Clover Health Frequently Asked Questions
Clover Health is a Medicare Advantage plan. To enroll, you must have Medicare Part A and Medicare Part B, and you must live in one of the counties we serve.
The majority of Clover Health’s Medicare Advantage plans have no monthly plan premium, which means that after you pay your monthly Part B premium, there is no additional premium for you to pay. Your monthly Part B premium is paid directly to Medicare, usually through a deduction to your social security check.
We understand that cost is a factor in your healthcare choices. The total amount you'll spend on your healthcare goes beyond monthly premiums. What you pay in copays and coinsurance when you receive care and at the pharmacy can be a big part of your financial responsibility. To estimate your costs for each of your medications more accurately, check our formulary. You can also learn the cost-shares for the medical services you use in your Evidence of Coverage. It's okay to ask a provider to estimate your financial responsibility.
Visit our Plans page and enter your ZIP code for a description of all the plans available in your area, including costs and benefits. Remember that any Clover Health plan premiums are in addition to the Part B premium you pay to participate in Medicare. Additional assistance, like the Low-Income Subsidy (LIS) or a State Pharmaceutical Assistance Program (SPAP), may reduce the amount you owe.
To enroll, contact our Enrollment team at the number provided at the bottom of this page. Our plans are also sold by independent brokers. We rely on our Telesales team and these independent brokers to present our plans accurately and to assist you in finding the best coverage for your unique circumstances. Please feel free to reach out to Member Services and share any comments you may have about the enrollment process.
Before you go, our Member Services team would like to help resolve any issues that may be preventing you from getting the most from your plan. We're happy to help with issues including accessing care, paying for care, and more.
If you do choose to leave Clover Health, you can initiate the process of disenrollment by notifying us in writing (handwritten or typed letter that you sign) that you want to leave the plan. Member Services can send you a form to facilitate this process, and can confirm whether you have a valid SEP to leave the plan. Medicare must approve all disenrollments before they are final, and will verify that you have a valid SEP. If you don't have a valid SEP, Medicare may not approve your request to leave the plan.
If you leave Clover Health with a valid SEP to return to Original Medicare or to a plan without Part D coverage, it's important to make other arrangements for your Part D coverage within 60 days of disenrollment. If you have any months without Part D, you may pay a penalty.
Yes. If your provider agrees to work with both Clover Health and your other health insurance plan, you may pay less for your benefits than with only one form of coverage. If you have more than one plan, each may cover a different set of services and have its own requirements for network, authorization, and referral. Each plan operates separately and has its own rules and policies that govern how care is administered. For a service to be covered by more than one plan, it has to be requested and performed in accordance with the network, authorization, and referral requirements for all plans that will be billed.
You're responsible for bringing evidence of all coverages to all appointments and to the pharmacy to get the benefits of all the plans. Your provider is responsible for billing each insurance plan correctly. If you ever receive a bill for a service that you think should be covered differently, please contact Member Services for assistance at 1-888-778-1478 (TTY 711) 8 am–8 pm local time, 7 days a week.*
A formulary is a list of drugs covered by your plan. Clover Health's formulary is maintained by Clover Health's Pharmacy team and Medicare. Clover Health updates the plan formularies as necessary to include new medications, or to adjust how some medications are covered. If something changes that affects your costs, we'll notify you in advance. Go to our Formulary page to see the complete formulary for each of Clover Health’s plans.
If you're currently taking a drug that isn't in our formulary, you can request an exception. See our Drug Transition Policy for more information.
No. Clover Health’s PPO plans have an open network, and you don't need a referral to see a specialist.
Check your plan's Summary of Benefits document or Evidence of Coverage document for a description of your share of cost for services, both in- and out-of-network. You can receive care from any provider who is willing to bill Clover Health, but depending on your plan's benefits you may pay a different amount of money for the same services.
Providers that are out-of-network are not required by law to accept Clover Health members, and it's up to the provider whether they want to see Clover Health members and whether or not they want to bill Clover Health. Call us anytime to see if a provider is willing to have a billing relationship with Clover Health, or to find a doctor who accepts our members. We're happy to reach out to any provider on your behalf to see if they'll accept Clover Health.
Our in-network providers know our benefits well, and they understand how to help you get the most from your coverage. Even if your share of the cost is the same in- and out-of-network, we encourage you to develop a relationship with an in-network provider. Your plan's Evidence of Coverage document and Summary of Benefits describe your share of cost in- and out-of-network.
The Evidence of Coverage document associated with your plan is your best tool for estimating your financial responsibility. This document describes what your plan covers and what your financial responsibility could be for any covered benefit. The online version is identical to the printed one, and it describes all our benefits, associated costs, and how to access care.
If you are uncertain about your share of cost or a bill you received, give us a call at 1-888-778-1478 (TTY 711) 8 am–8 pm local time, 7 days a week.* We will review the bill to ensure that you were billed the correct amount and assist in correcting it if necessary.
You can read information about all covered benefits in your Evidence of Coverage document. The Summary of Benefits for your plan describes the most commonly used benefits and offers more information about how to access the care you need. You can also call Member Services at 1-888-778-1478 (TTY 711) 8 am–8 pm local time, 7 days a week* to ask any questions you may have about what's covered, to estimate how much something might cost, or to help locate or access care.
The Evidence of Coverage document is your source of truth for understanding what's covered by your plan. It describes in detail what services and items can be paid for by Clover, including how much you'll pay for each. You can view the Evidence of Coverage document on our website. If you need a copy of your plan's Evidence of Coverage document, call Member Services.
The Annual Notice of Change is a document Clover uses to describe changes to your plan. We adjust our benefits from time to time. We send the Annual Notice of Change to your home by September 30th each year to describe changes to your plan.
The Summary of Benefits is a guide to using your Clover benefits. It's a great source for information about how to get the care you need, about the structure of your plan, and about Medicare and Medicare Advantage. To understand your plan and what's covered, start with the Summary of Benefits, and then refer to the more detailed description of each benefit in the Evidence of Coverage as necessary.
To support your wellness throughout the year, Clover offers an annual check-in called a Clover Care Visit (CCV). Our Care Management team includes nurse practitioners, medical assistants, and other licensed clinicians who can check in on you between doctor visits. In the comfort of your own home or other private location of your choice, our team provides an hour-long one-on-one wellness assessment and helps you better understand your medical needs. The CCV may include a physical examination, a review of current and past diagnoses and medications, and an opportunity to address your concerns and questions. We also offer telehealth appointments.
To schedule a Clover Care Visit with one of our staff, please call us at 1-888-778-1478 (TTY 711) 8 am–8 pm local time, 7 days a week.*
Copayments and coinsurance are two different kinds of cost-shares that our plans use to define your financial responsibility for covered services or items. A copay, or copayment, is a fixed amount of money that you pay for a covered benefit. Your plan pays the remainder of the cost. Coinsurance is the percentage of the total cost of a covered service or item that you pay. Your plan pays the rest.
An explanation of benefits (EOB) is the activity history for claims submitted to Clover Health by your doctors or other providers. An EOB is not a bill, it's a notification of claims that have been submitted to Clover Health that are paid or unpaid. If a claim is not paid, don't be alarmed; a provider may need to resubmit the claim before it's paid. If you receive a bill directly from the provider asking for payments, please contact Member Services and we can clarify whether the bill is your responsibility or not.
Unlike other Medicare Advantage plans with narrow networks, Clover has provider networks that are broad and open, enabling its members to see any doctor participating in Medicare who is willing to accept them. Clover also focuses on keeping out-of-pocket costs for its members to an absolute minimum and allows members to pay the same low cost-sharing regardless of whether the doctor is in- or out-of-network.
Yes. You can use your LIS with any of our plans, but our South Carolina Choice Value PPO is designed to coordinate with the benefits you're entitled to with the LIS.