Does the Medicare/HMO combination allow me to see a specialist? | News, Sports, Jobs


Question: I have Medicare and an HMO as secondary coverage. My doctor wants me to see a specialist. Can I go to any specialist he recommends? And when I travel?

Answer: Let me first clarify that for most people who have Medicare A & B, when your supplemental insurance card says HMO (Health Maintenance Organization), you are in a Medicare Advantage product. This means that your health insurance does not pay your medical expense claims; the HMO product pays all your claims. In this plan, you must stay within your network of approved providers who participate in your HMO plan. To find out who is participating, call the customer service number on the back of your insurance card; or go to their website and use the tools they have to find participating providers.

HMO insurance companies and different HMO products each have their own network of doctors and hospitals. You can’t assume that all physicians in Western New York participate in the network. Some companies also supply participating hospitals and physicians in surrounding areas, such as Erie, Bradford, Corry, or Warren, PA.

The networks also change from year to year. I can’t tell you how many times I’ve heard that Jamestown Area Medical Associates (JAMA) does not participate in BlueCross/BlueShield plans. This has changed, JAMA is now Great Lakes Physicians Group (GLPP) and all GLPP physicians and practitioners are networked with Medicare Highmark BlueCross/BlueShield from WNYplans. Insurance companies are always trying to expand their network of doctors, laboratories, hospitals, etc. attendees. The more participants they can list; the more satisfied you will be with their products.

There are a number of different Medicare Advantage insurance companies, some local and some national, offering HMO products. ALL of their networks are different and you should evaluate each network before signing up. If you are in the plan and now need a new type of doctor, you must make an appointment with their network of providers.

So if you’re not sure about your plan and who’s in it, or how to get a referral, or where you’re allowed to go, call your insurance company. Their customer service representatives may be the ones to clarify your situation. They can talk to you about your options. Some companies have local offices right here in town. If your plan has this local office, you can also drop by to ask questions, their staff are there to help.

If you choose a specialist without help from your insurance company, you may find that your insurance won’t foot the bill. So ask for help in advance and make sure you make the right choice for your situation.

If you have a specialist you want to see and YOUR plan does not cover that provider, you may consider changing your insurance to a product that covers that doctor/specialist. Medicare is a nationwide network of doctors and hospitals, but HMOs are NOT the same network as Original Medicare.

Your second question is about travel. When you travel and have Medicare plus an HMO product, you get emergency coverage only when you’re away from home. When you’re traveling across the country and something happens, injury, illness, heart attack or ear infection, use your resources, call that customer service number on the back of the card. Call the company and ask for help. They can direct you to the urgent care center, hospital or clinic to use. If it is a life-threatening emergency call 911 or get medical help right away, when things calm down call the insurance company and let them know what happened. Claims will be dealt with in time and you should be ok with the coverage. If claims are denied again, call customer service to initiate a reassessment of the claim. This usually fixes any automatic declines outside of the usual provider network.

Senior Life Matters is a community program sponsored by Lutheran Jamestown. For questions or concerns or to reach Janell Sluga, GCMC, call 716-720-9797 or email SLM@lutheran-jamestown.org.



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