Q: I have both the HMO and Medicare, with Medicare being my primary health plan. I received treatment from a heart specialist and an urologist not in the HMO network. The specialists are now billing me for the portion of the bill not paid by Medicare. The HMO did not pay any portion of the bill. Why?

A: The HMO did not pay any portion of the bills, because you were not in an emergency situation when you received treatment, and your HMO PCP did not refer you to the out-of-network doctors. To receive HMO benefits, you must always have a PCP coordinate your health care; including referring you to specialists, and you must pay the required HMO copayments of $20/PCP and $45/specialist. When you are in an emergency, life-threatening medical situation, you should seek care at the nearest medical facility, even if it is not in the HMO network. However, you should notify your HMO between 48 and 72 hours after the ER visit.

Q: I have been on disability retirement for several months and covered under Medicare Parts A & B. My spouse still works for the city, and I am covered under her health insurance. Medicare will not pay my health care claims until HMO Blue Texas HMO pays. Please explain.

A: Because you are covered under Medicare and the HMO, a large group health plan, federal law requires the city’s HMO provide your primary coverage. When your spouse retires, Medicare becomes your primary health plan. For you to continue receiving HMO benefits after she retires, she must elect to keep the plan, you must have a PCP to coordinate your health care, and you must pay the required copayments.