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Taking a closer look at Medicare HMOs

While health care coverage is a major concern for seniors, the selection process is getting more daunting by the day. One of the newest kids on the block is something called "Medicare HMO." If you've ever wondered what an HMO is or how to select one, this column is for you.

Q What is a Medicare HMO?

A This means a managed care program has agreed to accept Medicare reimbursement to provide health care services to the public. Medicare HMOs must be licensed by the Florida Department of Insurance.

Q What is the difference between an HMO and traditional health care?

A Your main point of reference in an HMO will be a "primary care" physician. Since one of the main ideas of HMOs is health promotion, this physician will take a keen interest in the state of your overall health. He or she will provide regular checkups and maintenance services and will make referrals to specialists when needed.

Q What does a Medicare HMO cost?

A You generally pay a fixed monthly fee that is somewhat less than what you would normally expect to pay for physician services. Sometimes you also pay a small co-payment when the service is received. No supplementary insurances are necessary or allowed. (This reduces a lot of insurance paperwork.)

Q Are HMOs a better buy than regular health care?

A Some HMOs are probably a little less expensive and offer some other conveniences worth considering. For instance, you will know what to expect in terms of your health care expense each month. Some consider HMOs a bargain because extras such as medications, dental care, hearing aids and eye glasses are sometimes included in the monthly fee.

Q My wife and I reside in Florida from Thanksgiving to Easter and then spend the rest of our year in Jersey. Would you recommend an HMO for us?

A HMOs generally require that the patient stay within their plan for all his or her health services. You must check very carefully to determine if the HMO you are considering will provide coverages both in Jersey and Florida.

Q Can a person get out of an HMO whenever he or she wishes?

A As part of a Medicare HMO, you have the option to leave at any time "effective the following month." It is a good idea to get a guarantee of this provision in writing, however.

Q What if an HMO enrollee wishes to see a physician who is not on the program?

A HMOs generally don't pay for physician visits unless it's with one of their own. Second opinions and the services of a specialist are not covered unless your primary care physician has made a specific referral. (Of course, you are free at any time to see a doctor outside the HMO system if you pay for it yourself.) You need to know ahead of time if your HMO has a "lock-in provision." If it does not, you may be able to see doctors outside of their system and still have Medicare pick up a portion of the bill.

Q The primary care physician I had selected was a great doctor. Unfortunately, he has left the HMO I am with and I have been reassigned to another physician. I have been very unsatisfied with care. How can I lodge a grievance?

A If your concerns are related to the quality of care received, contact the Agency for Health Care at (800) 226-1062. They will register your complaint and also work with you to help resolve the issue. (The staff people who answer the phones are very helpful and will talk to you at length to answer your questions.)

Selecting a managed care provider is certainly not for the faint of heart. A lot of initial leg work is required, both to compare the HMO plan with traditional coverages as well as to compare and contrast different HMO plans. You will find much variation. Begin by calling the Social Security Administration at (800) 772-1213. Request all their free booklets on Medicare/coordinated care plans.

Next, call the Florida Department of Insurance Consumer Help Line at (800) 342-2762 to request the current edition of Health Maintenance Organization Consumer's Guide. Ask which HMOs in your area have the Medicare affiliation and check for any possible complaints lodged against these organizations. Good luck!

Special thanks to Dr. Susan Pappas, medical anthropologist, for technical assistance with this column.

Helen Susik is a gerontologist with Suncoast Gerontology Center at the University of South Florida in Tampa. You can write to her c/o Seniority, the Times, P.O. Box 1121, St. Petersburg, 33731.