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JEWISH NEWS
10/24
1997
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ABCs Of Medicare HMOs
NORINE ZIMMER
Special to The Jewish News
A
, age 65 and as a Medicare
beneficiary, you can choose
how you will receive your
Medicare hospital and med-
ical benefits.
If you cannot afford to get the care
you need in traditional Medicare and
need to buy a Medicare supplemental
insurance product like Medigap, it may
be wise to choose a Medicare HMO.
These are a combination insurance
company and health care delivery sys-
tem (doctor/hospital). For a premium,
HMOs cover healthcare costs, and like
healthcare providers they furnish health
care.
Medicare contracts with HMOs to
provide the Medicare benefits and ser-
vices covered under the Medicare pro-
gram. HMOs can offer additional ben-
efits, either free or for an additional
charge.
Medicare HMOs vary in where ser-
vices are provided, how much care is
provided, how the government pays for
them, whether they are for profit or
non-profit, degree of choice of
providers, types of services rendered,
and premiums and copays for services.
Services must usually be obtained
from the professionals and facilities that
participate in the plan.
If you enroll in a Medicare HMO,
you will still get full Part A Medicare
coverage free. Part A pays for care in a
hospital, skilled nursing facility and
home and hospice care. You'll still have
to pay the almost $44 a month for Part
B coverage, coverage for doctor bills,
outpatient hospital care and some other
services. Traditional Medicare will only
pay 80 percent of Part B costs, whereas
a Medicare HMO will pay 100 per-
cent, but only if you go to one of the
HMO's doctors.
You will spend less money out-of-
pocket in a Medicare HMO than you
would in traditional Medicare because
traditional Medicare only pays about
80 percent of the cost of your care.
You will need to buy a supplemental
insurance like Medigap insurance to
cover the difference in health care
expenses Medicare doesn't cover. In ari
HMO, you won't need Medigap insur-
ance (which covers areas Medicare
doesn't), which saves about $1,000 a
year.
But, does less money mean less care?
Sixty-seven percent of Medicare
HMOs charge no additional premi-
ums. Twenty percent charge less than
$40 a month and the remainder
charges. Members are responsible for
Medicare's coinsurance deductibles and
other permissible charges.
Coinsurance is the portion of cov-
ered health care expenses, usually
expressed in a percentage like 80/20,
that policyholders must meet in addi-
tion to the deductible.
People in HMOs tend to get fewer
referrals for physical therapy services,
fewer referrals for mental health ser-
vices and half as many Medicare home
health visits as they would under tradi-H
tional Medicare. They're less likely to
be admitted to a hospital and their hos-
pital stays tend to be shorter.
A Medicare HMO might not be for
you if you are chronically ill or need to<
see many different specialists. HMOs
can also be problematic if you travel
frequently or live away from your regu-
lar home for part of the year.
Seniors should ask the HMO if they
have a reciprocity agreement with an
HMO in the state that they'll be visit-
ing. If the HMO does not and if the
senior is outside their HMO's area for
three months or more each year, they
should probably not join.
Compare plans before decision-mak-
ing, get information about each plan's
doctors, hospitals and other health carP_
facilities; are their locations and trans-
portation convenient and available to
you; if you move out of the plan's ser-
vice location, what happens; review the ,
Cj
plan's current list of providers.
Does the plan disclose how it and its
doctors are compensated; does the plan
operate urgent care centers for after-
hours treatment convenient for you; is
a telephone line for prompt evaluation
by a healthcare professional available?
Denials of claims are a potential haz-
ard in HMOs. However, you aren't
entirely at their mercy. Each plan is --
required to have an appeals process and
doctors, hospitals, skilled home health
to inform members of their appeal
agencies, pharmacies, and other health
rights. Last year, 64 percent of all
care providers or through referrals by
Medicare HMO disputes were settled
the plan. Services received outside the
in favor of the HMO, only 27 percent
plan are paid out-of-pocket except in
in favor of the patient according to thy__
emergency and out-of-area urgently
Health Care Financing Administration
needed care.
(HCFA).
Some risk plans offer point-of-ser-
Know the appeals process. Leave a
vice (POS) options, allowing members
paper trail documenting all correspon-
to use certain services outside the plan's
provider network. Expect to pay at least dence. Find out which HMO employ'
ee denied the claim and on what med-
20 percent of the bill in return for this
ical grounds. Appeal to a higher
flexibility.
authority within the HMO if necessary
Cost plans don't have lock-in
and enlist the help of the benefits man 7,
requirements. You can go to healthcare
ager. The HMO may respond favorably
providers affiliated with the plan and
to your employer rather than risk los-
pay the applicable copays or to
ing the company's business.
providers outside the plan where the
plan won't pay, but Medicare will prob-
Norine Zimmer is a Huntington
ably pays its share of the approved
between $40 and $80. It's those savings
that make HMOs so attractive.
Another attraction is the added ben-
efits. Most Medicare HMOs offer care
that traditional plans don't — annual
physicals, eye care, glasses, and pre-
scription drug coverage.
An HMO must enroll all eligible
Medicare beneficiaries who want to
enroll, regardless of their age, health
status or the amount or cost of the
health services needed. You can enroll
in any Medicare HMO without a
health screening unless you have end-
stage renal failure or are receiving hos-
pice care.
You can disenroll from your HMO
for any reason at any time. And that's
leading to fierce competition among
HMOs to sign up more seniors.
Before enrolling, find out whether
the plan has a risk or cost contract with
Medicare. The difference is important.
Risk plans have lock-in requirements,
meaning you generally must get all cov-
ered care through the plan's network of
,
❑
Woods gerontologist.