Medicare Managed Care
If you decide to enroll in a Medicare HMO, you should be careful to ensure there are no gaps in your insurance coverage. Enrollees who are dissatisfied with Medicare HMO’s have a variety of options.
Enrollment in a Medicare HMO offers many benefits and some disadvantages to beneficiaries. HMO enrollees do not need to have Medicare Supplement policies (Medigap coverage.) Advantages include:
- Lower and more predictable out-of-pocket costs.
- Coverage of services not covered by Medicare.
- Monthly premiums often lower than those of Medicare supplement insurance.
- Guaranteed enrollment regardless of current health, including disabled beneficiaries under age 65.
Who Can Enroll. Almost all Medicare beneficiaries can enroll in a Medicare HMO by contacting the HMO or the Social Security Administration at 1-800-772-1213. Enrollees continue to pay their Part B premium of $43.80 per month, which is usually automatically deducted from Social Security checks. You must live in an area served by the HMO.
If you decide to enroll in a Medicare HMO, you should be careful to ensure there are no gaps in your insurance coverage. Find out exactly when your HMO enrollment will begin, and make sure that any Medicare Supplemental policy you drop does not end before the HMO enrollment date, and that your insurer will refund any prepaid premiums.
What To Do If You Are Dissatisfied. Enrollees who are dissatisfied with Medicare HMO’s have a variety of options. If they are unhappy with their primary care doctor, they can switch to a different doctor who is a member of the HMO network. Treatment decisions, which the patient does not agree with, can be appealed within the HMO, and then to an impartial organization unaffiliated with the HMO. Enrollees can also easily switch to a different HMO, or go back to regular Medicare.
If you think your HMO is not meeting its obligations or may be violating your rights:
- Complain directly to the HMO. Every HMO is required to have an internal process to handle complaints.
- Contact your local or State Insurance Counseling and Assistance Program (ICA). Call the Medicare Hot Line at 1-800-638-6833, your local Area Agency on Aging, or the Eldercare Locator at 1-800-677-1116.
- Contact the Health and Human Service Office of Inspector General a 1-800-447-8477 or the Health Care Financing Administration to report improper practices.
If the HMO denies your appeal. If the HMO denies your appeal it automatically goes to an independent review organization, which reviews all cases in which a Medicare HMO does not reverse its initial decision.
Ending Your HMO Enrollment. Remember that a Medicare Supplement insurer can no longer refuse to insure you if you disenroll from a Medicare HMO and then go back to a fee-for-service plan within a specified period of time. This rule applies even if you have a preexisting condition. To get more information on companies who will provide Medigap insurance coverage, contact your state Insurance Department.
