As I coordinate prosthetic care for other amputees, I often am asked about the pros and cons of Medicare HMOs.

It's important to look at the BIG picture when answering this question. 

Prosthetic Limitations

Prosthetically speaking, many Medicare HMOs tend to be extremely cost aware and may shy away from certain components, such as microprocessor knees.  Medicare HMOs also frequently require long pre-authorization processes that can take up to 2-3 weeks and several levels of medical review.  It's not uncommon for an amputee to be required to visit more than one prosthetic facility, so that the insurance company can obtain multiple quotes for care.  The amputee's choice in prosthetic facilities may also be drastically limited in HMO plans.     

Large Patient Financial Costs

Though Medicare HMOs typically do not impose large coinsurances for medical care, often times prosthetic benefits include a large patient responsibility, such as 20% of the contracted rate.  Sometimes the co-insurance for prosthetic care does not even get applied to a patient's out of pocket maximum (OOP). 

Pros

Having said this, HMOs can offer affordable medical care for less, specifically drug coverage.  If an amputees has other health issues, the benefit of a Medicare HMO can outweigh the prosthetic disadvantages. 

There are Medicare HMOs out there that provide solid prosthetic coverage, but members need to be careful when contacting the insurance company for this information.  Remember, the benefits for durable medical equipment (DME) and prosthetics (sometimes referred to as external prosthetic benefits, or EPA)  can be very different.  When asking about prosthetic coverage, amputees need to give specifics.  Otherwise, the representative on the phone may assume the amputee is talking about DME and could provide misinformation.

As I said earlier, Medicare HMOs often impose large patient co-insurances for prosthetic care.  Straight Medicare also imposes a 20% co-insurance for prosthetics, which would be the amputee's responsibility unless he or she has a secondary insurance.  However, many prosthetic facilities have contracts with HMOs where the reimbursement may be based on a discount off the Medicare reimbursement.  So, the HMO 20% co-insurance would be based on a lower overall charge.  That means that an amputee's 20% coinsurance with an HMO may be slightly less than the straight Medicare 20% co-insurance without secondary insurance.    

As an amputee care coordinator, I avoid steering our clients in any specific direction.  Instead I try to give them all the information, encourage them to do the digging, and let them made that decision.