MEDICARE HMO how does it work?

With an HMO,

choice of

doctors,

hospitals,

nursing homes

and other

health care

providers is

limited

 When you enroll in a Medicare HMO, you are signing up to receive all your Medicare services through the HMO. This means you no longer have traditional fee-for-service Medicare, but must go through your HMO's network of managed care to receive the benefits covered by Medicare. Although you should keep your Medicare card, you shouldn't present it for payment purposes.

To receive covered care in an HMO, you must get prior approval by your primary care doctor for most services. This doctor, sometimes called a "gatekeeper," will decide in consultation with you which tests you will have, which specialists you should see, and whether or not you should be admitted to a hospital.

If you don't get prior approval, neither Medicare nor the HMO will pay for the services. You also are responsible for any services you receive outside of the HMO network.

The only exceptions are for emergency or urgently needed care you may receive outside the plan's service area, but you must follow any special rules your HMO may have in these cases to guarantee payment.

Enrollment

You may enroll in a Medicare HMO without health screening during an advertised 30-day open enrollment period. HMOs must have at least one open enrollment period each year. Coverage usually begins the first day of the month or no later than three months after your enrollment application has been received.

When you enroll, you must choose a primary care physician or one will be assigned to you. Usually, you may change your primary care doctor for any reason, but you must pick another one from the plan's network.

If you enroll in a plan and later move out of its service area, you will have to disenroll and either return to regular fee-for-service Medicare or enroll in another Medicare managed care plan that serves your new location.

    Medicare HMO Eligibility Requirements

  • Must be an eligible Medicare beneficiary
  • Must reside in an area served by a Medicare HMO
  • Cannot have end stage renal disease
  • Cannot be receiving Medicare hospice benefits
 You must

choose one

primary care

doctor and use

providers in the

HMO plan
UNDERSTANDING HMOs
In initial reviews of Medicare HMO experiences nationwide, the federal Department of Health and Human Services found common misunderstandings in several key areas.

Here are some main points to keep in mind.

  • If you apply to a Medicare HMO, you cannot be asked about health problems or be required to take a physical exam.
  • You have the right to appeal your HMOs refusal to provide or pay for services. See information on appeals under Know Your Rights.
  • You have the right to back out of enrollment after application, if you choose. See information on 30-day review and disenrollment under Know Your Rights.
  • You must use only those doctors, hospitals, nursing homes and other providers who are part of your plan for the HMO to pay for your care. This is often referred to as the "lock-in" provision.

    • Your primary doctor must refer you to a specialist in order for the HMO to cover the cost.

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