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By John M. Bigler In the last several years, many in the elderly community have considered Health Maintenance Organizations or HMO's financially beneficial. A large percentage of the American population are enrolled in some type of managed health care and there are 58,000,000 in HMO's specifically. Another concern is from Medicare recipients who typically have Medigap policies they have owned for a number of years. Medigap is the coverage obtained by Medicare recipients to pay the deductible and co-insurance payments required by Medicare. When an individual first joins the HMO, they cover these insurance gaps and therefore, the Medigap policy is no longer necessary. But it is a good idea to maintain your Medigap coverage for at least a few months to make certain that you are comfortable with the quality of care provided by the HMO. If you are not, re-acquiring a Medigap policy may be difficult and at a significantly higher cost than when you originally obtained it. Some HMO's also have growing pains as the result of their administrative offices becoming overwhelmed. There is a danger that if an HMO falls behind in its payments to doctors, the services provided to the patient may suffer. Another important criterion in choosing an HMO is the appeals process after a request for medical care has been denied. Recently, the Federal Courts have re-enforced the HMO patient's rights to a uniform series of protections and administrative remedies. Patients are entitled to written notices detailing specific reasons for the denial of medical services. They must also be given a clear explanation of their appeal rights. Claimant's have to be given an opportunity to appear in front of an administrative law judge to air their grievances. If they are unsuccessful, they then have the right to go to state or federal court. In my opinion, HMO's were originally designed to best serve the healthy young individual, but as the result of the increase in complaints, they are becoming more responsive to the needs of the elderly. It is always the rule that HMO's were preferred for their maintenance services rather than their more involved advanced care. These conditions are improving, however, since the HMO's have become more aware of the needs of the elderly consumer. Reprinted with permission of the Suffolk Times © 1999 [ Contact Us ] [ Guestbook ] [ Email ]  The Law Offices of John M. Bigler, Attorney At Law 1421 Wantagh Avenue, Wantagh, New York 11793-2206 1-888-ELDER-LAW · 516-409-6565 · Fax: 516-409-6522 E-Mail: info@biglerlaw.com · Web Site: www.biglerlaw.com |
That trend is expected to accelerate, especially since State Medicare and Medicaid programs either already offer or are expecting to extend such coverage to beneficiaries.
Selecting an HMO is a challenge which many elderly are concerned with. There are specific criteria that seniors should keep in mind. Roland Edelstein, a Board Member of the Five Towns Senior Center and an expert on HMOs suggests that "choosing one HMO over another is difficult for many reasons. The first is that their list of doctors changes almost overnight". Additionally, in order to attract customers, things such as eye glasses and hearing aids and other perks are offered. However, an interested individual should read the written policy from the HMO in order to be certain that these benefits will continue to be offered in the future.