A Cautionary Tale (or Adventures with a Medicare Advantage HMO Plan)

By TOM SWANSON, Chair, TVARA Healthcare Committee

So my mother-in-law aged into Medicare in 1993 before the creation of Advantage plans.

Sometime later she was convinced (I am sure by the then-equivalent of our TV modern-day health-insurance “expert,” Joe Willie Namath) that dropping Original Medicare, her Medicare Supplement, and her Prescription Drug plan in favor of enrolling in a Medicare Advantage HMO (Health Maintenance Organization) plan was the thing to do!

Enticed by such extras as SilverSneakers (which she really did enjoy for a while), she could not pass up the opportunity to obtain “more coverage than Medicare” in the form of hearing aids, eyeglasses, and the like at a zero premium.

Had I known then what I know now, I would have said something, maybe. After all, I am a son-in-law and as such, well … .

For many years, all was good. She was saving the money that would have been spent on a Medicare Supplement (otherwise known as a Medigap plan) and a Prescription Drug plan and getting SilverSneakers “for free.”

Good deal, and she was fine with it! All during this period, mother-in-law was a very active and healthy senior citizen. Not only did she drive a bright red Jeep that she was VERY proud to say could leave most other cars in the dust at a stoplight, she was a star at square dancing, which was a weekly endeavor. Turns out SilverSneakers was more of a “meet and greet” to her, and she got all the exercise anyone needed, square dancing.

But alas, as the years passed, mother-in-law had some body parts starting to fail. As it turns out, bouncing around on your legs at square dances does not do wonders for the knees of a more mature senior citizen.

After a while, the cushion between the bones in both knees was completely worn out on the inside of the legs, and she slowed to a hobble with the aid of a walker. But it was the pain that was becoming intolerable. Okay, no problem, I hopped on the internet and did a search of orthopedic doctors and clinics, looked at the ratings, read the “customer comments,” and called one of these offices.

Soon after “Hi” came the question, “What insurance does she have?”

Learning that she had an Advantage HMO plan elicited the comment, “Would like to help you, but we will need a referral.”

For those of you unfamiliar with the operation of an Advantage HMO plan, all health services are provided by and only by doctors, hospitals, clinics, rehab centers, and such that are in that plan’s network.

Also, and perhaps most important, the insured’s access to any of the network health services is controlled by the insured’s Primary Care Physician (PCP), including access to specialists such as an orthopedic clinic.

And so the adventure (for me, anyway) began. By that time, I was retired, a member of the TVARA Health Insurance Committee, and I thought I knew a thing or two about health insurance. But this would be my first hands-on experience with a Medicare Advantage HMO plan.

Whoa, Nelly! I soon learned I really had no idea. First, we needed to set up an appointment with the PCP for the purpose of obtaining a referral to someone who could help her knees. So that meant a visit to the PCP, then a visit to another clinic for knee X-rays, then a “package” sent to the insurance company by the PCP for approval of the referral recommendation.

After calling the PCP office several times, the insurance approval was obtained, and we showed up early for the appointment with the orthopedic specialist who was “in-network.” (Mother-in-law is an early riser and likes to have the first appointment of the day so she does not have to wait behind others whose appointments might run long.)

She also is never late for an appointment, so we were the first ones in the door. We checked in, and they asked for the referral paperwork.


This was supposed to have been all set up, so I helped mother-in-law to a chair in the lobby since her knees were killing her, and I immediately called the PCP office, only to listen to a recording of its office hours.

The office, I was told via recording, would be open in 50 minutes.

I left a message, even as others were coming into the orthopedic clinic and were being taken back to the exam rooms. Mother-in-law was NOT happy — she was there first! After a while I called again, hoping someone had come into the office and just hadn’t gotten to the phone messages yet. I left another message.

I called again at the official opening bell and LEFT ANOTHER MESSAGE.

Finally, someone called back, saying they had sent the required paperwork by fax days before, and the ortho clinic must have misplaced it.

Okay, you know how you are not supposed to shoot the messenger? Well, to say that my explaining this to the folks behind the desk at the clinic was not received well would be an understatement.

I called back to confirm the fax number, which they said WAS the number in their file, but they would send again. Time passed. Still nothing. I called back, and they said they had sent it, and the fax machine at the clinic must not be working.

I relayed this message, and now the clinic staff was starting to lose it, since they had been getting faxes all morning.

I called back. They would send again. More time passed, but by now another clinic worker not involved with our exercise mentioned that a fax machine somewhere kept calling their office’s main phone line.

I called back and began the discussion again, when the clinic staff member who had been involved from the beginning grabbed my phone and told the person on the other end to NOT push the button on their fax machine for the ortho office, but to type the number in manually. And this was done, I must note, in a tone and volume loud enough that now all those in the lobby understood the root cause of the problem!

Mother-in-law was still in pain and angry and now was also mortified. And none of this was reflecting well on son-in-law, who was there to help her out because of his knowledge of the healthcare-insurance process.

By now we were very, very late for the appointment, but they took us back, anyway. After another set of X-rays, the fax was not clear enough, which meant her options were surgery OR shots and weight-shifting knee braces.

She chose the latter, and after the shots, she was taken back to a fitting room for the braces. Once fitted, she walked around the room with a big smile. Immediate pain relief! Perfect!

The technician left to complete the paperwork and — after an extended period of time while mother-in-law continued to walk around the room with a smile — came back to remove the braces.

As it turned out, while the doctor was in-network, alas the braces were not of a type authorized under her Advantage HMO plan.

We walked out with no braces and with her in pain, waiting on the shots to kick in.

So next we were back with the PCP to arrange for a referral to an “in-network” clinic to fit authorized equipment. After waiting another week, the authorized set of knee braces fitted at the medical-appliance clinic were far inferior to the ones she wore at the orthopedic clinic, but, hey, they seemed to work, and she would be getting relief.


As it turned out (this is becoming a standard refrain), the clinic, which was basically a few rooms in an office building, had no stock, only samples — a very low-cost operation.

The braces had to be ordered and would arrive in a month or so (from China).

Did I mention that my wife and I live in Tennessee and mother-in-law lives in Tampa?

Weeks earlier we could have walked out of the orthopedic clinic with a smile on her face, but now we were returning to Tampa a month later to get a pair of Velcro-laced fabric braces.

They worked okay but were definitely not worth the wait and hassle.

Years ago, it became increasingly clear that mother-in-law was withdrawing due to hearing loss. In group situations such as at a restaurant or family gatherings she would go silent, not wanting to say something that was not appropriate to the conversation.

She was totally deaf in one ear and nearly there in the other.

Fortunately, we located an audiologist who fitted hearing aids with a feature in which the hearing aid in her bad ear captured the sound from that side and transmitted it to the hearing aid in her good ear in such a fashion that she regained her ability to perceive sound direction from either side.

The impact of these hearing aids was amazing. Needless to say, the Advantage HMO plan did not cover this type of device, so for her the plan was no better than Original Medicare — no insurance coverage.

Then came her fall and resulting broken leg close to the hip. HMO plans cover emergency services provided at out-of[1]network hospitals, but once the insured is stabilized, he or she is to be transferred to an in-network facility.

For mother-in-law, this meant a discharge from the hospital to an in-patient rehabilitation facility. However, only a few of these facilities were in the network, so she remained in the hospital until space was available, delaying any start on rehabilitation.

After the maximum number of days in a rehabilitation facility covered by the plan, it was determined she needed additional assistance in the activities of daily living, so her daughter and son-in-law in Cocoa Beach, a three-hour drive to the east of Tampa, invited her to stay with them until she regained her strength and footing.

Sounded like a great idea until it was discovered that Cocoa Beach was outside the HMO network of health-service providers. That meant if she accepted the invitation, she would be without medical-insurance coverage except for emergency services.

Even if she did declare a permanent change of address — which she loathed to do due to the ripple effect on other programs and services for seniors in Florida such as the homestead-tax exemption on her Tampa house, Social Security, and more — her insurance company did not sell a Medicare Advantage HMO plan in the Cocoa Beach area.

So after many years with a Medicare Advantage HMO plan, she returned to Original Medicare with a Medigap premium based on an issue-age of 93.

Now that will get your attention!

But now she can be in Cocoa Beach, or back in Tampa or back in Cocoa Beach and know she has direct access to any doctor, hospital, clinic, or health specialist in the United States that accepts Medicare coverage, and she does not need a referral or paperwork from a Primary Care Physician to go to them.

And since she is enrolled in Plan F, which covers the Part B deductible, she won’t even need to carry her checkbook.

She will just have to get used to carrying three ID cards again, instead of one. A small inconvenience compared to what she has gone through.