Medicare Advantage Frequently Asked Questions

Who can enroll in Medicare Advantage plans?

Most Medicare beneficiaries are eligible to enroll in HMOs. In general, HMOs cannot screen applicants to decide if they are healthy or delay coverage for pre-existing conditions. The only enrollment criteria for Medicare Advantage HMOs are:

You must have both Part A and Part B of Medicare.
You must live in the plan's service area.
You cannot have permanent kidney failure, called "End Stage Renal Disease," except under limited conditions.

If you develop permanent kidney failure after joining a managed care plan, the plan will provide, pay for, or arrange for your care.

Do I need to choose a separate prescription drug plan if I am enrolled in a Medicare Advantage plan?

No. Medicare Advantage plans provide prescription drug coverage within their plans. Most enrollees have been advised of any changes in prescription drug coverage. Call your Medicare Advantage plan if you have any questions.

What role does the Primary Care Physician (PCP) or "Gatekeeper" play in an HMO?

Primary care physicians, otherwise known as gatekeepers, are responsible for coordinating and managing the patient's medical care. This physician is also responsible for referring the patient to a specialist or other health care facility.

What does "Exclusion" mean in a managed care plan?

An "Exclusion" refers to items or services that are not covered under a managed care plan. Exclusions may include services not referred by your primary care physician, unless they are emergency services or urgently needed care, as well as any services that are not covered by original Medicare. Beneficiaries who select the option of Medicare Advantage should receive all the benefits provided for beneficiaries in original Medicare.

What if I have problems with my care?

If you belong to a Medicare HMO and you are unhappy with the quality of care you can:

Follow your HMO's grievance procedure, or
Complain to your state's Quality Improvement Organization (QIO). QIOs are groups of practicing doctors and other health care professionals under contract to Medicare to review the care provided to Medicare patients. IPRO is the QIO in New York State.

If you have reason to believe that your Medicare HMO did not give you necessary care, inappropriately ended your enrollment, charged you an excessive premium, or falsified or misrepresented information, you can write to:

Office of Managed Care, Cohen Building, Room 4406

330 Independence Avenue, SW

Washington, D.C. 20201

Describe your problem, and the Office of Managed Care will see that your case is reviewed.

In New York, if you have concerns about the quality of medical services your HMO plan provided, you may call your plan member services or call the Medicare Helpline at 1-800-633-4227. You may write to:

IPRO, Beneficiary Health Care Assessment Department

1979 Marcus Avenue

Lake Success, New York 11042

If you believe that your HMO has made an incorrect decision on coverage of benefits or payment of a claim, you can appeal this decision by requesting information on additional appeal rights through your HMO.