligible TODAY

Press 2 to verify whether the patient is eligible on a specific date (enter date)

Press 9 to listen to the instructions again

Press 0 to speak to a Provider Services Representative

Additional Instructions:

Press 1 to receive additional information about the patient/member

Press 2 to receive the patient’s primary care practitioner name and telephone number

Press 3 to fax information regarding the patient whose eligibility is being verified

Press 4 to verify eligibility for another patient/member

Press 5 to exit

Press 0 to speak to a Provider Services Representative

Primary Care Practitioner’s Role in Determining Eligibility

Primary care practitioners verify eligibility by consulting their panel listing in order to confirm that the member is a part of the practitioner’s panel.  The panel list is distributed on or about the first of every month.  The primary care practitioner should check the panel list each time a member is seen in the office. If a member’s name is on the panel list, the member is eligible with Gateway for that month.

If members insist they are effective, but do not appear on the panel list, the practitioner should call the Gateway Health Plan Medicare Assured^® Provider Services Department for help in determining eligibility.  (Refer to the Quick Reference section in this manual for phone number.)

Members’ Rights and Responsibilities

All Gateway members have rights and responsibilities.  They are as follows:

GATEWAY HEALTH PLAN Medicare Assured^®
MEMBERS’ RIGHTS AND RESPONSIBILITIES

Member Rights

• Right to be treated with fairness and respect
• Right to the privacy of your medical records and personal health information
• Right to see plan providers and get covered services within a reasonable period of time
• Right to know your treatment choices and participate in decisions about your health care
• Right to use advance directives (such as a living will or a power of attorney)
• Right to make complaints
• Right to get information about your health care coverage and costs
• Right to get information about Gateway Health Plan^®, Gateway Health Plan Medicare Assured^®, and plan providers

• To get familiar with your coverage and the rules you must follow to get care as a member.   
• To give his/her doctor and other providers the information they need to care for him/her, and to follow the treatment plans and instructions that he/she and his/her doctors agree upon.
• To act in a way that supports the care given to other patients and helps the smooth running of his/her doctor’s office, hospitals, and other offices.
• To pay his/her plan premiums and any co-payments he/she may owe for the covered services you get.
• To let Gateway Health Plan Medicare Assured^SM know if he/she has any questions, concerns, problems, or suggestions.