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HMO or Original Medicare with Medigap
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Advantages of HMOs
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1. You will not have to pay the Medicare deductibles and
co-insurance, so you will not need to purchase Medigap insurance to
cover those items. Medigap premiums may be too expensive for you.
2. You may receive coverage for services, which are not available
under Medicare's fee-for-service program. For example, some HMOs
offer an annual physical exam (important for early detection of
possible major health problems), eyeglasses, hearing aids and limited
dental care.
3. You will not have to "cope" with Medicare paperwork.
4. Your primary care physician will coordinate and manage your health
care. This may be important for some who are unable to navigate the
health care system.
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Disadvantages of HMOs
You can receive your health care only
through the HMO network of doctors and other health care providers and
hospitals, except emergency and urgent care situations. HMOs allow you
to select a primary care doctor only from those affiliated with the
plan. In New York City HMOs have
evolved in a few years from “you can be referred to a specialist
only by your primary doctor” to “you need a referral to go
to certain doctors, including specialists, for certain services.” This point is further developed in HMO segment 05 –
“…some HMOs and PPOs offer variations in access to benefits
and cost sharing that is difficult to distinguish.” Therefore, do click on this segment
because it offers situations that may confront you in your locality and
should be considered in a discussion of “Advantages of HMOs vs.
Disadvantages of HMOs.”
Additionally,
your primary care doctor or specialist may leave the HMO. Just as the
plan has 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. I also advise my clients
that a large majority of HMOs in New York City charge for hospital
stays.
If
you want to go where you wish, there is a new alternative -- PPOs (Preferred Provider
Organization) -- a managed care plan similar to an HMO, but with some
favorable differences. A PPO
allows you to go direct to a network specialist – you do not need
a referral from your primary care doctor. As was mentioned in segment 1, you
also have “access to providers outside the network, at higher
cost-sharing amounts than network providers.” The higher costs vary from plan to
plan, and you need to pay particular attention to your share of the
costs when you find yourself in an outside of the network hospital
– it can be very high – again, depending on the PPO
plan. A higher PPO premium plan
usually results in a more favorable cost sharing arrangement for the
plan policyholder.
To my mind, central to the question "HMO or Original Medicare with
Medigap?" is answers to the following questions: What is your
health status? Is it of a chronic nature? Are you satisfied with the
quality of care you are receiving now? Will the particular HMO be able
to deliver the type of treatment needed for your medical condition? I
try to be as neutral and objective as possible. However, when I believe
that the client may be jeopardizing his or her health, my attitude
becomes one of advocate.
Updated:
January 29, 2007
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