Perspective               

Medicare HMO Protections Needed

Millions of older and disabled Americans enrolled in Medicare HMOs are facing soaring health care premiums and benefit cuts in 2002 and 586,000 other people in Medicare HMOs are being forced to find another Medicare plan because their HMOs are pulling out of Medicare. To ensure that people in Medicare HMOs can get affordable health care from doctors they know and trust and enroll in the Medicare option of their choice, advocates are urging Congress to consider legislation that would protect people in Medicare HMOs in three key ways: 1) continue to allow people in Medicare HMOs to change Medicare plans whenever they choose; 2) provide people in Medicare HMOs the right to buy Medicare supplemental insurance if they switch to the traditional Medicare program; and 3) limit out-of-pocket costs for people in Medicare HMOs to no more than the out-of-pocket costs they would pay in traditional Medicare.

1. Continue to allow people in Medicare HMOs to change Medicare plans whenever they choose.
People with Medicare, consumer advocates, and private health plans all agree that Medicare should continue to allow people to switch Medicare health plans on a monthly basis. But the Medicare law in about to change to allow people only to change Medicare health plans annually. Once this law takes effect, people with Medicare will lose their ability to leave their Medicare plan even if their doctors leave the network or their health condition requires them to move in with a family member and out of the area temporarily.

2. Provide people in Medicare HMOs the right to buy Medicare supplemental insurance if they switch to the traditional Medicare program.
Anyone whose Medicare HMO changes benefits, raises premiums or whose doctor or other health care provider leaves the network should get the same right to buy Medicare supplemental insurance offered to people whose HMOs withdraw from the program. If they join a Medicare HMO, they should be able to leave as freely as doctors leave plan networks and as plans change their treatment options and raise premiums. They need the ability to switch to Original Medicare along with the right to buy a supplemental coverage.

3. Limit out-of-pocket costs for people in Medicare HMOs to no more than the out-of-pocket costs they would pay in traditional Medicare.
Medicare HMOs continue to raise premiums and co-payments for doctors' visits, specialists, lab tests and other health care services. People enrolled in Medicare HMOs expect low out-of-pocket costs. Now, some HMOs are making these costs excessive and unaffordable for people with costly health care needs-that is, people needing hospitalization, oxygen or chemotherapy. And no supplemental coverage is available to fill these critical gaps. Unless Congress limits cost-sharing in Medicare HMOs, these HMOs may jeopardize access to care for people in poor health.

Addressing these three issues will strengthen and improve the Medicare program for the nearly 6 million older and disabled Americans who are enrolled in Medicare HMOs.

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