Medicare Advantage: HMO Special Rules

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.)

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