Should You Make The Move To A Medicare Hmo?

Two years ago, after she had a suspicious mole removed, Helen Austin of Bowie, Md., got fed up with Medicare. First she had to complete a ton of paperwork. Then she waited months to get reimbursed, only to have her claim denied. Fortunately, the mole turned out to be harmless. But her ordeal with Medicare provider Capital Blue Cross/Pennsylvania Blue Shield led her to join a health maintenance organization that accepts Medicare patients.

Traditionally, organizations such as Blue Cross & Blue Shield process Medicare claims from any doctor a person chooses--called "fee for service" in health-care parlance. But to hold down the swelling cost of Medicare, the feds have been imploring Medicare recipients to enlist in HMOs, where a "gatekeeper" physician decides what care patients need and whether to refer them to specialists, who often work for a set fee. The downside: You can only see physicians in the HMO's network and may not be allowed to see a specialist. So some soul-searching is in order before signing up yourself or an aging parent.

For folks such as Austin, not having to seek reimbursement for doctor bills is a big attraction. The HMO handles all that. Another plus: HMOs provide built-in Medigap coverage, which picks up fees or services beyond what Medicare covers. For instance, Medicare pays for just the basics, namely inpatient hospital care and outpatient services. Medigap--insurance seniors normally purchase for themselves--handles prescription drugs, preventive care, and at-home recovery.

You pay less in premiums with a Medicare HMO. Medigap coverage for a patient choosing the fee-for-service Medicare option would cost an average of $778 annually. The exact premium depends on your age and how extensive you want your coverage to be. Since Washington is saving money on you in an HMO, you pay only $363 a year on average, and in some Medicare HMOs, you pay nothing. One fee that's the same: Both HMO and fee-for-service patients get $42.50 deducted from their Social Security checks.

ASK AROUND. Like Austin, more seniors are joining Medicare HMOs. But while the number of plans is growing, Medicare HMOs aren't available everywhere. One of the largest is Kaiser Permanente in Oakland, Calif. The American Association of Retired Persons, which offers a fee-for-service Medigap plan, is exploring an HMO option that will operate in 23 markets nationwide.

How do you find an HMO? Austin got advice from the United Seniors Health Cooperative (USHC), a nonprofit independent consumer group that told her of some introductory meetings in her area. She signed on with Optimum Choice Advantage in Rockville, Md. It helped that the internist she had been with for 10 years was a member.

While doctors in some HMOs work out of single-center facilities where all patients go for care, others, such as Austin's, don't. So she goes to many sites, depending on which specialist she's visiting.

Determining the quality of care you'll get from an HMO is difficult since there are no standardized qualifications that plans must meet. Still, check out the education and the board certification of prospective doctors and ask to see results of consumer-satisfaction surveys. By law, Medicare recipients can't total more than 50% of an HMO's practice. Once an HMO does reach 50%, it must then accept equal numbers of non-Medicare patients. But Medicare HMOs must accept all types of Medicare recipients, excluding only those with end-stage renal disease.

NO RESPONSE. Also check out procedures for specific operations you might need, to determine whether you'll get the type of care you want. If a plan won't respond, that gives an indication of how open the HMO is to disclosing its terms and policies. Contact your state's insurance regulators or office on aging to find out whether any complaints have been filed against the HMO. It's also a good idea to grant an adult child or your designated caregiver power of attorney when you join the plan. That way, if you become too ill to make decisions about your care, that responsibility will be switched to your designate. Besides, offspring who already may be enrolled in an HMO "often know the areas where HMOs cut corners," says Sue Andersen, a professor at George Washington Law School.

Once you have signed up, inform family members about the terms of your plan. Often when patients develop serious illnesses and are taken out of their plan's service area, they get stuck with uncovered bills.

You can also contact the National Committee for Quality Assurance which conducts accreditation reviews for many Medicare HMOs. An NCQA team of physicians and managed-care experts evaluates how well a health plan manages its physicians, hospitals, other providers, and administrative services. "Overall, we see a wide variation in quality of care, from plan to plan and from region to region," says NCQA spokesman Barry Scholl.

TRAVEL. One huge downside: If you spend long periods of time outside your HMO's service area, you're on your own. Many HMOs won't pay for out-of-network care. By law, members who leave their region for 90 days or less are covered for health emergencies only. Those out of the service area beyond 90 days should check to see whether they're covered at all. A few plans are developing a "travel benefit" that will cover--through affiliate HMOs--patients who leave their area, according to the Washington-based Health Care Financing Administration, the government agency that oversees Medicare.

Consider, too, the hospitals your HMO is affiliated with. Is it located so far away that getting care will be inconvenient? Also be sure to ask exactly what ailments your plan covers, especially if you have a family history of a specific illness. NYLcare65, for instance, doesn't pay for custodial care related to degenerative diseases such as Alzheimer's unless the deterioration includes physical symptoms.

Of course, you don't have to accept an HMO's medical decisions at face value. You can appeal. Helen Austin successfully fought an HMO edict that barred her from getting the full supply of heart medicine she needed. She contended that the rules entitled her to 100 doses or a 31-day supply. The HMO replied it had changed the rules so that Austin could only get a 31-day supply. But the HMO failed to mail advance notice of the change in rules, so Austin's appeal was successful.

Appealing may not always be a realistic choice because of the time, effort, and cost. So HMO enrollees should set aside an emergency fund to cover instances where they may need to go outside their network.

If you're dissatisfied with the care you're getting from your HMO, you have the right to opt out at any time. The change takes effect on the first day of the month following the HMO's receipt of your written notice. Many people, however, are reluctant to join an HMO, even with the escape clause, out of fear they'll have problems getting their old policy back. Indeed, they may end up with a higher premium when they reenter the old plan or endure a waiting period if they have developed a preexisting condition since leaving. So before you quit, find out whether you can get your old coverage back at the same premium--or at all.

Unfortunately, returning to a traditional Medicare plan may get harder in the next few years. Federal lawmakers are talking about limiting the number of times you can switch to just once a year. Enrollees would have a 90-day trial period for an HMO or a fee-for-service Medicare plan. Most counselors recommend keeping your Medigap policy until you are certain you're satisfied with a managed-care plan.

Above all, get your priorities straight. If you were used to freedom in choosing medical care before, you must give that up for the sake of convenience and saving money. Be sure that's a trade-off you or a parent may want to make.

Before it's here, it's on the Bloomberg Terminal.