Yale Physicians Guide to Medicare Managed Care Plans

The doctors and staff of the Yale Medical Group understand that the recent changes in Medicare provide new options for how you receive Medicare benefits. Making the choice between traditional Medicare and a Medicare managed care plan is an important decision requiring time to gather information and "comparison shop". To assist you in evaluating these options, we have developed this guide which outlines important aspects of both traditional and managed care Medicare.

The guide includes a comparison of benefits available from both types of coverage, frequently asked questions and a glossary of terms. The Medicare HMO Worksheet can be printed out and used to note important information from any managed care plan you may consider.
You may want to browse the entire Guide or you may click on any item on the menu below to explore a particular topic:

• Traditional Medicare and Medicare Managed Care: Choosing The Plan That Is Best For You
• Frequently Asked Questions About Medicare Managed Care
• Medicare and Managed Care Terms
• Comparison of Benefits: Traditional Medicare and Medicare HMOs
• Medicare Health Plans That Include Yale Providers
• Medicare HMO Worksheet

Choosing the Plan That Is Best For You

The new Medicare managed care plans offer the opportunity to change the way you receive benefits by enrolling in an "HMO type" of insurance plan. Medicare HMOs cover almost all aspects of care including hospital stays, doctor visits, prescriptions and preventative care without the need for supplemental or Medigap insurance. The basic goal of "managed care" is to coordinate health care in order to maximize quality and the scope of benefits while minimizing costs. The same high quality care is available in both traditional Medicare and managed care plans. The most important differences between these options are covered in this guide.

As you gather information, consider how you currently use health care services. Think about what your medical needs were in the last several years and what your needs may be in the near future. Each option before you has some advantages and disadvantages and the features and benefits of one plan may better meet your needs than another.

Here is a brief summary of factors to consider whether an HMO or traditional Medicare is better suited for you.

Medicare HMOs may be right for you if:

• You live in one area all year round.
• You are comfortable with HMOs and the approval needed for certain services.
• You would rather not complete insurance claim forms.
• Your current doctors and preferred hospitals are included in the HMO network.
• You would prefer to drop the Medigap insurance premiums.
• You would like a prescription policy, but cannot afford the extra insurance.

Traditional Medicare may be right for you if:

• You spend more than one month per year out of state and/or see doctors outside your state of residence.
• You are not comfortable with how HMOs use a specific network of providers and require approval of certain services.
• You prefer an open choice of doctors and hospitals.
• You are satisfied with the costs and services covered by Medicare Part A & B and your supplemental insurance.

Frequently Asked Questions About Medicare Managed Care

What are "medicare managed care plans?"

Medicare managed care plans, or HMOs, are insurance companies contracted with and approved by Medicare to provide health care services. Historically, HMOs are effective at reducing health care costs without lowering quality of care.

How much does it cost to join a Medicare HMO? Will I still pay Medicare Part B premium?

You must have Medicare Part B when you sign-up for a managed care plan. You will continue to pay the part B premium. Often, monthly member premiums in HMOs are less than "Medigap" or "supplemental" insurance.

What is the role of my "regular" doctor in an HMO?

Your regular doctor, or primary care physician, is responsible for coordinating your health care. Your doctor will refer you to a specialist in the HMO network of providers when needed and be responsible for getting HMO authorization for hospital admissions and certain tests or treatments.

Can I continue to see my doctors if I join an HMO?

Each HMO contracts with individual healthcare providers to be in the HMO network, that includes doctors and hospitals. You need to use network providers in order to receive full benefits. When considering a specific HMO, it is important to check that your family doctor, specialists and preferred hospital are included.

How do I find out more about managed care plans?

There are several helpful ways to learn more. The Healthcare Financing Administration (HCFA), the federal agency that runs Medicare, provides a web site that includes a comparison of all approved managed care plans in your area. The website is http://www.medicare.gov. You can call HCFA at 1-800-638-6833.

You can contact any Medicare HMO directly. Your local newspaper is likely to have announcements about information sessions sponsored by HMOs. Talk with friends and family who are in managed care plans to learn about their experiences.

Medicare And Managed Care Terms

Co-payment or Copay: The portion of costs paid by an HMO member for a service such as a doctorâs visit co-pay of $10.

Deductible and Co-Insurance: The dollar amount paid "out of pocket" for services. Traditional Medicare requires annual deductible and some co-insurance but HMOs do not.

HMO Provider Network: Health care providers who contract with managed care plans to provide services. Networks include doctors, hospitals, physical therapists, laboratories, home care agencies, pharmacies, chiropractors and podiatrists.

Primary Care Physician (PCP): The physician who provides routine or general care such as general internist, Ob/Gyn or pediatrician. The terms general, regular or family doctor also refer to a PCP.

Prior Authorization: HMOs require approval before certain services will be covered, such as surgery, hospital admission, and some "expensive" tests.

Referral: The steps required by an HMO when a doctor sends a patient to a specialist. For example, a physician refers a patient with heart problems to a cardiologist in the network.

Comparison of Benefits: Traditional Medicare and Medicare HMOs

Medicare Health Plans That Include Yale Providers

Yale physicians participate in these Medicare HMO plans: Cigna Health Care for Seniors, Connecticare 65MD Health Plan, Senior Security, Oxford Medicare Advantage, Physicians Health (PHS) Services, Smartchoice.

At this time, Yale physicians DO NOT participate in these Medicare plans: Anthem BlueCross/BlueShield, Kaiser Permanente, US Healthcare Medicare and Medspan.

Medicare HMO Worksheet

Click here to download and print out our Medicare HMO Plan worksheet to help you evaluate your needs and compare plan options. (This is a PDF file that requires Acrobat Reader.)