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Managed Care (HMO) Explained

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Managed care policies fall under Medicare Part C. These policies were originally designed to provide all of the medical services and supplies offered by Medicare, plus additional benefits such as prescription drug, vision and hearing coverage, as well as enhanced coverage within a skilled nursing facility. Most policies require individuals to sign over their Medicare benefits and pay a monthly premium in return for full coverage by the HMO's doctors, hospitals and services.

There is a yearly out-of-pocket limit with Managed Care. Once you reach that limit, the HMO is financially responsible for all services except prescription drug co-payments and durable medical equipment.

NOTE: HMO insurance companies only guarantee the policy for a year at a time. Each year, the insurance company decides whether or not to continue offering the policy. If the company opts to discontinue it, it is required to notify the policyholder ninety days before coverage ends and to provide information about purchasing a Medigap policy in the policyholder's area. Most people who already have Medigap coverage do not need to purchase a Managed Care policy.

Eligibility and Qualifications

• Coverage is available to: Individuals 65 or older
• Individuals entitled to Medicare Part A and enrolled in Medicare Part B
• Individuals who reside at home or in an assisted living facility
• Individuals who reside in the insurance company's service area

Coverage is not available to:

• Individuals with end-stage renal disease
• Individuals who reside in an institutional setting such as a skilled nursing facility

Posted in: Managed Care (HMO), Medicare & Medicaid

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