Perspective               

What To Do If Your Medicare HMO Says No

What do you do if your HMO says no? Well, if you're on Medicare, you may not know that if you are not getting care you need from your Medicare HMO or if your HMO is refusing to pay for care that you received, you can appeal the HMO's decision to obtain the needed services or payment.

Appealing an HMO denial of care or refusal to pay is free and pretty easy. All it takes is a letter to the HMO asking it to reconsider its decision. It helps if you include a letter from your doctor explaining why you need care. You should not worry about appealing because Medicare HMOs cannot disenroll you or deny you future services if you appeal a decision. A Medicare HMO must reply to your appeal in a timely manner and send any appeal decision that is not fully in your favor to an independent review agency.

Almost one in three seniors and people with disabilities win their appeals. So keep in mind your appeal rights if your doctor does not refer you to a specialist or admit you to a hospital when you believe you need this care; or if the HMO denies your claim for emergency or out-of-area urgent care.

Medicare Rights Center has these five tips about your care in a Medicare HMO:

  1. Do not take no for an answer.
    If the HMO or a doctor says a service is not covered, ask why. If a doctor isn't giving you the care you think you need, you may want to choose a new doctor.
  2. Know what Medicare covers.
    Call 1-800-638-6833 for a copy of the Medicare Handbook.
  3. Know the HMO's rules.
    HMOs must arrange and pay for care from out-of-network providers if they do not have providers who can deliver the care that is needed.
  4. Emergency care and out-of-area urgent care do not require prior authorization.
    HMOs must pay for care that you get in an emergency outside your HMO, including necessary follow-up care even if you do not notify the HMO immediately after you receive these services.
  5. The HMO must provide complex or costly medical care.
    An HMO cannot delay or deny services to you or encourage you to disenroll because you need this care.

The best advice Medicare Rights Center can offer Medicare HMO members is to appeal an HMO's decision if you don't think it is right.

For More Information, Contact: Shirley Gazsi, (212)869-3850, x19

_________________________________