HMO WOES

November 1998
		On January 1, almost half a million elderly and disabled Americans will lose their health coverage when several managed care plans no longer cover Medicare patients. What is the fate of Medicare? What options do people have? Experts answer your questions.

How do I know if I will lose medical coverage? Is the pullout legal? Why is healthcare so expensive? Can people just go back to Medicare? Why don't we raise rates? Does the medical industry charge too much? How can HMO's work with the government?

From the Editor: How will people know if their HMO's will cover them in 1999? What are the steps a person should take if they find out that they will indeed be dropped? Diane Archer responds: Unless people have heard from their Medicare HMOs that they will be dropping them, people should assume that their HMO will cover them in 1999. They can call the HMO customer service staff to confirm. Of course, premiums may increase and benefits may change in 1999. And, doctors can leave the network. They should get that information now to be sure they want to stay with their HMO. If they will be dropped, they should know that they will automatically be enrolled in traditional Medicare, the government fee-for-service program that covers care from virtually any doctor and hospital in the U.S. However, if they want this option, they will probably want supplemental coverage to fill gaps in traditional Medicare. If their former employer or union offers health benefits, they should call their former employer to see if they can get retiree coverage to fill gaps in traditional Medicare. Otherwise, they should call their state insurance department or State Health Insurance Assistance Program (800-638-6833 for number) for a list of the companies in their state offering supplemental coverage to traditional Medicare as well as information on their rights to get this coverage. So long as they stay in their HMO until the end of 1998 and they are over 65, under federal law, they are entitled to get supplemental coverage--Plans A, B, C and F-even if they are old or sick. (Some states, like NY, CT, MA and NJ, have more generous protections.) They should apply now because it can take two months for companies to process their application. If they want and there are other HMOs in their area, they can sign up with another HMO in their area. They should be sure to find out what the 1999 premiums, copays and additional benefits are and who the doctors and hospitals in the network are. They need to keep in mind that costs and benefits as well as the network of doctors and hospitals are subject to change. Tricia Neuman responds: More than 400,000 elderly and disabled people covered by Medicare HMOs in 1998 will be affected by the decision of many HMOs to pull out of the Medicare market by January 1999. Nearly 100 of the 350 risk contract Medicare HMOs have announced that they will not renew their contracts for 1999 or will be reducing their service areas. The plans are currently serving beneficiaries in close to 30 states. If you are in one of these HMOs, you should have received, or should soon receive, a letter from your plan explaining that the plan is dropping out of the market and that you will need to make a change by the end of this year. If you did not receive such a letter, and are concerned that your HMO may be pulling out, there are a number of places to call for additional information. You might want to begin by contacting your plan directly. You could call the automated Medicare Special Information number (1-800-318-2596) to find out about Medicare plans in your area. You could also call your local State Health Insurance and Assistance Program in your area. These programs are set up to help beneficiaries with their questions, concerns and problems with Medicare. If you are Internet-savvy, you can go to Medicare's Web site (www.Medicare.gov) for more information about plans that will be available in your area. If you learn that, indeed, your HMO is dropping out of your area, you will need to explore alternative options for coverage. The most important thing to remember is that you will have health insurance coverage under Medicare -- no matter what. If you do not join another HMO or another Medicare+Choice plan in your area, you will be covered under the traditional, fee-for-service Medicare program. If you elect coverage under traditional Medicare, you might want to consider purchasing a Medicare supplemental insurance policy, known as Medigap, to help fill in the gaps in Medicare's benefit package. Karen Ignagni responds: 1. Individuals currently covered by health plans that will not be participating in Medicare during 1999 already should have been notified. These individuals will have a number of choices. Most will have the opportunity to switch to another health plan participating in Medicare. And for all individuals, there is an opportunity to return to the traditional Medicare program. All individuals returning to traditional Medicare will be permitted to enroll in a Medicare Supplemental plan (often called "medigap") that covers gaps in traditional Medicare coverage. The letter sent to you by your health plan if it is withdrawing from the Medicare program in the county that you live in should (1) identify all other health plans participating in Medicare that will be available where you live during 1999 and (2) provide information on the individual's rights to return to the traditional Medicare program and to enroll in a "medigap" policy. Individuals who are in health plans leaving Medicare should read the letter carefully. For example, the opportunity to enroll in a medigap policy on favorable terms may depend on the date that you switch from your health plan to a medigap policy. The details are spelled out in the letter from your plan. While all individuals whose health plans are leaving Medicare should be notified by mail, you should call your health plan's member services center if you have any questions about whether your plan will remain available in your county during 1999. The member services number typically can be found on your membership card and/or in your health plan handbook. There are a number of sources of information that individuals can consult in making the best choice among health plans (or of medigap) for themselves. These include the member services departments of health plans continuing to serve your county (telephone numbers will be included in the letter mentioned above), state insurance departments and state government offices on aging (in some states, they provide information about health plans and medigap). Additionally, several states, including Florida and Maryland, issue report cards on HMOs that individuals may wish to consult when choosing a new plan. I also recommend that you check out AAHP's publication, "How to Choose a Health Plan," on our Web site. This document can be retrieved by pointing your Web browser to www.aahp.org/services/chooseplan.cfm. In addition, the Health Care Financing Administration maintains a Web site at www.medicare.gov tht has information on beneficiary options, medigap policies, and a telephone number for agencies that can provide assistance. Click to continue...