By Carol Abaya,
my husband and I (69 and 66) and my father (90) have been receiving lots
of information in the mail about Medicare + Choice and Medicare HMO’s.
There is so much material with different recommendations that we’re confused.
What is the best program?
can participate in the traditional Medicare program or receive medical
care through an HMO. There are key differences.
allows you the most flexibility, choice of doctors and treatment. You
and your doctor make the important decisions, and you receive treatment
accordingly. If Medicare, for some reason, refuses to pay for the treatment,
the denial comes after you have already received the care. You
can then appeal. This plan pays part of the cost of medical services and
you pay for the annual deductible and 20% copayment.
usually offer a broader package of services (medicine, eyeglasses, hearing
aids) than traditional Medicare. The amount you have to pay out-of-pocket
However, a strong
warning. HMO’s place a layer of cost-conscious administration (and strangers)
between you and your doctors.
First, your choice
of doctors is limited, as the doctor must be “in the HMO system.” An
Arizona doctor told me one of his long time elderly patients was forced
to change doctors because he was no longer in that HMO system.
Second, your doctor’s
recommendation for treatment can be denied by the HMO before the
treatment is provided. There have been cases where the patient died before
the appeal process was completed.
The HMO has the ability
to refuse to allow you to be treated at a critical time. Always remember
that in all managed care programs there is an administrative level (which
is difficult to “control”) which may come between you and your doctor
and optimal treatment.
You do not have to
change from the traditional fee for service Medicare program. This in
the long run gives you the most flexibility and choices.
If you are happy with
the way you now get your health care, you shouldn’t do anything. What
sounds too good to be true (new plans), often is.
Question: My mother’s
doctor is trying to get her to sign a contract with him and to charge
her higher rates. Can he do this?
You can enter into a private contract with any doctor (or other provider)
for treatment any time you want. But then the doctor can’t treat
any Medicare patients and receive payment from Medicare for 24 months.
If you sign a contract,
the doctor is free to charge private rates for the treatment. You pay
the whole bill. Medicare will not pay, even if a claim is submitted.
You may not use your medigap supplemental insurance, or any other insurance,
to help cover the costs. This process applies to Medicare - approved
treatment only. Physicians and providers who accept payment for Medicare
services cannot enter into private agreements with patients for treatments
covered by Medicare.
However, if your doctor
recommends a new treatment or medical procedure not approved by Medicare,
you can agree to pay the total cost yourself. The doctor will still be
able to treat other Medicare patients and receive payment. Physicians
can only be paid privately by patients for treatments and services not
covered by Medicare. In these cases, neither the physician nor patient
is penalized by Medicare.
With the traditional
Medicare plan (fee for services) doctors can “accept assignment” and
they are paid the amount approved by Medicare. Medicare bases its payments
on what it feels is customary and reasonable in that part of the country.
If the doctor does not accept assignment he can only charge 15% more
than what Medicare approves. This limitation on charges protects seniors
from doctors seeking to make more money and take advantage of those who
do not know their rights.
Question: My parents’
doctor told them that Medicare will pay for various tests to see if they
have cancer or osteoporosis. My company HMO told me that isn’t true.
Who is right?
parents’ doctor! Regardless of whether your parents are in the traditional
Medicare program or in an HMO, they are entitled to various preventive
treatments and tests, including:
- flu shot, once
- pneumonia shot,
- mammogram, one
- pap smear and
pelvic exam, once every three years, unless high risk
- colorectal cancer,
various tests depending on risk level
- diabetes monitoring,
in doctor’s office and now at home
- bone mass density,
depends on health and risk
Question: My parents
spend three winter months in Arizona. They are thinking about switching
to an HMO because of the medicines they both have to take and which are
paid for by the HMO. Should they switch?
HMOs only provide for and pay for medical services in a limited geographic
area. If one of your parents get ill in Arizona, who will he or she go
The HMO will not pay
the bills. Under the traditional Medicare program, medical bills will
be paid regardless of where the treatment in provided across the USA.
Question: My parents
(73 and 78) have very limited income and the amount deducted for Medicare
from their social security checks each month could be used for food.
Is there some way that they can get the medical insurance coverage, but
Yes, provided they meet certain low income and asset requirements.
Medicare Part A pays
for hospital care and is not paid for separately. It’s an integral part
of social security.
The cost of Part B
(medical-doctors-insurance) is dedicated from the amount your parents
There are three programs
that will pay for Part B, with certain conditions having to be met. (1)
Medicaid; (2) the “Qualified Medicare Beneficiary” (QMB) program; (3)
“Specified Low-Income Medicare Beneficiary (SLMB) program. QMB and SLMB
are federal and run by Health Care Financing Administration. Medicaid
is state operated.
Contact your state
local medical assistance agency, social service office or welfare office
for all three programs.
Question: My parents
(68 and 70) are planning a trip to the Caribbean, for the holidays. We
have been told that Medicare will not pay for medical or hospital expenses
if they get sick. Why not? After all, they pay for it from their social
Traditional Medicare (as opposed to HMOs) will pay for doctors and hospital
bills anywhere in the U.S.A. Most HMOs won’t even pay that. If someone
goes on a trip outside the HMO coverage area, they end up paying the bills.
While Medicare won’t
pay for out-of-country medical bills, there is travel medical insurance
available for a nominal fee. There is also insurance that will reimburse
a person for deposit and other payments made if he/she gets sick and can’t
make the trip. Travel agents have application forms and are generally
Question: I am
72, live alone and need an operation on my leg. The hospital says I have
to leave after 48 hours. But I won’t be able to walk freely and have
no one to help me. The doctor is advising a nursing home. I don’t want
to go into a nursing home and don’t have money to pay for one. What are
your doctor suggests a nursing home, he really is suggesting a rehab nursing
home where you can get both the medical help you need to recover and physical
therapy so you can return to and remain independent in your own home.
Medicare will pay
all the nursing home costs for up to 20 days. Then Medicare will pay
part of the bill through the 100th day.
Once home, Medicare
may also pay for a visiting nurse (up to 100 visits) to check your progress,
So, take advantage
of what Medicare will pay.
will not pay for custodial nursing or home care services.
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