January 2, 2001

Seniors reverting to health insurance through traditional Medicare in 2001 need to be mindful of available options that will help pay for medical services not covered by the federal program.

"Elderly citizens count on guaranteed rights, but they have important decisions to make during the first two months of 2001 to ensure they receive help filling in coverage gaps for expenses not reimbursed by Medicare," said Rose Ortega, a benefits counselor with the Houston/Harris County Area Agency on Aging at the Houston Department of Health and Human Services (HDHHS).

Medicare pays 80 percent of health care costs incurred by people 65 or older, but beneficiaries must come up with the remaining 20 percent after meeting deductibles and co-payments. Seven of the eight health maintenance organizations, or HMOs, providing Medicare services pulled out of the local market December 31, affecting about 100,000 beneficiaries in Harris County. The remaining HMO closed enrollment because of membership capacity.

Seniors who lost Medicare HMO coverage as a result of the HMO exodus have from January 1 to March 4 to purchase supplemental insurance, more commonly known as "Medigap policies." Insurance companies are barred from denying coverage or placing policy restrictions on seniors who meet the deadline for the guaranteed protection period, Ortega said. The period also guarantees coverage despite pre-existing conditions and protection from higher premiums because of current or past health conditions.

Seniors may buy any of the 10 standard Medigap plans, but only those labeled A, B, C or F guarantee protection from a medical history review by insurance companies. The Texas Department of Insurance approves the companies allowed to sell the guaranteed plans as well as the premium rates. Plans D, E, G, H, I and J are available from most insurers, but are subject to certain conditions and restrictions including pre-existing or current health conditions.

The guarantee protection covers all ten policies for first-time Medicare beneficiaries who have been in an HMO for less than 12 months. Also, people under age 65 and on Medicare due to a disability are guaranteed plans A, B, C and F if the insurance company sells such policies to people under 65.

The Qualified Medicare Beneficiaries (QMB) program serves as a supplemental policy for seniors with limited incomes. The program pays the Medicare Part B premium and all Medicare deductibles and co-payments.

Other alternatives for Medicare recipients with limited incomes include Interfaith Ministries Senior Health Network and the Harris County Hospital District’s Gold Card program. Seniors and disabled people 55 or older pay a $10 annual membership to Interfaith Ministries and then receive care from a designated network of providers which waive Medicare deductibles and co-payments. Only people who have Medicare A and B and do not receive Medicaid benefits are eligible for membership.

The Gold Card provides services on a sliding-scale basis through three hospitals, 12 health centers and a dental clinic.

For more information on Medicare health options, call the Houston/Harris County Area Agency on Aging’s Benefits Counseling Program at 713-794-9001 or 1-800-213-8471.