Last Updated: April 2006

A SUMMARY OF INDIVIDUAL'S RIGHTS IN REGARD TO MEDICARE HMOS

The material in this chapter has been licensed by the Medicare Rights Center

Individuals’ right to remain in Original Medicare

• Individuals have a choice between staying in Original Medicare and enrolling in a Medicare private health plan, such as an HMO or PPO. (For clarity, this chapter will refer to all Medicare private health plans as HMOs. People have the same rights in any type of Medicare private health plan.)

Individuals’ rights before joining an HMO

• HMO representatives cannot mislead people into enrolling in a health plan. Representatives must give clear and accurate information about HMO benefits and services.
• HMO representatives cannot pressure people into enrolling in an HMO. Consumers do not have to sign any forms or give their Social Security or Medicare number to the representative unless they want to enroll.
• HMOs cannot discriminate against people with Medicare because of their age or health status. The only people with Medicare who cannot enroll in Medicare HMOs are people with End-Stage Renal Disease. Otherwise, no matter what an individual’s age, disability, or health status, HMOs must accept anyone with Medicare who would like to enroll. 
• It is against the law for an HMO to require people to have a health screening or to ask questions about their health status that could be used to discriminate against them before they join an HMO. 

Individuals right to emergency care

• If plan members have an emergency or need immediate medical care, their Medicare managed care plan must cover their visit Emergency Room even if they:
  • go to hospital not in their plan’s network.
  • had a condition that turned out not to be a “true” emergency (for example, the person had chest pain and thought he/she was having a heart attack, but at the emergency room the doctors said he/she just had heart burn).
  • did not get pre-authorization to go to the emergency room.
  • did not call or write to the plan within the number of days or hours normally required by the plan.
    
• To be entitled to “emergency care,” plan members must have an emergency medical condition. A medical emergency is when any prudent person with an average knowledge of health and medicine believes that their condition could result in serious harm to their health, a body organ or part, or body functions. The person may have severe pain, a bad injury, sudden illness, or an illness that is quickly getting much worse. It is an emergency if the prudent lay person believes that the condition may cause any of the following:
  • Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child
  • Serious impairment to bodily functions;
  • Serious dysfunction of any bodily organ or part.
• Medicare managed care plans must cover emergency care anywhere in the country, and cannot charge members more than $50 for Emergency Room care, or what it would charge if they had obtained the services in-network, whichever is less.
• Medicare managed care plans must pay for follow-up care related to an emergency visit, although members must get it from their plan’s network doctors if they are well enough to travel to them.
• Medicare managed care plans must pay for ambulance trips that would be paid for if members were in Original Medicare. The ambulance company can only bill you the client the amount of his/her plan’s usual co-payment.

Individuals’ right to urgent care

• The HMO is financially responsible for urgently needed services. Urgently needed services are covered services that are not emergency services as already defined. Urgently needed care is provided when an enrollee is away from the Medicare health plan’s service area and when the services are medically necessary and immediately required. The types of situations that may require urgently needed services are:
  • an unforeseen illness, injury, or condition;
  • when it is not reasonable to obtain necessary services from the organization offering the Medicare plan


• It is important to remember that under unusual or extraordinary circumstances, services may be considered urgent if a member is in the plan’s service area, but the plan’s provider network is temporarily unavailable or inaccessible.

Individuals’ right to other medical services in a Medicare HMO

• HMOs must provide medically necessary services for all Medicare-covered benefits, and may also provide additional benefits. HMO members are entitled to the same benefits and services available under Original Medicare, although they must receive these services from the doctors, hospitals, home health agencies, and other health care providers in the HMO’s network. The exceptions, of course, are in emergency and urgently needed situations, and renal dialysis services that are provided while outside the service area. PPO enrollees can get care from providers not in the plan’s network, but they will have to pay more out-of-pocket.
  
  
• If an HMO does not have a doctor in its network that can provide a Medicare-covered service that members need, the HMO must arrange and pay for them to see a doctor outside of its network.



• The HMO is not allowed to try to get members to leave the plan, to delay or deny services, because they might need expensive treatments such as heart surgery, organ transplants, long-term nursing care or rehabilitative services.

Individuals’ rights when he/she is not satisfied with an HMO

If plan members:

• believe they need care that the HMO refuses to give them; or
• did not receive coverage from their HMO for any care they received, including emergency services, or urgent services, that they received outside the HMO’s service area;

Then they have the right to:

• appeal an HMO decision with which they disagree; and
• receive a timely response to their appeal.

Individuals’ right to leave an HMO

If plan members are not satisfied with the care they are receiving from their Medicare HMO, they have the right to switch to another HMO or disenroll from (leave) the HMO and return to original Medicare. Starting in 2006, people with Medicare can do so only two times a year. The two opportunities are either during:

• Annual Coordinated Election Period (ACEP), which is from November 15 to December 31 each year. Coverage chosen during the ACEP is effective January 1 of the following year.

  - or -

• Open Enrollment Period (OEP), which will run January 1 to June 30, 2006, and January 1 to March 31, 2007. Coverage chosen during the OEP is effective the first of the month after they enroll.

Plan members may also get a Special Enrollment Period, to disenroll or change their enrollment to another Medicare managed care plan or return to Original Medicare because of special circumstances. Some events that trigger a Special Enrollment Period include when the Medicare managed care plan in which the member is enrolled is terminated; when the enrollee moves out of the service area of the plan; or when the Medicare managed care organization offering the plan violated a material provision of its contract with the enrollee.

HOW TO LEAVE (DISENROLL FROM) A MEDICARE HMO

Q. What if my clients discover that they do not like their HMO?

A. If your clients are dissatisfied with their HMO for any reason, they have the right to switch HMOs. They will be automatically disenrolled from their old HMO when they sign up for a new HMO and the new HMO enrollment will become effective.

Your clients also have the right to disenroll from the HMO and return to Original Medicare. To disenroll they can either: 

• write a letter to their HMO stating that they want to disenroll (they should sign and date the letter); or
• fill out Form 566 “Disenrollment from Medicare Managed Care” at their local Social Security Office.

Your clients will be automatically enrolled in Original Medicare when they disenroll. 

Q. What if my clients move or take a long vacation?

A. If your clients are out of their Medicare HMO’s service area for more than 6 months, the HMO should automatically disenroll them. There are some exceptions to this rule, see Chapter 6A.

Q. Will my clients be able to buy Medicare supplemental insurance (Medigap) after they leave an HMO and return to Original Medicare?

A. Yes. In New York State, Medigap insurers must accept all individuals on Medicare, regardless of age or health. In addition, they may not impose a waiting period for pre-existing conditions for people who return to Original Medicare after disenrolling from a Medicare HMO as long as they begin Medigap insurance within 60 days of disenrollment. This prohibition only applies the first time an individual enrolls in a Medicare HMO.

Medicare supplemental insurance (“Medigap”) companies may impose a 6-month waiting period for pre-existing conditions on people who buy a Medigap policy more than 60 days after their return to Original Medicare. This means that the Medigap plan must enroll the person, but it does not have to pay for care related to the pre-existing condition until 6 months after the client’s new Medigap policy starts.

Q. What if my clients enrolled in a Medicare HMO without realizing it, or without being told what it would mean?

A. Sometimes people with Medicare enroll in HMOs without understanding that they have switched out of Original Medicare into a Medicare private health plan. Alternatively, the plan may never have explained its restrictions, such as the fact that enrollees can only go to in-network doctors and hospitals, and that they can only see specialists with referrals from their primary care providers. Or they mislead a person into believing the person’s doctors are in the plan’s network when in fact they are not. In situations like these, Medicare HMO enrollees may be able to obtain retroactive disenrollment by submitting a request for a retroactive disenrollment to the HMO or directly to the Centers for Medicare and Medicaid Services (CMS; formerly HCFA).

Written requests for retroactive disenrollment can also be sent to your clients’ local Social Security office. Requests should fully explain that your clients never understood that they had joined a Medicare HMO or that they never understood network restrictions.

If your clients are retroactively disenrolled, they will be covered as if they had been in Original Medicare, rather than in an HMO, for the time they were in the HMO. Past bills from non-HMO doctors and hospitals can then be submitted to Original Medicare for payment. They will have to pay Medicare co-insurance or deductibles related to any care that they received while in the HMO.