To HMO or Not to HMO: An Easy Guide to Help You Decide

Health Maintenance Organization, HMO, contract with Medicare to provide services to Medicare recipients who want this type of coverage. By law, HMO's that are enrolled Medicare beneficiaries are required to provide certain benefits at no additional charge. This included extended hospital stays, expanded home health benefits and coverage for certain drugs. Many of these organizations offer such services as dental care, hearing testing and hearing aids, and refractions for eyeglasses.

HMO's are prepaid health plans. As a member, you pay monthly premiums and in exchange the HMO provides comprehensive care for you and your family. This includes doctors' visits, hospital stays, emergency care, surgery, lab tests, x-rays and therapy. HMO's arrange for this care either directly in its own group practice or through doctors and other health care professionals under contract. You are limited to only those doctors or health care organizations that are under agreements with HMO, but in case of an emergency or a medical necessity occurs, exceptions can be made. With each office visit there may be a small co-payment, this could be as small as $5 for doctors' offices and $25 for emergency room visits. All in all your total medical costs will lower and more predictable than a fee-for-service insurance.

Here is a list of choices that may help you decide to HMO or not to HMO.

MEDICARE REQUIREMENTS FOR COVERAGE IN AN HMO:

•You must be enrolled in Medicare's medical insurance (Part B) and continue to pay the premiums.
•You must live within the area serviced by the HMO or CMP.
•You will usually be required to receive all care from the HMO or CMP, except in emergency or urgent situations.
•You cannot enroll in an HMO or CMP if you have chronic kidney disease. But if you are a member of an HMO or CMP when you develop chronic kidney disease, the care you need will be provided through the organization.
•If you have elected hospice care, you may not enroll in an HMO or CMP as long as the hospice election remains in effect. However, when you are already a member of an HMO or CMP, you may elect hospice and continue in the organization's plan. In that case you must receive all care related to your terminal illness from the hospice and not the HMO or CMP.

Questions to Ask About an HMO:

•Are there many doctors to choose from? Do you select from a list of contract physicians or from the available staff of a group practice? Which doctors are accepting new patients? How hard is it to change doctors if you decide you want someone else? How are referrals to specialists handled?
•Is it easy to get appointments? How far in advance must routine visits be scheduled? What arrangements does the HMO have for handling emergency care?
•Does the HMO offer the services I want? What preventive services are provided? Are there limits on medical tests, surgery, mental health care, home care, or other support offered? What if you need a special service not provided by the HMO?
•What is the service area of the HMO? Where are the facilities located in your community that serve HMO members? How convenient to your home and workplace are the doctors, hospitals, and emergency care centers that make up the HMO network? What happens if you or a family member are out of town and need medical treatment?
•What will the HMO plan cost? What is the yearly total for monthly fees? In addition, are there copayments for office visits, emergency care, prescribed drugs, or other services?

Because HMOs receive a fixed fee for your covered medical care, it is in their interest to make sure you get basic health care for problems before they become serious. HMOs typically provide preventive care, such as office visits, immunizations, well-baby checkups, mammograms, and physicals. The range of services covered vary in HMOs, so it is important to compare available plans. Some services, such as outpatient mental health care, often are provided only on a limited basis.

Many people like HMOs because they do not require claim forms for office visits or hospital stays. Instead, members present a card, like a credit card, at the doctor's office or hospital. However, in an HMO you may have to wait longer for an appointment than you would with a fee-for-service plan.

In some HMOs, doctors are salaried and they all have offices in an HMO building at one or more locations in your community as part of a prepaid group practice. In others, independent groups of doctors contract with the HMO to take care of patients. These are called individual practice associations (IPAs) and they are made up of private physicians in private offices who agree to care for HMO members. You select a doctor from a list of participating physicians that make up the IPA network. If you are thinking of switching into an IPA-type of HMO, ask your doctor if he or she participates in the plan.

In almost all HMOs, you either are assigned or you choose one doctor to serve as your primary care doctor. This doctor monitors your health and provides most of your medical care, referring you to specialists and other health care professionals as needed. You usually cannot see a specialist without a referral from your primary care doctor who is expected to manage the care you receive. This is one way that HMOs can limit your choice.
Which ever way you choose to go, it would probably be a good idea to ask friends and neighbors which insurance they prefer. The ultimate decision is still up to you and what fits your needs.