Perspective               

Getting the Most from Your Medicare HMO

If you are on Medicare, you can join a Medicare HMO. To get good care in your HMO, you must learn how to make your HMO work for you. You must follow the HMO’s rules for getting care. If you don’t, the HMO won’t pay.

Follow these five steps to get the most from your HMO: One – Know what the HMO must give you. The government protects people on Medicare by requiring Medicare HMOs to pay for certain services and care. Call 1-800-638-6833 to get a copy of the Medicare Handbook. It tells you what your HMO must pay for. Two – Know which doctors and hospitals you must use. The HMO will only pay for your care from the doctors and hospitals that are in your HMO. Get a list of the doctors and hospitals in the HMO. If you use a doctor or hospital who is not in the HMO, the HMO will not pay except in an emergency or in urgent care situations when you are away from home. Three – Know the HMO’s rules. Ask your HMO for its rule book and read it. If you don’t understand it, ask the HMO to explain its rules to you. Four – Know how to see the doctor. In an HMO, you must see your primary doctor before you can see a specialist. Your primary doctor will tell you if you can see a specialist, and which specialist you can see.

Remember, if you are satisfied with Original Medicare, the government-run fee for service program that covers care from virtually any doctor anywhere in the country, you do not need to join an HMO. And, if you have Medicaid, you should not join a Medicare HMO unless you are sure that the Medicare HMO will coordinate benefits with Medicaid. Keep in mind that you should never join a Medicaid HMO if you have Medicare.

If you would like more information about your Medicare options, call your State Insurance Counseling and Assistance program. The number is listed in the back of the Medicare handbook or call 1-800-638-6833. Your Senator or Congressperson should also be able to answer your questions.

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