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Medicare and Medicare HMOs Explained by Solkoff Legal


Medicare is the national health insurance program for seniors over the age of 65. Medicare comes in parts.

  • Part A is the primary hospital insurance component, which covers inpatient care in hospitals. It also covers hospice (end-of-life palliative care) and a very limited but important rehabilitation benefit for nursing homes and some home care.
  • Part B covers other medically necessary services such as doctor visits and outpatient care.
  • Part C allows you the choice of using a private health insurance company (HMO) instead of going directly through Medicare. It is really not even a part of Medicare but is instead another way of receiving similar services. More on Medicare HMOs in a moment.
  • Medicare Part D is the newest addition to the “parts” of Medicare. Part D pays towards prescription drugs.
    Solkoff Legal, P.A. advises most of its clients to stay out of Medicare HMOs and to instead subscribe to Medicare with the addition of a Medicare Supplement Policy. This article explains why and how. As with all of the articles and information on this website, you should not rely upon this article as legal advice for you or any other specific person. There are many factors that must be weighed. You should take this information and then consult with Solkoff Legal, P.A. or another qualified firm in your area.

Medicare HMOs provide a full spectrum of health insurance benefits including a more inclusive prescription drug benefit than Part D alone. There is no premium to pay, only co-pays and deductibles. The theory behind a Medicare HMO is to ration health care among its members so as to provide a broad base of services overall. The HMOs also make deals with providers to get better pricing and/or service utilization agreements. Medicare HMOs can be a good choice for some because of its cost-effectiveness but there is a major trade off. Not all facilities, doctors or other health care providers will accept your Medicare HMO. This often creates significant problems in access to the health care of choice. You may not be able to go to your choice of nursing home or specialist.

There are very big differences among health care providers and facilities. Not all health care facilities and providers provide the same quality of care. Solkoff Legal, P.A. prefers its clients to have as much freedom of choice as possible in selecting the best health care providers and facilities.

Medicare A&B plus a good supplemental policy provides some of the best health insurance available today even as compared to private health insurance. Some people do not want to pay the premiums or cannot afford to pay the premiums for the Medicare Supplement policy and up going with Medicare HMOs. These HMOs are instead of Parts A, B and D. With Medicare and a good supplemental policy, people have freedom of choice in health care. Almost all of the providers people would ever want will accept Medicare but not all accept HMOs and fewer still would accept the one HMO chosen by the patient.

In later years, when we KNOW we will need more health care, our health insurance is not the place to scrimp and save. We can save money in other areas (as demonstrated by many other articles on this web site) but we should not give up freedom of choice in our health care unless we simply cannot afford the premiums for supplemental policies. As further incentive not to go with a Medicare HMO, know that even if you realize you made a big mistake, you can no longer easily get out of the HMO. There are now only certain periods of time when you can disenroll from the HMO and get back to Medicare.

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