HMO Facts

Medicare HMO Plans are all the same in some ways. These are rules that are established by the tradition of HMO organizations and by Medicare.

HMO Organizational Facts

HMO stands for Heath Maintenance Organization. This is what is known as a managed care organization. HMO's were first introduced in 1973 to help control costs and improve care for people who worked for large companies (more than 25 employees). The model was adopted into the Medicare system in 2003. CK DATE. Currently about ΒΌ of Medicare recipients are registered under some sort of Advantage Plan.

HMOs are radically different than regular Medicare because patients are generally required to use network providers. These include doctors, nurses, hospitals, nursing homes, pharmacies and other providers. When a patient sees a provider out of network they will pay more out-of-pocket.

HMOs also revolve around a primary care physician. Patients will be required to choose a primary care physician who will manage their care. This primary care physician also must refer the patient to see a specialist except in the case of an emergency. Some plans have loosened up on the referral rule.

Beneficiary cost sharing is the idea behind HMOs. In the 1980's and even today HMO have a rather checkered reputation. Patients have complained about not being able to see specialists and about the quality of care they do receive. However, the benefits of an HMO lie in the cost savings that are offered through this type of plan. These savings are shared with the beneficiaries. By joining an HMO you agreeing to some of these cost cutting measures and probably increased inconvenience. However, the standard of care should not suffer.

Medicare Recipient's Keep their Rights

When a Medicare recipient joins a Medicare HMO they retain the same rights that they had under Original Medicare. These include the right to an appeal, a right to medically necessary treatment and a right to be treated honestly and ethically by all providers and administrators. Moreover, when a person joins an HMO he/she also gets an additional level of appeal that exists within the company before the case is escalated onto to Medicare. This extra appeal level can be very helpful because the company may not want the appeal to escalate for a variety of reasons. In addition, all Medicare appeals are contracted out to a third party company. These third party companies have a tendency to be very impartial. This impartiality tends to work against the patient and in favor of either Medicare or the company on the other end. The reason for this is that company and government employees generally keep better records than private individuals.

Auntie Lou says, "If you can get the company to settle the appeal in your favor take the money and run!"