Specialized Rules and Features for Medicare HMO's
Part 3, Chapter 11: Medicare and Medicare Related Programs: Medicare HMO's Page 2
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Medicare HMOs
However, Medicare HMOs generally have a series of specialized rules that participants must follow in order to obtain maximum benefits. First, some Medicare HMOs may provide full coverage only if the participant makes use of medical providers who are part of the plan network. Second, access to medical specialists or to expensive medical tests may be determined by the gatekeeper, the participant's primary care physician. That includes access to specialists such as neurologists, rheumotologists, and psychiatrists, as well as access to tests such as CAT scans and MRIs. Finally, some Medicare HMO's may provide coverage outside of the HMO's geographic area only for emergency treatment. (See Table l6 for a comparison of the traditional Medicare plan and Medicare HMOs.)
Although all Medicare HMOs have certain features in common, there may also be important differences between them. For example, some Medicare HMOs may provide reimbursement for both emergency care and urgent care outside the HMO's geographic area. In addition, some Medicare HMOs now offer a special option -- at additional cost -- that allows participants to occasionally see medical providers outside of the provider network and still qualify for some reimbursement. That option is generally referred to as a Point-of-Service or P0S Option.
In some cases, a Medigap policy may not be necessary when a Medicare beneficiary joins a Medicare HMO, since the coverage provided by the Medigap policy may simply duplicate coverage offered by the HMO. Canceling a Medigap policy may save a good deal of money. However, if you join a Medicare HMO and then cancel your Medigap policy, it's important to be aware that there is no guarantee that you will be able to enroll in a new Medigap policy of your choice if you decide to return to the traditional Medicare plan.
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