Problems with HMO Medicare Advantage Plans

[Alhambra]

The informed Senior market avoids switching to full Medicare Advantage HMO Plans due to it's HMO regulations of referrals system to specialists, where under the original Medicare they can go anywhere where the specialist takes Medicare.

With MA HMO, your own regular practitioner must be on the same network as the specialist. Needless to say there are multiple networks within one local area, and not all doctors are on the same network.

Incompatible networks means no referral possible, even if both doctors are listed on Plan's Approved Provider's Directory!

The referral also takes 5 to 10 days get processed for the appointment with the specialist to be able to get booked and god knows now how many days after all these pre-approval fiasco have completed, the specialist would have time to see the senior patient.

I'm truly wondering if it's merciful to switch seniors from their regular Medicare plans to HMO MA plan.

 

[GreenSky]

I think you have about 1/2 of the information to come to any conclusion about plans.

Contact me and I'll be happy to discuss this with you.

Rick

 

[Josh]

Alhambra, you really have no idea about what an MA HMO is. They do have downsides, but you aren't even in the ballpark about the referrals. Most carriers are pretty easy to work with and the referral can usually be done electronically in less than 2 minutes by a slightly knowledgeable member of the doctors office staff. Aetna has an open access hmo plan which doesn't even require referrals.

What you said *almost* makes as much sense as saying that a med supp is garbage because most seniors never use them.

 

[Alhambra]

Most carriers are pretty easy to work with and the referral can usually be done electronically in less than 2 minutes

Actually I'm new to this Industry. I've come from private party mortgage background. Nonetheless, I'm so glad that you're so fully content with the referral system available to the HMO industry.

My experience hasn't been the same with the carrier that I'm dealing with, particularly the client who came aboard on 5/01/2010 has not been appended to their database as of 5/07/2010, so the electronic referral was not possible.

 

[Josh]

Actually I'm new to this Industry. I've come from private party mortgage background. Nonetheless, I'm so glad that you're so fully content with the referral system available to the HMO industry.

My experience hasn't been the same with the carrier that I'm dealing with, particularly the client who came aboard on 5/01/2010 has not been appended to their database as of 5/07/2010, so the electronic referral was not possible.

I don't know that I'd say fully content, but it's significantly more user-friendly than the way you've explained it. If you were able to pay attention to the rest of the post there was some good information in there. The experience you're having with this carrier is certainly the exception and not the rule. Like I said, Aetna has an HMO that doesn't require referrals and I think that's the way things are leaning. Even the plans that do require referrals usually have systems in place that make it seamless for most members. Many carriers will even let the referral be done after the fact in the event of a miscommunication. Simply because one HMO botched up a new member (really new member) doesn't mean that all HMO's are bad. I also think the situation isn't as bad as it may seem. It sounds like the app went in at the eleventh hour and the client had doctors appointments scheduled (with a specialist) for right when it became effective, neither of those are good. If a member needs to see a doctor right away then the app should go in early enough (by the 15th) for the plan to be able to process it. That may very well have been the case, but even if it wasn't, it's rarely a good idea to have the client have doctors appointments scheduled for the first week or two of the new plan being effective if you want to have a better chance at avoiding situations like this.

 

[Tom Highway]

The referral system is plan specific, no? There are plans that require a referral to go to a specialist, but most do not.

You make some really general statements and think they apply to the whole MAPD market, which they don't.

 

[Josh]

The referral system is plan specific, no? There are plans that require a referral to go to a specialist, but most do not.

You make some really general statements and think they apply to the whole MAPD market, which they don't.

They are plan specific. In fact, they can be VERY plan specific. The traditional HMO model was you have to have a primary care doc and that doc must refer you to specialists in the network. No ifs, ands or buts about it. Some plans don't care if you have a PCP anymore (well, they'd like it, but they don't require it) and even the ones that do require it will often approve out of network referrals most of the time. Are there some companies that are buried in the past? Sure, but they are becoming the exception, not the rule.

 

[insurance0707]

I use a point of service MA HMO. Point of service Hmo's are pretty unique. They let you see pretty much any medicare provider but if you see providers that are in-network you pay a lower copay, if you go out of network, you have a deductible and than a little higher copay. It gives the client the flexability to go to doctors that are not part of the HMO.

I really like the concept of "point of service"

Also, if your client needs care due to an emergency (regardless of what type of HMO their in) they are covered regardless if the provider is in-network or out of network.