Transcription
SoutheasternPennsylvaniaChoosing aMedicare HMOA Guide for Older PennsylvaniansBucks Chester Delaware Montgomery PhiladelphiaThis guide is a joint effort ofthe Pennsylvania Health Care Cost Containment Counciland the Pennsylvania Department of AgingA Comparison of Medicare HMOs 1November 2001
Table of ContentsIs an HMO right for me?. 3Which Medicare HMOs are available where I live? . 4Comparing the Quality of Medicare HMOs . 5Preventing Illness . 6Managing On-going Illnesses . 8Acute Care. 10Member Satisfaction . 12Comparing Costs and Benefits . 15Company Profiles . 22Important Questions . 23Important Phone Numbers and Web Sites . Back coverThe information presented in this report wasverified at the time of publication. However,pending legislation and/or future changes byHMOs could alter this information.2 A Comparison of Medicare HMOsWhat is the purpose of this booklet?If you are 65 or over, and thinking about joining a MedicareHMO or have already decided to do so, this booklet is for you!This guide: provides information about HMOs and how they differ fromyour traditional Medicare coverage, compares the quality of services provided by differentHMOs, and gives you guidance on who can answer any specific questionsyou have while making your decision.What is a Medicare HMO?A Medicare HMO is a private (non-government) insurancecompany that manages the health care of the members enrolledin their program. The United States pays these companies a fixedamount of money each month for each member. The companythen helps pay for the medical care, both by doctors and hospitals, that the member needs during the time he or she is enrolled.HMOs work to keep the cost of health care under control bycoordinating care among different doctors, encouraging members to seek preventive services (such as tests and flu shots) andhelping members manage on-going diseases (such as heart problems or diabetes). HMOs also provide or support educationalprograms and guidelines for treatment.
Is an HMO right for me?Only you and your family can determine if an HMO isyour best Medicare option. Here are some things toconsider:Your costs may be lowerA monthly premium and charge each time you visit a doctorand, in some cases, the hospital, are all you typically pay ifyou use doctors that belong to the plan and follow theHMO s rules.There may be additional benefitsEnrollment is fairly simple and you cannot be turned downbecause of your health status. The exceptions are thosepeople who have end stage renal disease kidney failure. Fullcoverage begins on the date of your enrollment in a MedicareHMO.Need for a referralIn an HMO, you will receive most of your care from a primary care doctor. If you need to see a specialist, require labwork or go to the hospital, your primary care doctor will giveyou a referral. If you do not get this referral, the HMO maynot pay for the cost of the service. You may consider purchasing an additional benefit known as a point-of-serviceoption from those plans that offer one. For an additionalmonthly premium, this option gives you more freedom to seespecialists without the need for a referral.Possible loss of HMO coverageEach year, the HMO decides whether to offer policies to Medicarebeneficiaries for the following year. They may stop offeringcoverage in certain counties or stop participating in the MedicareHMO program altogether. The HMO can change which benefitsare offered or the amount you pay to receive these benefits.How do I enroll in a Medicare HMO?Medicare requires that you be enrolled in Medicare Parts A and Bbefore you can enroll in a Medicare HMO. Enrollment is simple:request an enrollment form from the HMO you choose, thencomplete and return the form.With a few exceptions, HMOs are required to accept new members regardless of their health status. However, some HMOs maybe limited in the number of new members they can enroll. Checkwith the HMO to see if it is still accepting new members, thenenroll as soon as possible.What is different for 2002?Beginning this year, enrollees must choose an HMO during theannual enrollment period, which is November and December of2001. You may change plans only one time during 2002, and thatchange must take place during the first six months of the year. To leavean HMO you may either notify the HMO in writing or complete aform at your local Social Security Office.A Comparison of Medicare HMOs 3
Which HMOs are available where I live?HMOs offer theirservices to residentsof specific counties.This list shows the plans currently available in your county,as well as the name of thatcompany s Medicare HMO.It should be noted that Personal Choice 65 is a PreferredProvider Organization (PPO),which differs in some waysfrom an HMO. See the information on Benefits and Copayments (on pages 16-21) tosee how this PPO differs fromthe HMOs.4 A Comparison of Medicare HMOsCountyHMOCompanyB u cksPersonal Choice 65 (PPO)Keystone 65 Standard Medical PlanKeystone 65 Basic Medical PlanIndependence Blue CrossKeystone Health Plan EastKeystone Health Plan EastChesterGolden MedicarePersonal Choice 65 (PPO)Keystone 65 Standard Medical PlanKeystone 65 Basic Medical PlanAetna U.S. HealthcareIndependence Blue CrossKeystone Health Plan EastKeystone Health Plan EastDelaw areGolden MedicarePersonal Choice 65 (PPO)Keystone 65 Standard Medical PlanKeystone 65 Basic Medical PlanAetna U.S. HealthcareIndependence Blue CrossKeystone Health Plan EastKeystone Health Plan EastMontgomeryPersonal Care PlusPersonal Choice 65 (PPO)Keystone 65 Standard Medical PlanKeystone 65 Basic Medical PlanAmeriChoiceIndependence Blue CrossKeystone Health Plan EastKeystone Health Plan EastPhiladelphiaGolden MedicarePersonal Care PlusWiseChoice for PhiladelphiaSenior PartnersPersonal Choice 65 (PPO)Keystone 65 Standard Medical PlanKeystone 65 Basic Medical PlanAetna U.S. HealthcareAmeriChoiceHealth Net of PASenior PartnersIndependence Blue CrossKeystone Health Plan EastKeystone Health Plan East
Comparingthe Qualityof Medicare HMOsThis section of the report provides information to helpyou choose between those plans available where you live.It will help you evaluate how well the HMOs: help their members stay well, help their members control diseases such as diabetes or heartproblems, and ensure that members are provided care to deal with injuries andillness.This section also includes responses to a survey of HMO membersthat indicates how satisfied the members are with their HMOs.ComparisonofofMedicareMedicareHMOsHMOs 5 5AAComparison
Preventing IllnessVisits to the DoctorIt is important to see your health care provider on a regularbasis so that health problems can be detected early. The graphbelow shows the percentage of HMO members who were seenby a health care provider within the last year.Percent of members seen by a health care providerwithin the past year *PA Medicare HMO Average91%Golden Medicare Plan94%Information reported on pages 6 through 21 wasprovided by the Federal government. All informationin this report is for calendar year 2000, with one footnotedexception.No information is included in this section for AmeriChoicebecause that HMO was new in 2000. Personal Choice 65,Independence Blue Cross s Preferred Provider Organization (PPO), was also relatively new. For this reason, not allmeasures are available for this PPO.6 A Comparison of Medicare HMOsHealth Net of PA85%Keystone 6591%Senior Partners75%* These data are for calendar year 1999.
Generally speaking, thehigher the percentage, thebetter the result.Breast Cancer ScreeningFlu ShotsThe flu is a highly contagious respiratory infection. Nationwide, over 40,000 people die from the flu every year. Peopleover 65 are at higher risk of having medical problems from theflu and should get a flu shot.An X-ray, known as a mammogram, can help find cancer in thebreast when the tumor is too small to be felt during self-examination. Finding a tumor early increases the chance that it can betreated successfully and can prevent the cancer from spreadingto other parts of the body.Percent of members over age 65 who received a flushot last yearPercent of female members (age 52 through 69) whoreceived a mammogram within the past two yearsNational Medicare HMO Average75%Golden Medicare Plan79%PA Medicare HMO Average74%Health Net of PAGolden Medicare Plan77%67%Health Net of PA61%Keystone 65 (all 5 counties)Keystone 65 (Bucks County)72%78%Keystone 65 (Chester/Delaware Counties)68%Keystone 65 (Montgomery County)Personal Choice 6548%75%Keystone 65 (Philadephia County)68%Senior Partners59%Senior Partners69%A Comparison of Medicare HMOs 7
Managing On-going IllnessesControl of High Blood PressureHMO members who have been diagnosed with hypertension(high blood pressure) should work with their doctor to controlthis problem. Controlled high blood pressure means a readingno higher than 140 over 90.Percent of members diagnosed with high bloodpressure whose blood pressure is controlledGolden Medicare Plan38%Health Net of PA24%Keystone 65 (all 5 counties)46%Senior Partners42%8 A Comparison of Medicare HMOs
Generally speaking, thehigher the percentage, thebetter the result.Annual Eye ExamsDIABETESMonitoring Kidney DiseaseHMO members with diabetes have a greater risk of developingserious eye disease such as glaucoma. It is important that HMOmembers with diabetes have an annual eye exam.Kidney disease is another concern of HMO members withdiabetes. Careful monitoring for the presence of kidney diseasehelps avoid several serious complications that may accompanydiabetes.Percent of members with diabetes who received aneye exam within the past yearPercent of members with diabetes who were checkedfor the beginnings of kidney disease within the pastyearGolden Medicare PlanGolden Medicare Plan59%78%Health Net of PAHealth Net of PA45%36%Keystone 65 (all 5 counties)Keystone 65 (all 5 counties)58%69%Personal Choice 65Personal Choice 6526%43%Senior PartnersSenior Partners46%34%A Comparison of Medicare HMOs 9
Acute CareHEART ATTACKUse of Beta BlockersResearch shows that when people who have had a heart attackuse a drug called a beta blocker, future heart attacks may beprevented.Percent of members who were prescribed betablockers after a heart attackGolden Medicare Plan97%Health Net of PA89%Keystone 65 (all 5 counties)95%Personal Choice 6593%Senior Partners (Not reported)10 A Comparison of Medicare HMOs
Generally speaking, thehigher the percentage, thebetter the result.Testing for Bad CholesterolThe level of cholesterol in the blood is directly related to developing heart disease and blocked arteries, which canlead to a heart attack. Bad cholesterol is the main cause of this clogging. The first graph shows the percentage ofan HMO s members who received a test to measure the level of bad cholesterol during the year 2000. The secondgraph shows the percentage of the HMO s members whose test showed a bad cholesterol level of less than 130 mg/dL. Any level less than 130 mg/dL decreases the risk to the person, so a higher percentage is a better result.Percent of members tested for bad cholesterolPercent of members who had a bad cholesterolscore of less than 130 mg/dLGolden Medicare PlanGolden Medicare Plan65%77%Health Net of PAHealth Net of PA22%33%Personal Choice (Not reported)Personal Choice 6579%Keystone 65 (all 5 counties)Keystone 65 (all 5 counties)59%62%Senior PartnersSenior Partners46%25%A Comparison of Medicare HMOs 11
Member SatisfactionOverall Rating of PlanGetting a Referral to a SpecialistThe graph below shows the percentage of members who ratedtheir own Medicare HMO as the best possible health plan.Based on all their experiences with their own health plan, theygave their plan a rating of 10 out of 10 (the highest score).Most HMOs require you to get a referral from your primarycare doctor if you need to see a specialist. The graph belowshows how many HMO members said they had no problemsgetting a referral to a specialist.Percent of members who rated their own MedicareHMO as the best possible health planPercent of members who said it was not a problem toget a referral to a specialistNational Medicare HMO AverageNational Medicare HMO Average83%41%PA Medicare HMO AverageMedicare Managed Care (PA)90%44%Golden Medicare PlanGolden Medicare Plan94%44%Health Net of PAHealth Net of PA82%48%Keystone 65 (Bucks County)Keystone 65 (Bucks County)88%44%Keystone 65 (Chester/Delaware Counties)45%Keystone 65 (Chester/Delaware Counties)Keystone 65 (Montgomery County)Keystone 65 (Montgomery County)89%91%43%Keystone 65 (Philadelphia County)Keystone 65 (Philadelphia County)88%48%Senior PartnersSenior Partners56%%12 A Comparison of Medicare HMOs79%
Generally speaking, thehigher the percentage, thebetter the result.Getting Care TestingQuicklyfor Bad CholesterolNo Problems Getting CareMembers were asked how often, in the past 6 months, they gothelp or advice when they called the doctor s office during regularoffice hours, got treatment for injury or illness as soon as theywanted it, got an appointment for routine care as soon as theywanted, and waited no more than 15 minutes past their appointment time.Plan members were asked if they had any problems in the past 6months finding a personal doctor or nurse, getting a referral to aspecialist, getting the care they and their doctor believed necessary, and getting care approved by the health plan withoutdelays.Percent of members who said they always got carewhen they needed it, without long waitsPercent of members who said they had no problemsgetting the care they neededNational Medicare HMO AverageNational Medicare HMO Average85%59%PA Medicare HMO AveragePA Medicare HMO Average90%67%Golden Medicare PlanGolden Medicare Plan92%69%Health Net of PAHealth Net of PA60%84%Keystone 65 (Bucks County)Keystone 65 (Bucks County)90%62%Keystone 65 (Chester/Delaware Counties)66%Keystone 65 (Chester/Delaware Counties)Keystone 65 (Montgomery County)Keystone 65 (Montgomery County)91%89%61%Keystone 65 (Philadelphia County)Keystone 65 (Philadelphia County)91%63%Senior PartnersSenior Partners54%%82%A Comparison of Medicare HMOs 13
Member SatisfactionCommunication with DoctorsGenerally speaking, thehigher the percentage, thebetter the result.Receiving the Best Possible CareMembers answered survey questions that asked them how often,in the last 6 months, doctors in their HMO listened carefully,explained things in a way they could understand, showed respectfor what they had to say, and spent enough time with them.HMO members rated the health care they received in the past 6months. The graph below shows the percentage of memberswho gave their personal health care a score of 10 on a scale of 0(the worst care) to 10 (the best possible care).Percent of members who said their doctors in theirMedicare HMO always communicated wellPercent of members who rated their own care as thebest possible careNational Medicare HMO AverageNational Medicare HMO Average68%48%PA Medicare HMO AveragePA Medicare HMO Average56%74%Golden Medicare PlanGolden Medicare Plan74%Health Net of PA57%Health Net of PA74%Keystone 65 (Bucks County)58%Keystone 65 (Bucks County)72%Keystone 65 (Chester/Delaware Counties)55%Keystone 65 (Chester/Delaware Counties)75%Keystone 65 (Montgomery County)55%Keystone 65 (Montgomery County)73%Keystone 65 (Philadelphia County)55%Keystone 65 (Philadelphia County)75%Senior PartnersSenior Partners71%14 A Comparison of Medicare HMOs59%56%6
ComparingCosts and Benefitsof Medicare HMOsThis section provides an overview of Medicare HMOcosts and benefits. Contact the HMOs for more detailabout the information contained in this section.For each of the HMOs listed, you still pay the Medicare Part Bpremium in addition to any premium charged by the plan. Forthe Year 2002, the Medicare Part B premium will be MOs 1515
What is the cost to you?Golden Medicare(Aetna U.S. Healthcare)Philadelphia CityPhiladelphia Suburbs 80 62Personal Care Plus(AmeriChoice)WiseChoice of Philadelphia(Health Net of PA) 0 0AdditionalMonthlyPremiumPrimary CareDoctorCo-PaymentYou pay 10 to 15 foreach office visit forMedicare-coveredservices.You pay 20 to 25 foreach office visit forMedicare-covered services.You pay 5 for each officevisit for Medicare-coveredservices.You pay 20% of the cost of theoffice visit for Medicare-coveredservices.Specialist VisitCo-PaymentYou pay 20 for a visit to aspecialist for Medicarecovered services IF yourprimary care doctorreferred you.You pay 25 for a visit to aspecialist for Medicarecovered services IF yourprimary care doctor referredyo u .You pay 5 for a visit to aspecialist for Medicarecovered services IF yourprimary care doctor referredyo u .You pay 20% of the cost of thevisit to a specialist for Medicarecovered services IF your primarycare doctor referred you.RoutinePhysical ExamYou pay 10 for eachexam with one allowed peryear.You pay 20 for each examwith one allowed per year.You pay 5 per exam withone allowed per year. Adoctor's office visit copayment may also apply.There is no co-payment forroutine physical exams and nolimit on the number of examsyou may have.In HospitalCareThere is no co-payment forInpatient Hospital servicesat a network hospital. Youare covered for unlimiteddays each benefit period.You pay 850 for eachMedicare-covered stay in anetwork hospital. You arecovered for unlimited dayseach benefit period.You are covered for unlimiteddays each benefit period.You pay a deductible of 792.You pay 0/day for days 1-60and 198/day for days 61-90 ofa Medicare-covered stay in anetwork hospital. You arecovered for 90-days eachbenefit period.OutpatientSurgeryNo co-payment for eachMedicare-covered visit toan ambulatory surgerycenter. You pay 20 foreach Medicare-coveredvisit to an outpatienthospital facility.No co-payment for eachMedicare-covered visit toan ambulatory surgerycenter. You pay 25 foreach Medicare-coveredvisit to an outpatienthospital facility.No co-payment for eachMedicare-covered visit to anambulatory surgical center orto an outpatient hospitalfacility.You pay 20% of the cost foreach Medicare-covered visit toan ambulatory surgery center orto an outpatient hospital facility.16 A Comparison of Medicare HMOs
Personal Choice 65(Independence BlueCross)Keystone 65 (Keystone Health Plan East)Standard PlanBasic PlanSenior lphiaCityPhiladelphiaSuburbs 35 94 0 59AdditionalMonthly 135 0PremiumPrimary CareDoctorCo-PaymentYou pay 10 for eachprimary care doctor officevisit for Medicare-coveredservices.You pay 10 for each officevisit for Medicare-coveredservices.You pay 15 for each office visitfor Medicare-covered services.No co-payment forMedicare-covered services.SpecialistVisitCo-PaymentYou pay 25 for a visit to aspecialist for Medicarecovered services. You DONOT need a referral to seea specialist in the network.You pay 15 for a visit to aspecialist for Medicare-coveredservices IF your primary caredoctor referred you.You pay 20 for a visit to aspecialist for Medicare-coveredservices IF your primary caredoctor referred you.You pay 15 for a visit to aspecialist for Medicarecovered services IF yourprimary care doctorreferred you.RoutinePhysicalE xamYou pay 10 for each examwith one allowed per year.You pay 10 per exam withone allowed per year.You pay 15 per exam with oneallowed each year.No co-payment.You are allowed unlimitedexams each year.In HospitalCareThere is no co-payment forInpatient Hospital servicesat a network hospital. Youare covered for unlimiteddays each benefit periodNo co-payment for services ina network hospital. You arecovered for unlimited dayseach benefit period.You pay a deductible of 750with no co-payment for servicesin a network hospital. You arecovered for unlimited days eachbenefit period.No co-payment withcoverage for 90 days eachbenefit period.OutpatientSurgeryYou pay 0 for eachMedicare-covered visit to anambulatory surgical centeror to an outpatient hospitalfacility.You pay 0 for each Medicarecovered visit to an ambulatorysurgical center or to anoutpatient hospital facility.You pay 250 for eachMedicare-covered visit to anambulatory surgical center or toan outpatient hospital facility.There is no co-payment foreach Medicare-coveredvisit to an ambulatorysurgical center or to anoutpatient hospital facility.A Comparison of Medicare HMOs 17
Comparing BenefitsGolden Medicare(Aetna U.S. Healthcare)Philadelphia CityPersonal Care Plus(AmeriChoice)WiseChoice for Philadelphia(Health Net of PA)Philadelphia SuburbsPHARMACY BENEFITSNo limit on generic drugs. 300 per year limit on brand drugs(on formulary or not).No pharmacy benefit. 375 per six months limit on allNo pharmacy benefit.formulary drugs (generic or brand).NO coverage for drugs not onformulary.Drug Co-PaymentsDrug Co-Payments30-day supply:Generic (formulary OR nonformulary): You pay 15.Formulary brand: You pay 30.Non-formulary brand: You pay 50.30-day supply:Generic: You pay 10.Brand: You pay 20.90-day mail order supply:Generic (formulary OR nonformulary): You pay 30.Formulary brand: You pay 60.Non-formulary brand: You pay 100.90-day mail order supply:Generic: You pay 20.Brand: You pay 40.Check with the HMO for moredetails and to get a copy of thedrugs on the formulary.Check with the HMO for moredetails and to get a copy of thedrugs on the formulary.Note: This section includes several major benefits offered by the HMOs. All HMOs offer additional benefits suchas chiropractic, podiatry, mental health, skilled nursing facility and home health care services. Check with eachHMO or the Medicare Web site (www.medicare.gov) for a complete list of benefits and what your costs will be.18 A Comparison of Medicare HMOs
Personal Choice 65(Independence Blue Cross)Keystone 65(Keystone Health Plan East)Standard PlanPhiladelphiaCityPhiladelphiaSuburbsSenior PartnersBasic PlanPhiladelphiaCityPhiladelphiaSuburbsPHARMACY BENEFITSNo limit on generic drugs, eitherformulary or non-formulary.You may add prescription drug coverage for an additional premium byselecting one of the following options:No limit on formulary genericdrugs.No coverage for brand drugs.Option 1: You pay 35/month.Unlimited generic drugs with 10 co-payment and no annual coveragelimit.Authorization may be required forformulary drugs.Drug Co-paymentsOn plan formulary30-day supply:Generic: You pay 10.90-day mail order supply:Generic: You pay 20.Not on plan formulary30-day supply:Generic: You pay 15.Must use designated pharmacies.Check with the HMO for moredetails.Option 2: You pay 70/month.Unlimited generic drugs with 10 co-payment and no annual coveragelimit. 15 co-payment for brand drugs on formulary and 25 for brand nonformulary.Brand drugs have a 375 coverage limit every 6 months.Contact the HMO for more detailsand specific co-paymentrequirements.Option 3: You pay 80/month.Unlimited generic drugs with 10 co-payment and no annual coveragelimit. 15 co-payment for brand drugs on formulary and 25 for brand nonformulary.Brand drugs have a 500 coverage limit every 6 months.Contact the HMO for more details and a copy of their formulary.A Comparison of Medicare HMOs 19
Comparing BenefitsGolden Medicare(Aetna U.S. Healthcare)Philadelphia CityPersonal Care Plus(AmeriChoice)WiseChoice for Philadelphia(Health Net of PA)Philadelphia SuburbsVISION SERVICESRoutine eye exam: You pay 20(1 per year).Medicare-covered exam(for diagnosis and treatment ofeye disease): You pay 20.One pair glasses/contacts aftercataract surgery: No co-payment.Routine eye exam: You pay 25(1 per year).Medicare-covered exam(for diagnosis and treatment ofeye disease): You pay 25.One pair glasses/contacts aftercataract surgery: No co-payment.Routine eye exam: You pay 10(1 per year).Medicare-covered exam (fordiagnosis and treatment of eyedisease): You pay 10.HMO pays 150 per year foreyewear, with no co-pay (glasses,contacts, lenses and frames).One pair glasses/contacts aftercataract surgery: No co-payment.Routine eye exam/non-Medicarecovered glasses: N o coverageMedicare-covered exam(diagnosis/treatment of eyedisease): You pay 20% of thecost of the exam.Glasses/contacts after cataractsurgery: You pay 20%.Oral exam, including cleanings,fluoride treatment and x-rays: Noco-payment.Oral exam: You pay 3.Cleanings, fluoride, x-rays: Noco-payment.Additional benefits also available.Medicare-covered hearing exam:You pay 5.Routine hearing exam (with alimit of one per year): You pay 5.Fitting of hearing aid: You pay 5.Each hearing aid: No co-paymentfor up to one aid every 3 years( 300 allowance for hearing aidsover 3 years).Medicare-covered hearing exam:You pay 20% of the cost of theexam.Routine hearing tests andhearing aids: No coverage.DENTAL SERVICESNo coverageHEARING SERVICESMedicare-covered hearing exam:You pay 20.Routine hearing exam (with alimit of one per year): You pay 20.Fitting of hearing aid: No copayment. 500 allowance over three yearsfor hearing aids.No payment for hearing aids.20 A Comparison of Medicare HMOsMedicare-covered hearing exam:You pay 25.Routine hearing exam (with alimit of one per year): You pay 25.Fitting of hearing aid: No copayment. 500 allowance over three yearsfor hearing aids.No co-payment for hearing aids.
Personal Choice 65(Independence Blue Cross)Keystone 65(Keystone Health Plan East)Standard PlanPhiladelphiaCityPhiladelphiaSuburbsSenior PartnersBasic PlanPhiladelphiaCityPhiladelphiaSuburbsVISION SERVICESRoutine eye exam/ nonMedicare-covered glasses: Nocoverage.Medicare-covered exam (fordiagnosis/treatment of eyedisease): You pay 25.Glasses/contacts after cataractsurgery: No co-payment.Routine eye exam: You pay 15Routine eye exam: You pay 20(1 every 2 years).(1 every 2 years).Medicare-covered examMedicare-covered exam(for diagnosis and treatment of eye (for diagnosis and treatment of eyedisease): You pay 15.disease): You pay 20. 100 coverage every 2 years for 100 coverage every 2 years foreye wear.eye wear.No co-payment for one pairNo co-payment for one pairglasses, one pair contacts, one pairglasses, one pair contacts, onelenses, and one pair frames every 2pair lenses, and one pair framesyears.every 2 years.Routine eye exam: No co-payment(1 every 2 years).Oral exam (one every 6 months): You pay 10.Oral exam (2 per year): No copayment.Medicare-covered exam (fordiagnosis and treatment of eyedisease): No co-payment.There is no co-payment for onepair glasses, one pair contacts, onepair lenses, one pair frames every2 years.DENTAL SERVICESNo coverage.Cleanings (one every 6 months): No co-payment.Cleanings (2 per year): No copayment.HEARING SERVICESMedicare-covered hearingexam: You pay 25.Routine hearing tests andhearing aids: No coverage.Medicare-covered hearing exam:You pay 15.Routine hearing exam (1 allowedevery 3 years): You pay 15.Fitting of hearing aid (1 allowedevery 3 years):You pay 15. 500 allowance for hearing aidsover 3 years.Medicare-covered hearing exam:You pay 20.Routine hearing exam (1 allowedevery 3 years): You pay 20.Fitting of hearing aid (1 every 3years): You pay 20. 500 allowance for hearing aidsover 3 years.No co-payment for:Medicare-covered hearing exam.Routine hearing test.Hearing aids (1 every 3 years). 5 0 0 a l l o w a n c e fo r h e a ri n g a i d severy 3 years.A Comparison of Medicare HMOs 21
Company ProfilesMedicareEnrollmentJanuary 2001Aetna U.S. Healthcare *108,599Percent Change inEnrollment from January2000Percent of AppealsSettled in Favorof MemberNCQAAccreditationStatus-19.1%13.1%E xce l l e n tAmeriChoice1,205N ew pl an i n 2000Too newCommendableHealth Net of PA8,241-22.0%50.0%Not Accredited15,05727.0%21.4%F ul l126,3021.0%18.3%E xce l l e n t103.7%NA**CommendableIndependence BlueCross (PPO)Keystone Health PlanE astSenior Partners* Enrollment listed for Aetnais statewide.8,531This is the total number ofmembers in eachMedicare HMO as ofJanuary 31, 2001.This is the change in eachHMO's enrollment from theprevious year.This figure shows thepercentage of appeals fordenial of care or paymentthat were decided in favorof the member who filedthe appeal.** Not applicable. Samplesize too small.22 A Comparison of Medicare HMOsNational Committee forQuality Assurance (NCQA)is a non-profit agency thatrates the overall quality ofHMOs. Excellent is thehighest rating given toHMOs; Commendable isthe next highest. Full is thehighest rating given toP P O p l a n s. C h e ckwww.ncqa.org for the lateststatus.
Important Questions.to ask yourself.to ask your doctor or HMO What will my out of pocket expenses (such as co-paysand deductibles) be when I visit my doctor, enter thehospital, or go to an outpatient surgery center? Is my doctor in the HMO s network? If not, am I willingto change doctors? What routine visits, physical exams, dental work, eyeexams and hearing exams does each plan cover? What is the annual or quarterly dollar limit on prescription drug coverage? Are the doctors offices, labs and other services in theHMO network convenient for me? Is (are) my preferred hospital(s) in the HMO s network? If I travel or spend several months in a second home, willthe HMO make arrangements with other plans in thoseareas to provide health care services while I m there? If I live in a continuing care retirement community, is itpart of the HMO s network? Do I live in an area where the lon
Personal Choice 65 (PPO) Independence Blue Cross Keystone 65 Standard Medical Plan Keystone Health Plan East Keystone 65 Basic Medical Plan Keystone Health Plan East Philadelphia Golden Medicare Aetna U.S. Healthcare Personal Care Plus
