Medicare HMOs must provide a minimum of rights, such as direct access to a specialist if you have a serious health condition.

HMO Managed care type of Medicare Advantage plans must also contain provision for what Medicare calls Emergency Care and Urgently Needed Care. Learn the rules now "just in case" -- including what to do if you travel outside the Plan's area or outside the U.S. 

For information, see:

• What Rights Do I Have As A Member Of A Medicare HMO  
• Emergency Care  
• Urgently Needed Care
• What Should I Do If I Have An Emergency Or Urgently Need Care?  
• What To Do If You Intend To Do Travel Outside Your Service Area Including Outside The Country 
• How Do I Handle A Bill For Emergency Or Urgently Needed Care?  
  

Because Medicare HMOs must be approved by the federal government you have more rights as a member than you would under a regular HMO. They include:

• If you have a complex or serious medical condition, the right to receive a treatment plan that includes direct access to a specialist. This usually takes the form of giving you a permanent referral to a specialist who then acts as your Primary Care Physician (PCP).
• The right to protection from discrimination in marketing and enrollment practices. If you are enrolling during an open enrollment period. an HMO cannot try to deny or discourage you from enrolling based on your health condition. Medicare HMOs are also prohibited from attempting to terminate your membership because of anticipated medical charges.
• The right to information about what is covered and how much, if anything, you have to pay.
• The right to information about all treatment options available to you including a course of treatment that the HMO does not intend to cover.
• An HMO and its providers cannot withhold treatment options simply because they are not routinely covered.
• The right to appeal a decision to deny or limit payment for medical care is provided under a mandated appeals procedure. (For information, see: Medicare Advantage: How To Appeal.)
• The right to know how your Medicare health plan pays its doctors - which includes a right to know whether or not your doctor is eligible for additional payments or bonuses for meeting cost saving goals or quotas.
• Every woman has the right to have a specialist in women's health as her Primary Care Physician (PCP).

The right to receive emergency care, including Urgently Needed Care no matter where in the U.S. you are. (To learn more, click here.)

Because of past problems some members had getting their HMO to pay for emergency care provided outside their network, the federal government has created a "prudent layperson" definition of an emergency that the HMO must cover whether you have the emergency in the area the HMO covers or everywhere else in the U.S.

A Medical Emergency includes severe pain, an injury, sudden illness, or suddenly worsening illness that you believe may cause serious danger to your health if you do not get immediate medical care.

Examples of emergencies include:

• Chest pains or other symptoms that could indicate a heart attack.
• Severe or uncontrolled bleeding.
• Severe abdominal pain.
• An accident that causes pain to a limb that might be broken.
• Unexplained severe headache.
• A cut or piercing of the skin to the extent that stitches may be required to close it.

Examples of what would (probably) not be emergencies include:

• Sore throat.
• Small cut.
• Congestion due to cold or flu.
• Upset stomach.

Any of these, if severe enough or associated with a known serious condition, could be a covered emergency. 

Medicare defines Urgently Needed Care as an unexpected illness or injury that needs immediate medical attention, but is not life threatening.

Urgently Needed Care is only covered when provided by non-network providers if you are temporarily outside the HMO service area. If you are in the HMO's service area, you must receive Urgently Needed Care from a network provider in order for it to be covered.

Examples of Urgently Needed Care:

• Food poisoning causing diarrhea and/or vomiting.
• Replacing needed medication that was lost with your luggage.
• Flu or other illness severe enough to require medical attention.
•  Blisters or other foot problems that impair your ability to walk comfortably.

Your Medicare Advantage Plan must provide access to Emergency and Urgently Needed Care services 24 hours a day, 7 days a week.

If an event happens, it is advisable to take a moment to think about whether the emergency seems to be life threatening or not.

If the emergency seems to be life threatening

• Seek help anywhere immediately. Do not waste time trying to get to a network facility if emergency care is available closer. The Medicare Advantage Plan must cover it as long as you receive emergency care anywhere in the United States.
• If it turns out that the situation was not life threatening, the Plan must still pay for the costs as long as you reasonably believed that it was. For example: you have chest pains while on vacation. Thinking it may be a heart attack, you call 9-1-1. Even if it turns out to just be the spicy dish you had for dinner causing the discomfort, the Medicare Advantage Plan must still pay.

If the emergency is Urgently Needed Care

• If you are within your Plan's service area, you are expected to go to a network facility for care, unless your Plan instructs you to do otherwise.
• Your Plan must pay for "Urgently Needed Care" provided outside the network if you are temporarily out of the Plan's service area and cannot wait until you return. 

Ask your Plan for a written copy of it's policy about medical care outside the area. The policy will tell you what, where and how coverage is provided. Your Medicare Advantage Plan may offer more care than Medicare requires.

If you are going to travel outside the country, and there is no coverage, see how to obtain coverage in Travel. 

If you receive a bill for emergency or urgently needed care provided outside your Medicare Advantage Plan network, you should do two things:

• Write a letter to your Plan.
  • Explain the circumstances surrounding the charge.
  • Include the bill.
  • List the names of the doctors, ambulances, and other medical providers that may also be sending bills. A single trip to the Emergency Room will generate bills from: the hospital, the ambulance company, at least one and probably more doctors and possibly some outside laboratory charges.
  • If possible give the mailing addresses of all the providers if you were able to obtain them.
  • Keep a copy of the letter and all enclosures for your file.
• As a backup:
  • Call the group that billed you directly.
  • Ask them to submit bills directly to the Medicare Advantage Plan. Be sure you have the Plan's claims billing address before calling.
  • It is advisable to make notes of the conversation, including the name and direct number of the person with whom you spoke. File the notes with your information about your health plan.

If your Medicare Advantage Plan attempts to deny the coverage, it must list your rights of appeal in the denial letter. 

For information about appealing denials about a Medicare Advantage claim, click here.