If you or a family member is a resident of a nursing facility, personal care home, or continuing care retirement community (CCRC) which includes access to a nursing facility, and are thinking about enrolling in a Medicare HMO, there are some unique considerations regarding the delivery of Medicare covered services you should address when you gather and review information.

note about

long-term

care

• Are the appropriate facility staff (medical director, billing office, etc.) aware of any changes in insurance coverage; for example, a switch from Medicare fee-for-service to a Medicare HMO plan?
• Is the facility in the HMO service network? If not, will service still be provided? Take note: some hospitalized residents of continuing care retirement communities (CCRCs) who are enrolled in Medicare HMOs have been discharged to other nursing facilities under contract with the managed care plan rather than to those in their retirement communities. This can isolate residents from family and friends and, in some cases, separate spouses.
• Does the facility know which labs, pharmacies and other services to bill?
• Will primary care physicians conduct visits and exams in the facility? How often?
• How is transportation arranged?
• How are prior authorizations for treatments and supplies handled? How quickly are they handled?
• There may be other areas of care affected and you may want to review the HMO plan with your facility's Health Care Services office or designated staff to identify and resolve all potential problems.