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Managed Care: Questions and Answers for ESRD Patients

What is managed care?

There is no standard definition of managed care. But, basically, it is a system which provides quality health care while keeping costs down by coordinating or managing services.

There are many different managed care organizations. A managed care organization may be a group of physicians, a hospital or any organization that is responsible for the delivery of health care to the people enrolled in it.

A managed care plan is a type of insurance policy that covers varying costs of your medical care. There are two main types of managed care plans: HMOs and PPOs. See below to learn more.

What is an HMO?

HMO stands for health maintenance organization. An HMO is one type of managed care plan. An HMO covers health care costs and provides health care services in exchange for a single payment per patient.

Typically, with an HMO plan you choose a primary care physician (PCP) and all your healthcare needs are coordinated through your PCP.   Often you need a referral from your PCP to see specialists.

What is a PPO?

PPO stands for preferred provider organization.  PPO plans often offer more flexibility so you can go to any health care professional you want without a referral—inside or outside of your network.  

Staying inside your network means smaller copays. If you choose to go outside your network, you'll have higher out-of-pocket costs, and not all services may be covered.

If I have Medicare, can I also be enrolled in an HMO?

That depends. Some HMOs have contracts with Medicare. If you were already enrolled in an HMO before developing ESRD, you are permitted to remain enrolled if your HMO has a contract with Medicare. At present, however, ESRD patients who are not already enrolled may not enroll in HMOs with Medicare contracts.

If I cannot enroll in an HMO with a Medicare contract, how are costs for ESRD treatments covered?

As a U.S. citizen, you are eligible for traditional Medicare coverage if you or spouse have worked and paid into FICA, no matter what your age, on the basis of ESRD. The Medicare ESRD Program pays for 80% of the treatment costs for dialysis patients, and 80% of the cost of immunosuppressant medication for transplant recipients. Medicare will cover 100% minus the deductible of the costs of a kidney transplant.   If you have a transplant, Medicare may terminate after 3 years, unless you are over 65 or have another disability.

If you are also covered by an employer group health plan, that plan may pay for treatment costs initially (30 months) while Medicare covers a part of the remaining costs. Then, after 30 months, Medicare begins to pay 80% and the employer group health plan becomes the secondary payer.

Click here for more information on Medicare and coverage options for transplant and dialysis patients.

I am already enrolled in a managed care plan. Are there differences from one plan to another?

Yes. Different managed care plans may have different co-payments and may offer different services and benefits. In general, it is important to know that managed care plans have either Risk contracts with Medicare, or Cost contracts. While most HMOs are Risk Plans, you should call your HMO's Consumer Services Department to be certain and to get more information about coverage.

What are Medicare Cost Plans?

Medicare Cost Plans allow you to get medical care from doctors and other health care providers who are not affiliated with the plan. If you go to a provider affiliated with the plan, you pay only the co-payment. If you go to providers outside the plan, your managed care plan will not pay, but Medicare will pay its share of the charges. (An example of a Cost Plan is a Preferred Provider Organization [PPO]).

What are Medicare Risk Plans?

Medicare Risk Plans are types of health care coverage for persons who are eligible for Medicare and over the age of 65. You receive medical treatment from specific health care providers who are either paid in advance, or else are contracted to provide such services. Medicare Risk Plans cover most hospital and physician services. In some cases, there are other types of benefits such as prescription coverage. However, Risk Plans have "lock-in" requirements. This means that (with few exceptions) you may not go outside the plan for services. If you do, neither the plan nor Medicare will pay for the services.

What if my plan does not provide a renal (kidney) nutritionist (dietitian), a renal social worker and a nephrology nurse?

When you are enrolled in an HMO, you have a right to medically necessary care. Managed care plans have doctors and other qualified health care professionals available in all specialties of medicine. If your HMO does not have enough qualified providers, it must arrange for the services you need to be provided for you outside the plan. This must be done in a timely manner, and at no extra cost to you. However, you should be aware that managed care plans usually have no obligation to provide any service which would not be available under Medicare fee-for service.

What is fee-for-service?

Fee-for-service is a system, other than managed care, through which you can receive your Medicare medical and hospital benefits. With fee-for-service, you have the freedom to choose any physician, medical facility or health care provider approved by Medicare. You pay a fee each time you receive medical treatment, and Medicare pays a part of your expenses for health services. You are responsible for certain deductibles, and for the part of your bill which Medicare does not pay.

How often do I have to have a referral for services from my PCP?

It depends on your HMO. In any case, it is important that you get referrals which are approved by your HMO, or you may have to pay for all of the services yourself.

Will my plan allow me to see my nephrology professionals as often as I need or want to see them?

Your HMO should not restrict the days or hours that you may be seen by the plan's providers. However, you should keep in mind that another function of managed care plans is to deliver quality care while limiting unwarranted or unnecessary services.

If your HMO refuses to provide services you request or feel that you need, you may make a complaint, in writing, directly to your HMO. Every HMO has a system to handle complaints. HMO's are also required to give you instructions on how to file a complaint.

What options or choices do I have if I want to change my PCP, my nephrologist, or my dialysis unit?

If you decide to change your primary care physician or your nephrologist, most managed care plans will usually let you do so as long as you select another PCP or nephrologist affiliated with your plan or at the same facility. If you should decide to change dialysis units, your options may be limited.

Can my nephrologist be my primary care physician?

Possibly. The policies on who can be your PCP vary from one HMO to another. To find out if your nephrologist can be your primary care physician, you need to contact your plan's Consumer Services Department.

Can I choose the dialysis or transplant unit that is easiest for me to travel to?

Possibly, if your HMO's facilities are available to you in your area. Most often, however, you may not be free to use any facility you choose. If you choose to use a dialysis or transplant unit not affiliated with your plan you will have to pay the entire bill yourself.  However, there are some restrictions on how far away they can reasonably make you travel to receive medical treatment; in most cases this is within 30 miles.

What happens if I need emergency care outside of my HMO's service area?

HMO's must cover emergency medical care and unforeseen out-of-area urgent care. If you do need out-of-area urgent care, your HMO should be notified as soon as possible. As a rule, routine dialysis is not considered emergency care, and your HMO may not pay for it as such when you are traveling. In Medicare risk, members must be able to receive dialysis throughout the U.S. For Medicare cost plans, treatments while traveling may be covered in full, but if not you may be able to use original Medicare which would cover 80%.  

How do I know if my plan pays for my prescriptions and other medications?

You need to call your HMO's Consumer Services Department to find out:

  • what prescription medications your plan covers
    • * Some managed cared Medicare plans require you to sign up for their Part D Plan
  • if there are limits to the coverage
  • whether you are required to use certain pharmacies

How can I speed up referrals or appointments for special tests or medical evaluations ordered by my PCP in preparation for a kidney transplant?

If you believe that you are waiting an unreasonably long time for a referral to a specialist in or outside of your plan or if you experience an unreasonable delay in scheduling a transplant workup or any other needed services ordered by your PCP, you should contact your HMO, directly, and file a complaint.

If my plan makes a decision that I don't agree with, is there some way that I can appeal the decision?

Yes. You have appeal rights and your HMO must provide you with written information about them. Usually, the process begins with your written request to your HMO asking it to review the decision in question. If the HMO review organization does not decide completely in your favor, you can contact Medicare to ask for a hearing.

You need to use specific terms in your appeal in order for it to be reviewed for approval. Ask your HMO to provide you with the information necessary for you to prepare an acceptable written request.

What about special situations such as finding approved dialysis treatment facilities while traveling?

If you need to make treatment arrangements when getting ready to go on a trip, you can talk to your HMO's Case Manager, a renal social worker at your dialysis unit, the dialysis center closest to where you want to visit, or else contact your HMO's Consumer Services Department.

Are there special questions I should ask my HMO?

  • Does my plan cover over-the-counter medications?
  • Does my plan cover wheelchairs or other medical equipment?
  • Does my plan provide for transportation to and from medical appointments?
  • Will my plan cover nutrition counseling before I start dialysis, and after a transplant?
  • Does my plan provide for services like flu vaccines or TB tests?

Where to go for Answers, Information and Help

Every state in the United States, plus the District of Columbia, Puerto Rico and the Virgin Islands, has a health insurance counseling program that can help you with your medical coverage problems. To find out the phone number of the insurance counseling program in your state, you can call the Medicare toll-free hot line at: 1-800-638-6833.

If you have questions or problems involving a complaint, contact the Health and Human Services (HHS) Office of Inspector General, toll-free, at 1-800-HHS-TIPS.

If you are having trouble with a decisions-appeal or you believe your HMO is not meeting its obligations, you can call the Medicare Hot-Line (above), the HHS Office (above) or the Center for Health Plans and Providers (CHPP) at 1-410-786-4164.

If your concerns have to do with medical services to the elderly, you need to call the Office of the Aging. To find out the number of your local aging office, you can call the Eldercare Locator number at: 1-800-677-1116. 

Last Reviewed: 03/30/2017
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