Benefits/Limitations Of Medicare+ Choice Plans

Benefits:

• Medicare+ Choice HMOs cannot turn you down due to age, poor health, or pre-existing conditions. (Exceptions: You can be turned down if you have End-Stage Renal Disease. Also, Cost Contract HMOs can turn you down if you are in the Medicare Hospice Program.)
• If you are under 65 with Medicare due to a disability, you may enroll in either type of Medicare HMO and not be denied.
• Medicare HMOs must provide all Medicare covered services.
• You can choose a Primary Care Physician (PCP) who coordinates all of your care. You can change your PCP within the network.
• Medicare HMOs may provide some services that Medicare doesn't usually cover, such as routine physicals and foot care, dental care, eye exams, prescriptions, hearing aids, and other preventive services.
• You usually have less out-of-pocket expenses, such as premiums, copayments for doctor services and prescription drugs. You do not need a Medicare supplement policy.
• You have no bills or claim forms to complete. Filing and organizing of claims is done by the Medicare HMO.
• You have 24-hour access to services, including emergency or urgent care with providers outside of the network. This includes foreign travel not covered by Medicare.
• Medicare requires and monitors quality assurance for doctors and facilities.
• The Medicare HMO must enable you to appeal denial of claims or services. If the service is still denied. then you have other appeal rights with Medicare.

Limitations:

• You must live within the service area of the Medicare HMO. If you move outside of the service area, then you must join a different plan or get a Medicare supplement policy to go with your Original Medicare.
• You must follow the rules and use the providers in the plan, except for emergency or urgently needed care. (Exception: Cost Contract HMOs allow you to use providers outside of the network and Medicare will still pay 80% of the approved amount.)
• Your current doctor or hospital may not be part of the Medicare HMO network, so you would have to choose a new doctor or hospital.
• You must get a referral from your Primary Care Physician to receive care from health care providers outside of the network, or the plan will not pay (unless you are in a Cost Contract HMO).
• A provider could leave the plan or the plan's contract with Medicare could be cancelled. Then, you would have to find another Medicare HMO or get a Medicare Supplement Policy to go with your Original Medicare.
• If your Primary Care Physician leaves the plan, then you would have to choose another PCP.
• If you live outside of the plan area for 12 or more months in a row, the Medicare HMO may ask you to disenroll and re-enroll when you return to the area. However, if a Medicare HMO is available where you are living, you could enroll in it for coverage while you were outside of your regular plan area, and then re-enroll in your plan when you return home.
• Medicare HMOs may require you to use particular medications to lower their costs and yours.

Source: Indiana Senior Health Insurance Information Program (SHIIP)