Let me first clarify that for most individuals who have Medicare A & B, when your additional insurance card says HMO (Health Maintenance Organization), you are in a Medicare Advantage Product. That means your Medicare is not paying your medical claims; the HMO product pays all your claims. In this plan, you need to stay within your network of approved providers that participate in your HMO plan. To find out who participates, call the customer service number on the back of your insurance card; or go to their website and use the tools they have there to search for participating providers.
The HMO insurance companies and individual HMO products each have their own network of physicians and hospitals. You can’t assume that all doctors in Western New York are participating in the network. Some companies also provide participating hospitals and physicians in surrounding areas, like Erie, Bradford, Corry, or Warren, PA.
The networks also change year to year. I can’t tell you how many times I have heard that Jamestown Area Medical Associates (JAMA) doesn’t participate in the BlueCross/BlueShield plans. This has changed, JAMA is now Great Lakes Physicians Group (GLPP) and all of the GLPP physicians and practitioners are in-network with the Medicare Highmark BlueCross/ BlueShield of WNYplans. The insurance companies are always working to expand their network of participating physicians, labs, hospitals, etc. The more that they can list as participating; 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 must evaluate each network before you enroll. If you are in the plan and now need a new type of physician, you must make an appointment with their network of providers.
So if you are unsure about your plan and who participates, or how to get a referral, or where you are allowed to go, call your insurance company. Their customer service representatives can be the ones to clarify your situation. They can talk you through your options. Some of the companies have local offices right here in town. If your plan has that local office, you can go there as well to ask questions, their staff is there to help.
If you choose a Specialist without the guidance of your insurance company, you may find your insurance won’t pay the bill. So ask for help ahead of time and be sure you are making the correct choice for your situation.
If you have a Specialist you want to go see and YOUR plan doesn’t cover that provider, you can consider switching your insurance to a product that does cover that physician/specialist. Medicare is a National network of physicians and hospitals, but HMO’s are NOT the same network as Original Medicare.
Your second question relates to travel. When you are traveling and you have Medicare plus an HMO product, you have emergency coverage only when away from home. As you travel around the country, and something happens, an injury, a sickness, 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 assistance. 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. The claims will be processed in time and you should be okay with regards to coverage. If the claims are denied again call customer service to initiate a re-evaluation of the claim. This usually corrects any automatic denial outside of the usual network of providers.