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CentralPennsylvaniaChoosing aMedicare HMOA Guide for Older PennsylvaniansBerks Carbon Centre Clearfield Clinton Columbia Cumberland Dauphin Huntington JuniataLackawanna Lancaster Lebanon Lehigh Luzerne Lycoming Mifflin Monroe MontourNorthampton Northumberland Perry Schuylkill Snyder Union WyomingThis guide is a joint effort ofthe Pennsylvania Health Care Cost Containment Council and the Pennsylvania Department of AgingNovember 2001A Comparison of Medicare HMOs 1
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 . 20Important Questions . 21Important 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. Thislist shows the plans currentlyavailable in your county, as well asthe name of that company s Medicare HMO. If your county is notlisted, no Medicare HMO is currently available to you.4 A Comparison of Medicare HMOsCountyBerksMedicare HMOsKeystone Health Plan (KHP) Central Senior BlueCarbonGeisinger GoldCentreHealthAmerica Advantra, KHP Central Senior BlueClearfieldGeisinger GoldClintonGeisinger GoldColumbiaGeisinger Gold, KHP Central Senior BlueCumberlandKHP Central Senior BlueDauphinGeisinger Gold, KHP Central Senior BlueHuntingtonGeisinger GoldJuniataGeisinger Gold, KHP Central Senior BlueL ackaw an n aGeisinger GoldLancasterGeisinger GoldL eb an o nGeisinger GoldLehighKHP Central Senior BlueLuz erneGeisinger GoldLycomingGeisinger GoldMifflinGeisinger Gold, KHP Central Senior BlueMonroeGeisinger GoldMontourGeisinger Gold, KHP Central Senior BlueNorthamptonKHP Central Senior BlueNorthumberlandKHP Central Senior BluePerryKHP Central Senior BlueSchuylkillGeisinger Gold, KHP Central Senior BlueS n yd erGeisinger Gold, KHP Central Senior BlueUnionGeisinger Gold, KHP Central Senior BlueWyomingGeisinger Gold
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%Geisinger Gold (Scranton/Wilkes Barre)94%Information reported on pages 6 through 21 wasprovided by the Federal government. All information in this report is for calendar year 2000,with two footnoted exceptions.Geisinger Gold (Willliamsport)96%HealthAmerica Advantra91%KHP Central Senior Blue93%* These data are for calendar year 1999.6 A Comparison of Medicare HMOs
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 year *Percent of female members (age 52 through 69) whoreceived a mammogram within the past two yearsGeisinger GoldNational Medicare HMO Average75%79%PA Medicare HMO Average74%Geisinger Gold (Scranton/Wilkes Barre)70%HealthAmerica Advantra90%Geisinger Gold (Williamsport)73%HealthAmerica Advantra73%KHP Central Senior Blue82%KHP Central Senior Blue75%* These data are for calendar year 1999.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 controlledGeisinger Gold51%HealthAmerica Advantra57%KHP Central Senior Blue52%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 pastyearGeisinger GoldGeisinger Gold61%84%HealthAmerica AdvantraHealthAmerica Advantra46%81%KHP Central Senior BlueKHP Central Senior Blue87%52%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 attackGeisinger Gold97%HealthAmerica Advantra - Not AvailableKHP Central Senior Blue96%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 cholesterolGeisinger GoldPercent of members who had a bad cholesterolscore of less than 130 mg/dLGeisinger Gold80%HealthAmerica Advantra65%HealthAmerica Advantra84%KHP Central Senior Blue69%KHP Central Senior Blue80%70%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 Average41%83%PA Medicare HMO AveragePA Medicare HMO Average44%90%Geisinger Gold (Northeast and Northcentral PA)Geisinger Gold (Northeast and Northcentral PA)56%Geisinger Gold (Southcentral PA)93%Geisinger Gold (Southcentral PA)88%59%HealthAmerica AdvantraHealthAmerica Advantra93%45%KHP Central Senior BlueKHP Central Senior Blue37%12 A Comparison of Medicare HMOs90%
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 Average59%85%PA Medicare HMO AveragePA Medicare HMO Average67%Geisinger Gold (Northeast and Northcentral PA)90%Geisinger Gold (Northeast and Northcentral PA)68%Geisinger Gold (Southcentral PA)92%Geisinger Gold (Southcentral PA)68%HealthAmerica Advantra90%HealthAmerica Advantra65%KHP Central Senior Blue91%KHP Central Senior Blue68%90%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 Average48%68%PA Medicare HMO AveragePA Medicare HMO Average56%74%Geisinger Gold (Northeast and Northcentral PA)Geisinger Gold (Northeast and Northcentral PA)61%75%Geisinger Gold (Southcentral PA)Geisinger Gold (Southcentral PA)63%77%HealthAmerica AdvantraHealthAmerica Advantra55%72%KHP Central Senior BlueKHP Central Senior Blue74%14 A Comparison of Medicare HMOs50%
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?G eisinger H ealth P lan G oldA dditionalM onthlyP rem iumCarbon, Monroe,WyomingBlair, Cambria,Clearfield,Huntington,Juniata, MifflinClinton,Columbia,Lycoming,Montour,S ch u yl ki l l ,Snyder, UnionD auphi n,Lancaster,LebanonL a cka w a n n aLuzerne 49 60 65 64 55 133P rim ary C areD octorC o-P aym entS pecialistV isitC o-P aym entYou pay a 5 co-payment for each visit toyour primary care doctor's office for Medicare-covered services.You pay a 5 co-payment for each visit to a specialist for Medicare-covered servicesIF your primary care doctor referred you to that specialist.R outineP hysicalE xamYou pay a 5 co-payment for a physical exam, with a limit of one exam per year.In H ospitalC areThere is no co-payment for hospital servicesas long as you go to a hospital in the HMO's network.You are covered for unlimited days each benefit period.O utpatientS urgeryThere is no co-payment for each Medicare-covered visit toan ambulatory surgery center or to an outpatient hospital facility in the HMO's network.16 A Comparison of Medicare HMOs
HealthAmerica AdvantraA dditionalM onthlyP rem iumK eystone H ealth P lan C entralS enior B lue 1S enior B lue 2S enior B lue 3CentreD auphi n, Lehi gh,Nor thamptonBerks, Cumberland(par tial), Schuylkill,Centre, Columbia,Juniata, Mifflin, Montour,Nor thumberland, Perry,Snyder, Union 119 138 54 100P rim ary C areD octorC o-P aym entYou pay a 10 co-payment for eachvisit to your primary care doctor forMedicare-covered services.You pay a 10 co-payment for each visit toyour primary care doctor for Medicare-covered services.S pecialistV isitC o-P aym entYou pay a 10 co-payment for eachvisit to a specialist for Medicarecovered services IF your primarycare doctor referred you to thatspecialist.You pay a 10 co-payment for each visit to a specialist for Medicare-covered servicesIF your primary care doctor referred you to that specialist.R outineP hysicalE xamYou pay a 10 co-payment for aphysical exam, with a limit of oneexam per year.In H ospitalC areYou pay 250 for each Medicarecovered stay in a network hospital.You are covered for unlimited days ineach benefit period.O utpatientS urgeryThere is no co-payment for eachMedicare-covered visit to anambulatory surgery center or to anoutpatient hospital facility.You pay a 10 co-payment for a physical exam,with a limit of one exam per year.You are covered for unlimited days in each benefit period.There is no co-payment.There is no co-payment for each Medicare-covered visit to an ambulatory surgerycenter or to an outpatient hospital facility.A Comparison of Medicare HMOs 17
Comparing BenefitsG eisingerH ealth P lan G oldH ealthA m ericaA dvantraCarbon, Clearfield, Clinton,Columbia, Dauphin, Huntington,Juniata, Lackawanna, Lancaster,Lebanon, Luzerne, Lycoming,Mifflin, Monroe, Montour,Schuylkill, Snyder, Union,WyomingCentreK eystone H ealth P lan C entralS enior B lue 1S enior B lue 2S enior B lue 3D auphi n, Lehi gh,Nor thamptonBerks, Cumberland(par tial), SchuylkillCentre, Columbia, Juniata,Mifflin, Montour,Nor thumberland, Perry,Snyder, UnionP H A R M A C Y B E N E FITSNo pharmacy benefit.No pharmacy benefit.You pay 50% of thecost for all drugs up toa 90-day supply, withan overall benefit limitof 250 per quar ter.No pharmacy benefit.Ask the H MO fordetails and a copy oftheir formulary.V IS IO N S E R V IC E SRoutine eye exam: No copayment (1 allowed per year).Routine eye exam: You pay 10 (1 allowed per year).Medicare-covered exam (fordiagnosis and treatment ofeye disease): No co-payment.Medicare-covered exam (fordiagnosis and treatment ofeye disease): You pay 10.HMO pays for one pairglasses/contacts after eachcataract surgery with no copayment.HMO pays for one pairglasses/contacts after eachcataract surgery with no copayment.HMO pays up to 150covered for eyewear with noco-payment for one pairglasses or one pair contacts.HMO pays up to 150 foreyewear every 2 years.18 A Comparison of Medicare HMOsNo coverage for non-Medicare covered eye exams.Medicare-covered exam (for diagnosis and treatment of eye disease): Youpay 10.HMO pays for one pair glasses/contacts after each cataract surgery with noco-payment.
G eisingerH ealth P lan G oldCarbon, Clearfield, Clinton,Columbia, Dauphin,Huntington, Juniata,Lackawanna, Lancaster,Lebanon, Luzerne, Lycoming,Mifflin, Monroe, Montour,Schuylkill, Snyder, Union,WyomingH ealthA m ericaA dvantraCentreK eystone H ealth P lan C entralS enior B lue 1S enior B lue 2S enior B lue 3D auphi n, Lehi gh,Nor thamptonBerks, Cumberland (par tial),S ch u yl ki l lCentre, Columbia, Juniata,Mifflin, Montour,Nor thumberland, Perry,Snyder, UnionD E N TA L S E R V IC E SNo dental coverage.No dental coverage.No dental coverage.H E A R IN G S E R V IC E SMedicare-covered hearingexam: No co-payment.Routine hearing exam(with a limit of one peryear): No co-payment.Fitting of hearing aid: noco-payment (with one visitallowed).Medicare-covered hearingexam: You pay 10.Medicare-covered hearing exam: You pay 10.Routine hearing exam (one per year): You pay 10.Routine hearing exam (oneFitting of hearing aid: You pay 10.per year): You pay 10.HMO gives a 400 allowance for hearing aids every 3 years, with no co-payment.HMO gives a 500allowance for hearing aidsevery 3 years, with no copayment.HMO gives a 400allowance for hearing aids,with no co-payment. Askfor details.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.A Comparison of Medicare HMOs 19
Company ProfilesM edicareE nrollm entJanuary 2001P ercentC hange inE nrollm entfromJanuary 2000P ercentofA ppealsS ettled in FavorofM em berNCQAA ccreditationS tatusG eisinger H ealth P lan36,698-21.3%8.8%Not AccreditedH ealthA m erica*21,9908.0%7.1%E xce l l e n tK eystone H ealth P lanC entral24,535-1.4%18.5%E xce l l e n tThis is the total number ofmembers in eachMedicare HMO as ofJanuary 31, 2001.This is the change in eachHMO's enrollment from theprevious year.* E nrollm entfigure forH ealthA m erica is statew ide.20 A Comparison of Medicare HMOsThis figure shows thepercentage of appeals fordenial of care or paymentthat were decided in favorof the member who filedthe appeal.National Committee forQuality Assurance (NCQA)is a non-profit agency thatrates the overall quality ofHMOs. E xcellentis thehighest rating given toHMOs.Check www.ncqa.org forthe latest status.
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 long-term care facilities arepart of an HMO network? If I need to see a specialist regularly, does the HMO snetwork have the type of doctors I need to see? Is the HMO accepting additional members? Are participating doctors accepting new patients? What hours are available for appointments with doctors? Where do I go for emergencies during doctor office hoursand after hours? What are the HMO s monthly premiums for the differentlevels of available coverage? Is there a telephone hotline for medical advice? Are mail order pharmacies available? How easy is it for me to see a specialist? What are therules for getting approval to see a specialist? Can I change doctors if I am not satisfied with the doctor Ihave? What are the requirements for notifying the HMO afterreceiving emergency care?ComparisonofofMedicareMedicareHMOsHMOs 2121AAComparison
Notes22 A Comparison of Medicare HMOs
A Comparison of Medicare HMOs 23
Company Contact Phone NumbersFor more details about the HMOs in this booklet, contact:Geisinger1-800-631-1656Keystone Health Plan encies Providing Information for SeniorsMedicare 1-800-633-4227Web site: www.medicare.govU.S. Government hotline for information about the MedicareprogramAPPRISE 1-800-783-7067 Web site: www.aging.state.pa.usHelp for Pennsylvanians on health insurance from thePennsylvania Department of AgingSocial Security Administration 1-800-772-1213Pennsylvania Department of Public Welfare Help Line1-800-692-7462Financial assistance programs for low-income seniorsPennsylvania Health Care Cost Containment CouncilMarc P. Volavka, Executive Director225 Market Street, Suite 400Harrisburg, PA 17101Phone: 717-232-6787Fax: 717-232-3821Web site: www.phc4.org24 A Comparison of Medicare HMOsLegal Hotline for Older Americans 1-800-262-5297A non-profit agency providing legal advice for seniorsMedicare Fraud and Abuse Hotline 1-800-447-8477To report cases of abuse of the Medicare billing programPharmaceutical Assistance (PACE) 1-800-225-7223State program to provide financial assistance for seniors prescription drugs(Hearing Impaired) 1-800-222-9004Veterans Affairs (Benefits Information) 1-800-827-1000Provides information and programs to military veteransAlzheimer s Association 1-800-272-3900Pennsylvania Dental Association 1-800-692-7256Information on programs providing dental care for seniorsAmerican Diabetes Association1-800-DIABETES (1-800-342-2383) Web site: www.diabetes.orgSupport and information for seniors with diabetesAARP Pennsylvania 1-717-238-2277 Web site: www.aarp.orgAdvocacy group for older AmericansPennsylvania Department of AgingRichard Browdie, Secretary555 Walnut Street, 5th floorHarrisburg, PA 17101-1919Phone: 717-783-1550Fax: 717-783-6842Web site: www.aging.state.pa.us
Medicare HMO as of January 31, 2001. This is the change in each HMO's enrollment from the previous year. This figure shows the percentage of appeals for denial of care or payment that were decided in favor of the member who filed the appeal. National Committee for Quality Assurance (NCQA)
