The Leading Business Education Network for Doctors, Financial Advisors and Health Industry Consultants

What is a Social HMO – Should My Patients Join? 

Staff Writers

A New Model Evolves 

A social HMO offers extended coverage for some of the unconventional expenses associated with senior healthcare, such as transportation and in-home day care not covered by traditional MCOs.  

According to the American Association of Health Plans (AAHP), social HMOs provide coordinated services by uniting federal and state funds and services, to benefit the elderly. 

The Four Medicare Plans 

There are currently four S/HMO’s participating in Medicare and each has eligibility criteria http://endoflifecare.tripod.com/imbeddedlinks/id1.html 

These S/HMO plans are located in: Portland, Oregon; Long Beach, California; Brooklyn, New York; and Las Vegas, Nevada.  Listed below are the four plans and the criteria for joining each plan.  

1. Kaiser Permanente, Portland Oregon

The enrollee must be 65 years of age or older, must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in Kaiser Permanente’s S/HMO service area. The enrollee cannot have end-stage renal disease, or reside in an institutional setting. In order to receive the long-term care benefit, an expanded care resource coordinator will visit you at home to determine if you qualify for nursing home certification based on criteria established by the State of Oregon Senior and Disabled Services. These criteria may include needing daily ongoing assistance from another person with one of the following activities of daily living: walking or transferring indoors, eating, managing medications, controlling difficult or dangerous behavior, controlling your bowels or bladder, or the need for protection and supervision because of confusion or frailty.  

2. SCAN, Long Beach California

The enrollee must be 65 years of age or older, must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in SCAN’s service area. The enrollee cannot have end-stage renal disease. In addition, in order to receive extended home care services, members must have a Nursing Home Certificate which indicates that the member’s informal support system, such as a family member or care giver, is not sufficient to keep the member out of a nursing home. 

3. Elderplan, Brooklyn, New York

The enrollee must be 65 years of age or older, must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in Elderplan’s service area. The enrollee cannot have end-stage renal disease. In order to receive chronic care benefits, the enrollee must meet state nursing home certifiable criteria. 

4. Health Plan of Nevada, Las Vegas, Nevada

The enrollee must be at least 65 years of age, or may be under 65 if they are disabled. The enrollee must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in Health Plan of Nevada’s service area. The enrollee cannot have end-stage renal disease. For the long-term care benefit, the beneficiary must meet certain criteria based on established medical, psychological, functional, and social criteria as well as needing to be medically necessary.

Assessment

As always however, it’s “buyer-beware” as these new-wave organizations continue to evolve and morph; but your experiences are invited so that others may benefit.

Conclusion

Your comments are appreciated.

For related info: The Business of Medical Practice [Advanced Profit Maximization Techniques for Savvy Doctors]
http://www.springerpub.com/prod.aspx?prod_id=23759

Institutional: www.HealthcareFinancials.com

Terminolog: www.HealthDictionarySeries.com

Filed under: Managed Care |