| In an effort to provide options for health care, Medicare
beneficiaries who are enrolled in Parts A and B are allowed to choose managed care as a
replacement for traditional fee-for-service Medicare. Health maintenance organizations
(HMOs) have been providing health care services at a financial savings for Medicare
beneficiaries for several years. Because a large percentage of seniors cannot afford
supplemental insurance, managed care is reshaping the way many beneficiaries receive their
health care. If Medicare beneficiaries properly evaluate their health, personal
preferences and finances, participating in a Medicare HMO can be a healthy, inexpensive
way to receive needed health care. Prior to enrolling in a managed care plan,
beneficiaries must realize that HMOs provide medically necessary services while
controlling costs and specifically, they advocate for preventive care. If a beneficiary
only visits the doctor when a specific problem occurs and chooses not to take advantage of
regular check ups and preventive services, an HMO may not be a good choice.
In Harris County, eight HMOs are approved to provide Medicare services and are
accepting new participants.
These plans include Cigna, Humana, Memorial Sisters of Charity, MethodistCare, Nylcare,
Prudential, Secure Horizons and Texas Health Choice.
Beneficiaries must evaluate if participating in an HMO is a good choice and select the
plan that best meets their particular needs.
The first step in evaluating HMO participation is to ask your current |
|
If a beneficiary only visits the doctor when a
specific problem occurs and chooses not to take advantage of regular check ups and
preventive services, an HMO may not be a good choice.
physician if he or she participates with any of the plans which are approved by the
Health Care Financing Administration and accepting clients. Ask if he or she is
categorized as a primary care physician who is accepting clients and how long has he or
she been in the plan. If the physician is a member of more than one plan, evaluate the
plans based on personal needs. If the preferred physician does not participate in managed
care, evaluate if the beneficiary easily adjusts to changes in medical providers? Other
important questions include:
· Does the plan have any point-of- service features that allow the beneficiary to seek
medical care from providers outside the network without a written or verbal |
|
referral? If so, how much will this feature cost and are
there any restrictions? · Which hospitals and specialists participate in the plan? How
long have they been members? Is the beneficiary allowed to use any hospital or specialist
in the plan?
· How many physicians and hospitals have remained in the plan for three or more years?
How many leave the plan each year?
· Are any friends or relatives plan members? What is their opinion?
· What type of coverage is available when traveling outside the coverage area?
· On average, how long do beneficiaries have to wait for written authorizations or
referrals?
· How soon will I be notified if my primary care physician or specialist leaves the
plan? What allowances are made if I am unable to immediately find another primary care
physician who is accepting new patients?
· How many beneficiaries disenrolled during the last 12 months? Did they give any
particular reasons?
· What benefits are available for routine podiatry care?
· Does the plan include vision benefits? Are allowances for prescription glasses
reasonable? How often does the plan approve glasses?
· What allowances are made for hearing assessments and hearing aids?
· Is prescription drug coverage available? If so, what is the dollar limit and does
the HMO have a restrictive drug formulary? Get a copy of the formulary to determine if the
medications you usually take are included. Also, if the brand |