Medicare, PPO's and HMO's

Insurance coverage can be confusing. There may be times when a client arrives thinking they had specific services under their policy or with Medicare only to find out they do not. I hear often "I was not aware of that," or "How come that was never explained to me," or "that's not fair!" It's unfortunate that I am the bearer of bad news or the "reality check" for some. However, it is important to know that not all services are covered by ones insurance or by Medicare or by their secondary or supplemental insurance plans. It is also unfortunate that not all plans are explained to individuals when they sign up. Often customers tell me that they are sold on the fact that they are saving money and not informed that some of the benefits are lost.

I am no expert on insurance or on what plan each person has, however, there are a few points I'd like to point out.

By signing up for an HMO plan, most plans will automatically re-assign your Medicare benefits to that plan. Often times this is NOT explained. Most HMO plans are less expensive, however, they also limit coverage, pay less to your service providers and ultimately, limit the quality of your care. A lot of people think that just because they have medicare they will get medicare services. However, with most HMO's they may have signed their benefits over the the HMO and have now lost some benefits or higher level of care and services as a result without even knowing.

PPO's are varied and can have what they call "in-network" and "out-of-network" benefit coverage. These plans can have various payment options however, typically you do NOT have to sign over Medicare benefits, but you may have more out of packet expenses, such as co-payments for medical visits and/or higher deductibles to meet BEFORE your insurance will cover you.

Medicare is another confusing insurance. Often individuals only have to meet their yearly deductible. The other thing to note about Medicare, is that Medicare only pays a portion of an "allowed amount" of billed services. If an individual has a secondary or supplemental insurance, sometimes these secondary or supllemental insurance will pay the difference. However, if they do not pay the difference, providers can bill individuals for the remaining amount. Also, providers are NOT allowed to collect these payments upfront. Services MUST be billed to medicare first before payment can be collected by your service provider (at least for Physical Therapy)

Altho this is not an exhaustive explanation of insurances, it is important for each individual to know what their policy says and what it does and does not cover. Ultimately you are responsible for your health, your health-care coverage and your financial duties under your policy.

You can go to our website and see the codes we most often bill and check with your provider to see if they cover these codes and if you qualify for our services and what your responsibility will be. We are glad to assist you in providing as much information as possible when time allows.