Your Medicare … with Cheri Brown: My doctor is no longer accepting my HMO. Now what?

Medicare Supplements are different than Medicare Advantage plans.

Dear Medicare Cheri,

My doctor says they will no longer accept Medicare HMO plans. I want to keep this doctor! He’s great — what are my options for next year?

Signed, Love my Doctor!

Dear Doctor Lover,

Cheri Brown

Good news! You have options.

You can stay with a Medicare Advantage plan and switch to a PPO (preferred provider organization). These plans have in-network providers, you will pay much less in copays and coinsurance when you use these providers. All other providers are out of network, you will pay much more in copays and coinsurance if you use the out of network providers.

If you choose this type of Medicare Advantage Plan, read the fine print, also known as the Evidence of Coverage. Review the maximum out of pocket (the most you pay for A and B covered items) for in network and out of network. Verify what happens should you need urgent, or emergency care out of network. Verify the network frequently to ensure you stay in-network as much as possible.

The other option is a Medicare Supplement. Medicare Supplements are different than Medicare Advantage plans. With an Advantage Plan, Medicare pays the insurance company to care for you and your Medicare goes dormant. With a supplement plan, Medicare pays first, and the supplement (also called MediGap) plan pays the remainder. Any coinsurance you pay is based on which of the supplement plans you choose. A supplement plan gives you the freedom to see any physician that accepts Medicare. The premiums are higher than Medicare Advantage plans, and the premiums generally increase annually.

Medicare Supplements are not PPO’s. A PPO has in network and out of network pricing. A supplement will be accepted by any provider that accepts Medicare. If they don’t accept Medicare, you do not have coverage.  Fortunately, most providers in Santa Clara County accept Medicare.

To join a Medicare supplement, you either need a Guarantee Issue or be able to pass the Underwriting questionnaire. If you answer yes to any of the underwriting questions you will not be able to join. Some Guarantee Issue situations are the first 12 months of being on Medicare, the first 12 months of moving from a supplement to an Advantage Plan, moving to a new county where your current plan number is not available (note this is not just based on the insurance company but the actual plan filing number).

I hope you can find a plan that works for you and your doctor.

Cheri Brown is a licensed insurance agent with decades of experience. She can be contacted at (408) 476-0034, [email protected] and through her website www.cheri-brown.com.