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In this section you will find...
Last Updated: April 2006
Q.How can I find out which Medicare HMOs and
PPOs are available where my client lives?
A. Your clients can only join the Medicare HMOs and
PPOs that operate in their local area. Not all areas have Medicare HMOs
and PPOs. The New York City Department for the Aging (DFTA) operates
a Health Insurance Information, Counseling and Assistance Program
(HIICAP) hotline that will answer questions about Medicare, managed care,
and other health insurance. A list of all the Medicare managed care plans
in their service area is available from the HIICAPs. Your clients
can also meet in person with a counselor from DFTA. To arrange this,
call DFTA at 212-333-5511.
In addition, the Medicare website offers the “Medicare
Personal Plan Finder,” which allows consumers to identify Medicare
HMOs and PPOs in their area. The website is available at www.medicare.gov/MPFF.asp
If
your clients wish to continue visiting the health care providers
that they currently see, they should ask them which Medicare HMOs and
PPOs they are affiliated with. Keep in mind, however, that these doctors
and hospitals may not be able to provide services in an HMO or PPO in
the same way as in Original Medicare if they must follow HMO and PPO
rules on care. Also, they can leave the HMO or PPO network at any time,
while your clients cannot.
Q.
Where can my clients find out about the different plans that the Medicare
managed care organizations are selling?
A. They can contact the
National Medicare Hotline (1-800-MEDICARE or 1-800-633-4227, and for
the hearing impaired, TTY/TDD 1-877-486-2048), or visit the Medicare
website at www.medicare.gov.
In addition, the Medicare website (www.medicare.gov)
offers the “Medicare Personal Plan Finder” which allows consumers
to identify Medicare Advantage Plans in their area and compare
characteristics of these plans. This website is available at www.medicare.gov/MPPF.asp.
The Health Insurance Information, Counseling and Assistance Program
(HIICAP) can also be a good source of information when comparing Medicare
health plans. Call 212-333-5511 to find the nearest insurance counseling
office.
Doctors can be a good source of information about HMOs
and PPOs. People who have conditions or diseases similar to your clients’ conditions
or other plan enrollees, can also be helpful.
Many of your clients’ questions can be answered by speaking directly
with the HMO or PPO. Call the Medicare HMOs and PPOs in their area and ask
for brochures. Ask for information on the following:
- Costs, benefits, and restrictions on coverage
- Names, locations and descriptions of the doctors, hospitals, home
health agencies and skilled nursing facilities available through the
HMO
- Whether preferred doctors are still accepting new patients
- Customer satisfaction
- Member disenrollment (leaving the plan) rate, which can show
members’ level of satisfaction
Speak to a sales representative or a customer service representative to
get information. Your clients should ask as many questions of the managed
care organization’s representatives as they need in order to feel
comfortable choosing a plan.
Medicare HMOs and PPOs often arrange group meetings for people on Medicare,
such as a coffee hour at a local diner, or a slide show at a senior center.
Many HMOs and PPOs will also offer to send a representative to your clients’ homes.
They should ask the sales representative as many questions as possible.
Here are some facts your clients should know.
- They do not have to see a representative in order to join an
HMO or a PPO. If he/she does see one, they should not sign
up right away. They should always think it over after the representative
has left.
- If the sales representative or customer representative is
unable to answer their questions, they should ask for the
name and number of a person who can.
- They should ask people
who are enrolled in the private plan if they have been pleased
with it.
Medicare HMO and PPO enrollees must pay the Part B premium,
unless the plan offers a reduction of the Part B premium as a benefit.
Some HMOs and PPOs charge no other premium; others charge an additional
premium. Most Medicare health plan enrollees do not need Medigap insurance.
Some HMOs and PPOs charge higher premiums for versions of their plan
that have better “options.” Different plans will offer variety
of options:
- The size of the network of doctors and/or hospitals
- Whether there
is a point-of-service (POS) option, allowing enrollees
to go to doctors outside the network and still get the
HMO to pay part of the bill
- How much enrollees must pay in copayments
(the flat fee they pay for each visit)
- How much coverage
they offer for prescription, dental, and other benefits
A copayment is a flat fee that that must be paid each
time your client sees his/her doctor. Different HMOs and PPOs
have different copayments, and even within the same plan, there may
be different copayments for different services, such as primary care
provider (PCP) visits, specialist visits, hospital stays and emergency
room visits.
Coinsurance is the percentage of a medical care bill
for which your clients are responsible. For example, if a plan charges
20% coinsurance for physician visits, then your clients are responsible
for paying $20 of a $100 doctor’s visit. HMOs and PPOs usually
don’t charge co-insurance for standard services received
within the network. Plans that let enrollees go outside the network
(e.g. HMOs with a POS option or PPOs) usually do charge coinsurance,
which can be as much as 20% of the bill.
Plans may also charge either coinsurance or copayments for
mental health care, prescription drug benefits, skilled nursing
facility stays, and dental care.
Every Medicare HMO and PPO is required to provide all Medicare Part
A and Part B-covered services, including doctors’ services, hospitalization,
skilled nursing facility care, home health care, therapy and durable
medical equipment. Medicare HMOs and PPOs can also offer enrollees Medicare
drug coverage (Part D) and additional benefits, such as:
- Extra preventive care
- Prescription drug coverage
- Eye care, hearing aids, or dental
care
- A point-of-service (POS) option
- Health club memberships or discounts,
or free health magazines
- Disease management programs for chronic
illnesses, or other health
programs
Ask for a list of the benefits and services that
the HMO or PPO offers in addition to the services Medicare covers, any
costs for these extra benefits, and any restrictions on their use.
More
information about the Medicare prescription drug benefit is in
Chapter 6F.
Every HMO has its own network of doctors and hospitals that enrollees
must use in order to obtain coverage. Some HMOs also offer a point-of-service
(POS) option, which may provide partial coverage for out-of-network
doctor visits. Here are some issues to consider before your client chooses
a POS option:
- A POS option can be a good alternative if your clients want to use
an out-of-network doctor, or they need doctors with special skills
who are not part of the HMO network.
- HMOs may require an additional payment when they use the POS
option to go to an out-of-network doctor, costs can add up quickly
if your clients use out-of-network doctors frequently. To avoid
these extra costs, they might consider joining an HMO that includes
their doctors or switching to Original Medicare with a Medigap policy.
- A POS option with many restrictions may not be worth getting. Compare
restrictions and coverage of different plans.
Prescription drug benefits (Part D) vary across
health plans. Your client should keep the following issues in mind
when comparing prescription drug benefits:
- Plans have a “formulary” or list of drugs that
they cover. Find out whether the plan’s formulary includes the
drugs that your client currently uses, and keep in mind that formularies
may change at any time.
- Plans can charge different amounts for different drugs. Plans generally
encourage the use of generic drugs by having lower copays
for them.
- Compare premiums, deductible, copayments and limits on coverage between
plans.
More information about the Medicare prescription drug
benefit is in
Chapter 6F.
For benefits, such as dental
care, eye care,
and hearing aid coverage, there may be provider networks that
you must utilize and rules concerning maximum benefits or
restrictions with which your client will have to comply.
Q. How can your client choose between HMOs and PPOs based upon the
networks of doctors and hospitals?
How can my clients choose between HMOs and PPOs based upon the networks
of doctors and hospitals?
Doctors in the HMO’s or PPO’s
network:
Find out which doctors and hospitals are in the
plan’s network.
Ask each HMO or PPO for a “provider directory,” the list
of the doctors, hospitals, skilled nursing facilities, home health
agencies, pharmacies and other healthcare providers who are in
their network. See page 33 for suggestions on how to choose a
Medicare managed care doctor. Remember that doctors and hospitals can
leave the network at any time.
Going outside the HMO’s or PPO’s
network:
Your client should find out what services are covered
when you go outside the HMO’s or PPO’s network. All HMOs
are required to cover urgent care and emergency care outside
of the service area. PPOs and HMO plans with POS options cover
out-of-network care, although the out-of-pocket costs will be higher
for these providers.
- Does the HMO let your clients go to doctors for non-urgent care
when they are outside the plan’s service area? For example, some
HMOs have agreements with HMOs in other areas to provide non-urgent care
for enrollees in other regions of the U.S. This may be known as a “traveler,” “visitor,” or “passport” program.
- What are the restrictions on the use of out-of-network
providers when your client is enrolled in a PPO or an HMO
with a point-of-service option?
For example, these plans may choose to provide these services for
a much higher out-of-pocket cost. In addition, they may require that prior
approval is obtained to receive certain services.
Q. How can
your client choose between HMOs and PPOs based on their quality of
care?
A. When possible, get information from an independent
source such as doctors, friends, neighbors, and family members and not
from the plan your client is considering joining. Information your client
gets directly from different plans is hard to compare since it maybe
collected in different ways. Although it is important to know, upon request
Medicare plans are required to give consumers the information about the
number and type of complaints that they receive from their enrollees.
Another source is the website www.medicare.gov,
which has some comparisons of health plans based on their quality of
care. This information is also available through 1-800-MEDICARE. In addition,
the National Center on Quality Assurance puts out a health plan report,
which can be useful for comparing plans. Report cards are available at
the website www.ncqa.org.
Many organizations and companies known for their Medicare
supplemental insurance policies are in the Medicare managed care business.
However, keep in mind that a well-established brand name is no guarantee
of quality care. It is a good idea to look as closely at the well-recognized
plans as the lesser-known plans.
- Does the doctor your client sees contract with the plan?
- Is the hospital your client uses in the network of hospitals that
the plan uses? If not, are there other hospitals in a
geographically convenient location for your client?
- How often does the drug formulary change? More information about
the Medicare prescription drug benefit is in Chapter
6F.
- What benefits does the plan offer that meets your client’s
individual needs? For example, is there a disease management
plan? Do they provide case management services? Is durable medical
equipment easily accessible?
- What type of health prevention services does the plan offer?
- What additional benefits does the plan offer?
- How satisfied overall
are HMO or PPO enrollees with their care, and how does
that compare to other plans? Upon request Medicare plans are required
to give consumers the information about the number and type of complaints
that they receive from their enrollees.
If an HMO’s or PPO’s enrollees appear to be satisfied
with their care, your clients still can’t be sure that they will
be equally satisfied. People who do not use their health plan frequently
tend to have less complicated issues with the plan. If your clients
need to use a lot of health care services, they will also want to ask
if the HMO or PPO has any information on the satisfaction of enrollees
with a similar condition to your clients’? Are there higher copays
for treatments your clients will need?
Groups and magazines that publish ratings of managed care plans base
some of their quality-of-care rankings on preventive care measures, such
as how many women over the age of 50 receive mammography.
Just as hospitals with excellent care for cancer may not necessarily
do as well for childbirth, HMOs and PPOs that are good at keeping healthy
people well may not be as good at caring for people with chronic or complex
conditions. Does the HMO or PPO your client is thinking of joining have
any information on the quality of care for people with specific health
conditions? For example if your client is pregnant find out what percentage
of women received a prenatal visit early in her pregnancy? Or find out
what percentage of women had a pap test in the past three years? If your
client has asthma find out what percentage of asthmatics received the
appropriate medication.
Look for ratings in the managed care report cards occasionally printed
in many national publications, such as Consumer Reports, US News
and World Report and Newsweek. Get quality of care ratings on Medicare
managed care plans on www.medicare.gov or
from the National Committee for Quality Assurance (NCQA) www.ncqa.org.
Your client’s present or former employer may also be able to give
your client “report cards” on the Medicare health plans that
they offer to their employees and retirees.
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