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C A H C |
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Medicare Managed Care |
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Connecticut Association for Home Care |
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If you are considering joining a Medicare contracting Health Maintenance Organization (HMO), or are enrolled in an HMO, please read the following.
What are Medicare Contracting HMOs Medicare contracts with HMOs to provide a full range of Medicare benefits to you. Medicare contracting HMOs must give you all the health care services that are covered under the Medicare Program, except Hospice services. In addition, HMOs may offer additional benefits, either at no charge or for an additional charge. Get discount coupons for brooklyn movers.
In general, if you enroll in an HMO plan: · You must get all of your medical care through the plan's doctors, hospitals, skilled nursing facilities, home health agencies, and other health care providers. You may however get emergency care and unforeseen out-of-area urgently needed care when necessary from non-plan providers. · You must select a primary care doctor participating in the plan. This doctor is responsible for coordinating your care. You must obtain a referral from this doctor in order to see a specialist or obtain other services through the plan.
Enrollment and Disenrollment Rights When you are considering enrolling in an HMO, the HMO must: · Provide you with complete and accurate information. · Enroll you without regard to your health status. · Not offer you gifts or other financial inducements to encourage you to enroll.
Make sure the HMO representative tells you whether the HMO offers any additional benefits besides those covered under the Medicare program. If so, check if there are limits on how often you can use the benefits or how much the HMO will pay for them. In addition, the HMO representative must tell you if the HMO requires copayments for any services, including drugs, and the amounts of such copayments. mugen HP Pre 3
Make sure the HMO representative tells you about all the HMO providers and facilities that will be available to you in your area including home health agencies and skilled nursing facilities associated with the HMO. Check if there are any limitations on using the HMO-affiliated providers.
An HMO must enroll all eligible Medicare beneficiaries who want to enroll, regardless of their age, health status, or the amount or cost of the health services needed. HMOs are not allowed to make you undergo a health screening before you enroll. Pre-enrollment questions about your health or physical status are against the law. Before you enroll, HMO representatives should not ask: cash net usa · How often you visit the doctor. · How many doctors you have. · How many times you have been hospitalized in the last year. · Whether you have any conditions for which you take medicine on a regular basis. · Whether you exercise regularly.
Disenrollment is your Decision Once you are enrolled in an HMO, you may wish to disenroll at some point. Your HMO cannot try to keep you from disenrolling nor can the HMO try to get you to leave. You must submit a written request to disenroll. Make sure your HMO tells you the date when your disenrollment is effective. It is normally the first day of the month following receipt of your disenrollment request. NOTE: If you get services from a non-HMO provider while you are still a member of your HMO, neither your HMO nor Medicare will pay.
Your Rights to Medical Services in an HMO When you are enrolled in an HMO, you have a right to: · Medically necessary care in a timely manner. · Emergency medical care and unforeseen out-of-area urgent care.
The HMO may not: · Create or permit delays like repeated busy signals when you call to make appointments. · Make you wait an unreasonably long time for appointments. · Unreasonably restrict the days or hours that you may be seen by the plan's providers. · Create or permit unreasonable delays in arranging for surgery, hospitalization or other services by using review or approval mechanisms. · Inappropriately deny or limit referrals to specialists in or outside the plan. · Unreasonably limit the amount of nursing home, home health or therapy services.
How to Make a Complaint You should be aware that you and your HMO may disagree about what care is medically necessary. You have the right to appeal if you believe that medically necessary care has been denied, reduced or terminated inappropriately.
The appeals process begins with your written request to the HMO asking it to review the denial, reduction or termination. If the HMO does not reverse its decision, the appeal automatically goes next to an independent review organization that contracts with Medicare to review HMO denials. If the review organization does not decide fully in your favor, you may request a hearing from Medicare. If you need help in deciding whether to appeal, or if you have questions regarding what you must do to appeal, you can contact your local or State Insurance Counseling and Assistance (ICA) Program. Call the Medicare Hotline at 800.638.6833 to get the number of the ICA in your area.
If you have a complaint about the quality of care you have received from the HMO or any of its providers, you can complain to the HMO or to Qualidigm, Connecticut’s Quality Improvement Organization. Qualidigm monitors the quality of care provided to Medicare beneficiaries. Call the Qualidigm at 860.632.2008. |
