Question: What can I do, now that my mother is having hip surgery and I know she will need rehab? I thought she could go anywhere, but her insurance limits where she can go. I thought she had Medicare, but now I have found out she has a Medicare Advantage Plan.

Answer: There are a whole host of things that you can do to help make this hip surgery and recovery successful. You are starting the process off in a good way, by asking questions and getting information. Your mother does have Medicare Part A and B. She has decided to add to that a Medicare Advantage Plan (hopefully with Prescription Drug Coverage). This type of plan actually takes over her insurance coverage and stands in front of Medicare. When you choose a Medicare Advantage Plan, it is important you understand the rules of that type of coverage. There are primarily two types of Medicare Advantage Plans that we see, Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). There is a third, Private-Fee-For Service (PFFS), but we do not see those as often, as there are only two PFFS plans available.

An HMO requires that you use providers that are in its network, participating providers. This includes, doctors, hospitals, clinics, rehab facilities, labs, etc. When choosing an HMO, it is important to review where and with whom, you doctor to be sure they are in the network of providers this plan offers. Each company offering HMO coverage has a different network of providers.

A PPO plan provides both in and out of network coverage. This means you can theoretically go wherever you wish, and probably do not need referrals. If you use providers that are “in network,” you pay a set amount for the co-pay ($10 or 20 percent). If you use “out of network” providers, you will usually pay a higher amount for services ($75 or 40 percent). You have a price incentive to use providers that are “in network.”

In choosing between these two types of plans, those with Medicare often chose a plan that is PPO thinking it gives them more options for coverage. That is true it definitely does appear to give you more options.

One of the problems we are finding locally is that in a PPO plan you may find that you cannot find providers in our region who are willing to allow you to come to them.

Let me explain this a little differently. For the providers when deciding to join in a plan’s network, you are agreeing to the amount of reimbursement that plan agrees to pay. The provider signs a contract with the insurance company and they agree to the reimbursement levels and policies of the insurance company.

With out of network rules, the providers have decided they do not agree to the terms the insurance company is offering for their services. In declining the opportunity to be “in network” the provider is saying “No, I am not happy with those terms.” If the provider then accepts your appointment or your stay in their facility, they will be getting the “out of network” reimbursement rate. This rate may be the same or lower than an “in network” provider. For the provider if they were not happy with the ‘in network’ terms, they will be even less happy with the “out of network” terms and reimbursements. So often we find providers saying, “No, we don’t take that insurance,” or “No you can’t come to our facility.”

This may mean that if your mother has an HMO network she must find a facility that takes her insurance. That should not be too hard for most of the HMO products sold in our part of the country. If she has a PPO product, she may find that she does not have any ‘in network’ providers for rehab, and the others- the ‘out of network’ providers will not offer to provide services to her. This has been more common that we like to think. The national insurance companies, selling PPO plans would like you to believe that you can ‘go anywhere’. In real life, I find that sometimes these PPO plans are much more limiting than the definition of a PPO indicates.

Now, what can you do about it? Your mother may need this surgery right away and you do not have time to switch her insurance for this situation. If this is the case, I would suggest you work with the Hospital Social Work/Case Management Department to help find an appropriate plan for your mother’s rehab. That is exactly their job and what they are trained to do. Her current Insurance Company also may have individuals that could help evaluate other options open to your mother.

If the surgery is something that will be done in the near future, but not immediately, you may have time to review the options of switching her insurance coverage to something that is going to work better for her situation now. We call this opportunity to switch a Special Enrollment Period (SEP). This SEP allows you to evaluate the current coverage your mother has and decide if maybe switching her to a plan that will provide more appropriate coverage for her needs at this time. Many times those with Medicare choose an insurance product to add on to their Medicare and then let it roll over year-to-year, not using the enrollment periods to switch their insurance. This may be the reason to evaluate her current coverage and decide if that is still the appropriate plan for her.

You have resources available to you, medicare.gov, medicarerights.org , as well as local individuals at Office for the Aging, Southwestern Independent Living center, or Senior Life Matters.

I hope her surgery goes well and she recovers quickly. I also want to thank you for supporting her as she goes through this process.

To contact Janell Sluga, GCMC with questions or concerns, please call 720-9797 or e-mail her at janells@lutheran-jamestown.org.