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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.