Selecting a Medicare Health Maintenance Organization (HMO)

In choosing an HMO, you must decide what is most important to you. Ask each HMO you are considering for written information on their benefits and services. Ask for a membership information booklet. After you review what benefits are available and decide what is important, you can compare plans. Before you make your decision you should consider the following:

Premium: What is the HMO's monthly premium? How often and by how much can the plan raise your premiums?

Cost: What is the total cost to you, including premiums, coinsurance, copayments, deductibles, or other out-of-pocket expenses? Generally, plans that offer you more freedom of choice of providers or cover additional benefits will cost you more.

Benefits: Are there any additional benefits that may be offered, and is there an additional charge for these benefits?

Enrollment: If you enroll when will coverage begin? Once your enrollment is effective, you must follow the HMO's rules. Find out exactly when your HMO coverage becomes effective so you will not make costly mistakes.

Specialty Care: Can you choose a specialist as your primary care physician? Under what circumstances can you use a specialist or other health care professional outside the HMO?

Referrals: Do doctors have to receive permission from the HMO before referring you to a specialist, admitting you to a hospital, or other types of treatment?

Additional Services: What services does the HMO offer in addition to those covered under Medicare-fee-for service?

Coverage: What coverage do you already have? How does it compare to the coverage you will receive from the plan?

Prescription Drugs: What will your prescription drugs cost under the plan's formulary (list of covered drugs)? What are your drug needs?

Pharmacy Choice: What pharmacies can you use?

Choices: What doctors, hospitals, and other medical providers are affiliated with the HMO? Can you choose a primary care physician? Does the HMO have its own specialists? If you want to see a specialist, can you refer yourself or does your primary doctor refer you? Are affiliated or contracting primary care doctors accepting new patients?

Exclusions: What are the benefits that are excluded but would be covered under a traditional Medicare supplement policy?

Location: Where will you go for care? Are there places near where you live? How does the HMO handle care when you are away from home? What is the procedure for after hours care?

Remember: Medicare Advantage plans are not regulated by the state of Wisconsin Office of the Commissioner of Insurance (OCI). Therefore, these plans are not required to cover Wisconsin mandated benefits, nor are the plans guaranteed renewable for life like Medicare supplement policies. Examples of benefits mandated by Wisconsin insurance law include chiropractic care and treatment of mental and nervous disorders, alcoholism and other drug abuse. For more information on mandated benefits, call the OCI at 266-0103 (In Madison) or 1-800-236-8517 (Statewide) and request a copy of Fact Sheet on Mandated Benefits in Health Insurance Policies. A copy is also available on OCI's Web site at