The Social Security Administration has published a guide to
managed care for Medicare beneficiaries.  Since the disability
community has questioned the adequacy of coverage through managed
care approaches, this guide may provide information of general
use to health care consumers with disabilities.

Jamal Mazrui
National Council on Disability
Email: 74444.1076@compuserve.com

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                         Medicare Managed Care


Medicare Managed Care Medicare beneficiaries can enroll in health
maintenance organizations and other managed care plans

Table of Contents

It's Your Choice!
How Do the Fee-for-Service and Managed Care Systems Work?
Can I Enroll In a Managed Care Plan?
How Can I Join a Plan and
When Does My Coverage Begin?
What Other Factors Should I Consider?
If I Enroll, Where Do I Go For Care?
Plan Hospital and Medical Benefits Do I Select My Own Doctor?
What About Specialists and Hospital Care?
How Can I Appeal a Payment Decision Made by an HMO?
What are the Advantages of Joining a Managed Care Plan?
What are the Disadvantages of Joining a Managed Care Plan?
How and When May I Disenroll?
Do I Need Medigap Insurance If I Join a Managed Care Plan?

Medicare SELECT Health
Insurance Information and Counseling

It's Your Choice One important decision you may have to make as a
Medicare beneficiary is how you will receive your Medicare hospital and
medical benefits. If you live in an area served by a managed care plan,
and most beneficiaries do, you have a choice.

You can receive your Medicare benefits through the fee-for-service
delivery system or through a managed care plan such as a health
maintenance organization (HMO).

Whether you choose fee-for-service or managed care, you receive all of
Medicare's hospital and medical benefits to which you are entitled. The
differences between the two systems include how the benefits are
delivered, how and when payment is made, and how much you might have to
pay out of your pocket.

How Do The Fee-for-Service And Managed Care Systems Work? Under the
fee-for-service payment system, you can choose any licensed physician
and use the services of any hospital, health care provider or facility
certified by Medicare.

Generally, a fee is paid each time a service is used. Medicare pays a
share of your hospital, doctor, and other health care expenses. You are
responsible for certain deductibles and coinsurance payments--the
portion of the bill Medicare does not pay. You must also pay all
permissible charges in excess of Medicare's approved amounts as well as
charges for services not covered by Medicare.

Some of those potential out-of-pocket costs can be avoided or reduced
through the purchase of private insurance to supplement Medicare. It is
called "Medigap" insurance and it is specifically designed to
close some of the payment gaps in your Medicare coverage.

Managed care plans might be thought of as a combination insurance
company and a health care delivery system (doctor/hospital). Like an
insurance company, they cover health care costs in return for a premium,
and like a doctor or hospital, they provide health care services.

In addition to being called managed care plans, they also are known as
prepaid or coordinated care plans, or just HMOs.

Each plan has its own network of hospitals, skilled nursing facilities,
doctors and other health care professionals. Services usually must be
obtained from the professionals and facilities that are part of the
plan.

Depending on how the plan is organized, the services are provided either
at one or more centrally located health facilities or in the private
practice offices of the doctors and other health care professionals
affiliated with the plan.

Plans may charge enrollees a monthly premium, which can vary from plan
to plan and is subject to change annually. Plans that have premiums
typically charge from $50 to $75 per month.

In addition to a monthly premium, plans commonly charge a small
copayment for each appointment and drug prescription.

Copayments typically range from $5 to $15.Usually there are no
additional charges by the plan no matter how many times you visit the
doctor, are hospitalized, or use other covered services.

Can I Enroll in a Managed Care Plan? Most Medicare beneficiaries are
eligible for enrollment in a managed care plan, and most parts of the
country are served by one or more plans that have contracts with the
Health Care Financing Administration (HCFA) to serve Medicare
beneficiaries.

The only enrollment requirements are:

1. You must at least be enrolled in Medicare Part B (it pays doctor
bills) and continue to pay the Part B monthly premium. The premium is
$42.50 per month in 1996.

2. You cannot have elected care from a Medicare-certified hospice.*

3. You cannot be medically determined to have end-stage renal disease
(ESRD).* If, however, you are a member of a plan when you first be come
eligible for Medicare and the plan has a Medicare contract, you may
change to Medicare membership with the plan even if you have ESRD.

4. You must live within the area in which the plan has a Medicare
contract to provide services.

*If you choose hospice care for a terminal illness after joining a
managed care plan, you will receive hospice services from a
Medicare-approved hospice, but you can stay in the plan. If you do, the
plan is required to  provide or arrange for all covered health care
unrelated to the terminal illness.  Also, if after joining a plan you
are medically determined to have end-stage renal disease, the plan is
required to provide or arrange for your care.

How Do I Join a Plan and When Does My Coverage Begin? You can get the
names of the managed care plans in your area by calling your State
insurance counseling office or by calling Medicare at 1-800-638-6833.

All plans that contract with Medicare must have an advertised open
enrollment period of at least 30 days once a year. Most plans, however,
have continuous open enrollment, so you may join at anytime. Medicare
beneficiaries cannot be denied membership because of poor health, a
disability, or preexisting condition.

Depending on the day of the month that you enroll, you may choose to
have coverage begin either the first day of the month after your
enrollment application is received by the plan or up to three months
later. The plan must give you written information explaining your
coverage and when it starts.

Before joining a plan, read the plan's membership materials. Make sure
you understand your rights as a plan member and know what benefits you
will receive.

If you live in an area served by more than one plan, compare premiums,
copayments, and benefits to determine which plan best suits your needs
at a price you can afford.

What Other Factors Should I Consider? Get information about the doctors
available to serve you and the hospitals and other health care
facilities affiliated with the plan. Determine whether the plan's
providers are in a location convenient to you and whether transportation
is available at all hours to get you to them.

Also, carefully consider the advantages and disadvantages of plan
membership if you travel a lot or live part of the year in another
State. Plans must provide coverage for a fixed period of time when you
travel.

Another factor to keep in mind is that if you enroll in a plan and later
move out of the plan's service area, you will have to disenroll and
either return to regular fee-for-service Medicare or enroll in a plan
that serves your new location.

If I Enroll, Where Do I Go For Care? Before enrolling in a managed care
plan, find out whether the plan has a "risk" or a "cost" contract with
Medicare. There is an important difference.

Risk Plans: These plans have "lock-in" requirements. This means that you
generally must receive all covered care through the plan or through
referrals by the plan.

With few exceptions, if you go outside the plan for services, neither
the plan nor Medicare will pay for those services. You will have to pay
the entire bill out of your own pocket.

The only exceptions recognized by all Medicare-contracting plans are for
emergency services, which you may receive anywhere in the United States,
and urgently needed care, which you may receive while temporarily away
from the plan's service area.

If you receive emergency or urgently needed care, the doctor or hospital
that provides the service will either bill you or your plan. If the bill
is given to you, present it to the plan yourself and keep a copy for
your records. If possible, let the plan know whenever you are in an
emergency situation.

In addition to paying for emergency and urgently needed care received
outside the plan, a few risk plans offer what is called a
"point-of-service" (POS) option.

Under the POS option, the plan permits you to receive certain services
outside the plan's provider network and the plan will pay a percentage
of the charges. In return for this flexibility expect to pay at least 20
percent of the bill.

Cost Plans: These plans do not have lock-in requirements. If you enroll
in a cost plan, you can either go to health care providers affiliated
with the plan and pay only the applicable co-payments, or you can go to
providers outside the plan.

If you go to providers outside the plan, the plan probably will not pay
but Medicare will. Medicare will pay its share of the approved charges.

You will be responsible for Medicare's coinsurance and deductibles and
other permissible charges, just as if you were receiving care under the
fee-for-service system.

Because cost plans do not have a lock-in requirement, they may be a good
choice for you if you travel frequently or live outside the plan's
service area part of the year.

Plan Hospital And Medical Benefits While the package of benefits can
vary from plan to plan, all plans must provide all of the Medicare
benefits available in their respective services areas.

Plans may also offer extra benefits not otherwise covered by
fee-for-service Medicare. The extra benefits can include, for example,
physical exams, scheduled inoculations and other preventive care,
prescription drugs, dental care, hearing aids and eyeglasses, as well as
coverage for overseas travel.

Plans with risk contracts either provide the extra benefits at no
additional cost or require you to purchase them as a condition of
enrolling in the plan. Any additional benefits offered by cost plans may
cost members more.

Do I Select My Own Doctor? Most managed care plans require you to
select a primary care doctor from those affiliated with the plan when
you first enroll. If you do not make a selection, one will be assigned
to you.

Primary care doctors manage their patients' medical and hospital care.
If for any reason you want to change your primary care doctor, the plan
generally will let you do so as long as you select another one of the
plan's primary care doctors.

What About Specialists and Hospital Care? Managed care plans have
doctors available in all specialties of medicine. However, to see a
specialist, you must be referred by your primary care physician if the
plan is to pay for the specialist's services. Your primary care
physician will help choose the specialist for you.

Just as a plan arranges in advance with specific doctors to care for
members, it generally has contracts with specific hospitals, skilled
nursing facilities, home health care agencies and other health care
providers to serve its members. Some of the larger plans, however, have
their own hospitals and other health care facilities.

By coordinating primary, specialty, inpatient, and outpatient treatment,
plans can deliver appropriate care while minimizing duplicative and
unwarranted services.

How Can I Appeal a Payment Decision Made by an HMO? Managed care plans
that contract with Medicare have a system that you can use to appeal
payment decisions. You can file an appeal if your plan:

Refuses to pay for Medicare-covered services;
Refuses to provide services you request; or
Decides not to pay for the care you received from doctors or hospitals
who are not part of the plan because the plan determined that the
care was not for emergency or out-of-area urgent care.

If you believe that care should be paid for or provided, and it was not,
you should file a request for reconsideration by the plan. Your
membership materials give details on your Medicare appeal rights.

If you need more information or help, call any Social Security
Administration office, your health plan, or your State insurance
counseling office.

What are the Advantages of Joining a Managed Care Plan? People join
managed care plans for several reasons. Some of the most frequently
mentioned include:

- It can be easier to get all services through one source (for example,
  doctors' services, hospital care, laboratory tests, X-rays, etc.)
- Quality of care may be enhanced because of the coordination of services.
- It's easier to budget medical costs because you know the amount of any
  premiums in advance, and the total of other out-of-pocket expenses is
  likely to be less than under the fee-for-service system.
- You generally pay only a nominal copayment when you use a service.
  Some plans do not charge copayments for certain specified services.
- In many cases, benefits beyond those covered by Medicare are available
  at either no additional charge or a nominal charge.
- You will not need Medigap insurance to supplement your Medicare
  coverage because the plan provides you with all or most of the same
  benefits at no additional cost.
- Paperwork is virtually eliminated.
- Unlike Medigap insurers who in some cases can refuse to sell you a
  policy if you have a health problem, plans generally must accept all
  Medicare applicants.

What are the Disadvantages of Joining a Managed Care Plan? The
disadvantages of enrolling in a managed care plan include:
- You may not be free to go to any physician or hospital you choose.
  Except when you need emergency or unforeseen out-of-area urgent care
  services, you generally must use the plans providers or else the plan
  will not pay.
- You may need to have the prior approval of your primary physician to
  see a specialist, have elective surgery, or obtain equipment or other
  medical services.
- It can take up to 30 days to disenroll, and you must
  continue to use the HMO providers until you are disenrolled.

How and When May I Disenroll? If you enroll in a plan and later decide
to return to fee-for-service Medicare, you may disenroll at any time. To
disenroll, state in writing that you want to withdraw from the plan and
return to traditional Medicare coverage.

Give the written statement either to the plan's administrative office or
to your local Social Security Administration or, if appropriate, your
Railroad Retirement Board office. Your coverage under the
fee-for-service system will begin the first day of the following month.

If you want to change from one managed care plan to another, you may do
so by simply enrolling in the other plan as long as it has a Medicare
contract. You are automatically disenrolled from the first plan.

Do I Need Medigap Insurance if I Join a Managed Care Plan? Medigap
insurance is another issue that you should consider if you are thinking
about enrolling in a plan, or if you are already in a plan and are
thinking about disenrolling.

If you have a Medigap policy and decide to enroll in a plan, you may
either keep the policy or, if after deciding you like the plan, you may
cancel it. You will generally not need a Medigap policy if you enroll in
a Medicare-contracting plan.

A Medigap policy could be of value to you if you left a plan and
returned to fee-for-service Medicare. If you previously had a Medigap
policy but dropped it while in the plan or never had one before you
joined the plan, you might not be able to buy the policy of your choice,
especially if you have a health problem.

Before you give up your Medigap policy, or let a Medigap open enrollment
period expire, you should consider discussing your particular
circumstances with your State insurance counseling office. The services
are free.

The counseling offices also have free copies of the Guide to Health
Insurance for People With Medicare.

Medicare SELECT Medicare SELECT is another health insurance option that
you may want to consider as you seek to get the most health insurance
for your dollar. While Medicare SELECT is not the same as managed care,
it does incorporate some of the features of managed care and is
sometimes offered by HMOs as well as various insurance companies.

Medicare SELECT is the same as standard Medigap insurance in nearly all
respects. If you buy a Medicare SELECT policy, you are buying one of the
standard Medigap plans approved for sale in your State.

The only difference between Medicare SELECT and standard Medigap
insurance is that each SELECT insurer has specific hospitals, and in
some cases specific doctors, that you must use, except in an emergency,
in order to be eligible for full benefits. Medicare SELECT policies
generally have lower premiums in comparison to other Medigap policies
because of this requirement.

When you go to the insurer's "preferred providers", Medicare
pays its share of the approved charges and the insurer is responsible
for the full supplemental benefits provided for in the policy.

In general, Medicare SELECT policies are not required to pay any
benefits if you do not use a preferred provider for non-emergency
services. Medicare, however, will still pay its share of approved
charges regardless of the provider you choose.

Congress designed Medicare SELECT as an experimental program and
initially approved its availability in 15 states. Last year Congress
expanded the program to include all states and extended it for another
three years. Even if Congress decides not to continue Medicare SELECT,
insurers will be required to honor all existing Medicare SELECT
policies.

If you have a Medicare SELECT policy and the program  is terminated in
1998, you will be able to either:

1. Keep the SELECT policy with no changes in benefits or; 2. Purchase
another Medigap policy offered by the insurer, if the insurer issues
Medigap insurance other than Medicare SELECT. To the extent possible,
the replacement policy would have to  provide similar benefits.  You
could not be denied coverage because of poor health.

While authorized for sale in every State, Medicare SELECT may not yet
have been approved for sale in your State. You can find out whether it
is available to you by calling your State insurance department or State
insurance counseling office.

For more information about Medicare, you may obtain a copy of Your
Medicare Handbook from any Social Security Administration office or by
calling 1-800-638-6833.

Health Insurance Information &amp; Counseling Every State, plus Puerto
Rico, the Virgin Islands, and the District of Columbia, has a health
insurance counseling program that can give you free information and
assistance on Medicare, Medicaid, Medigap, long term care and other
health insurance benefits. You can call your state counseling office and
ask for names of HMOs in your area.  Phone numbers are listed below (the
800 numbers work only within the state). If you have trouble reaching
your counseling office, call the Medicare hotline at
1-800-638-6833.

Alabama      1-800-243-5463
Alaska       1-800-478-6065
Arizona          1-800-432-4040
Arkansas         1-800-852-5494
California       1-800-434-0222
Colorado         1-800-544-9181
Connecticut      1-800-994-9422
Delaware         1-800-336-9500
District of
Columbia         (202) 676-3900
Florida          1-800-963-5337
Georgia          1-800-669-8387
Hawaii           (808)586-0100
Idaho            1-800-488-5725
Illinois         1-800-548-9034
Indiana          1-800-452-4800
Iowa             1-800-351-4664
Kansas           1-800-432-3535
Kentucky         1-800-372-2973
Louisiana        1-800-259-5301
Maine            1-800-750-5353
Maryland         1-800-243-3425
Massachusetts    1-800-882-2003
Michigan         1-800-803-7174
Minnesota        1-800-882-6262
Mississippi      1-800-948-3090
Missouri         1-800-390-3330
Montana          1-800-332-2272
Nebraska         (402)471-2201
Nevada           1-800-307-4444
New Hampshire    1-800-852-3388
New Jersey       1-800-792-8820
New Mexico       1-800-432-2080
New York         1-800-333-4114
North Carolina   1-800-443-9354
North Dakota     1-800-247-0560
Ohio             1-800-686-1578
Oklahoma         1-800-763-2828
Oregon           1-800-722-4134
Pennsylvania     1-800-783-7067
Puerto Rico      (809) 721-8590
Rhode Island     1-800-322-2880
South Carolina   1-800-868-9095
South Dakota     1-800-822-8804
Tennessee        1-800-525-2816
Texas            1-800-252-3439
Utah             1-800-439-3805
Vermont          (802)828-3302
Virginia         1-800-552-3402
Virgin Islands   (809)774-2991
Washington       1-800-397-4422
West Virginia    1-800-642-9004
Wisconsin        1-800-242-1060
Wyoming          1-800-856-4398

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