HMO Part C: The Good and Ugly


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Hey everybody,

I have read snips of the horrid of HMOs Part C in the past by some of you on this forum. None of you, however, ever stated what the horror is or was; you only stated it's just really bad. Okay, I'm wondering, what is so bad?

Would anybody mind sharing what some of the horror was or is?

I also have to believe that there was some good too. Afterall, each product has its place in this world for certain situations with specific people. Okay. Cool.

We also know certain or even all products are not appropriate for everybody or even some bodies; that said, what is the good to HMO? I know there has to be some good.

Also, when is an HMO a good fit; or appropriate to sell to somebody? My only take is what: when they do not mind going through a referral process or is there more to this concept?

I've never sold HMO Part C so hence my querries. I'm just trying to learn most efficaciously in addition to my other searches. I would greatly appreciate the response and thank you much in advance.



P.S. Whatever you state good, bad, or indifferent for HMO Part C, is this also the same for group health insurance HMO (through employer) or is that a whole other animal?
There are actually two questions rolled into one here.

The horrors of HMO: HMO stands for Health Maintenance Organization and is based on the premise of having all your medical records under the supervision of one Primary Care Physician who is, if you will, the gatekeeper for all of your medical procedures and whatnot. Every thing is housed, if you will, under the companies physical location, under your Primary Care Physicians name. It makes it easier for them to access your files, and also easier to spot something that may be important, and warn you about it, before it grows into something severe.

The assumption has long been that HMO's are run by business people, and that is who makes your decisions, not the doctors, nor you, the patient. For every example I can show you, that that is not the case, I can also show you a case that backs up that assumption.

For those that don't like HMO's, the assumptions are:

  1. I don't have any access to "good" doctors, only those that work on salary, because they don't have the expertise to go out on their own
  2. I feel like cattle, going into their building and waiting in a huge room, with God knows who, waiting for my name to be called
  3. They don't pay any claims, and make me jump through hoops just to get what I want. I have a friend, who is not in an HMO, and her doctor is the best in the city, and doesn't have any of these problems.
For those that like HMO's, the assumptions are:

  1. They take good care of me. I don't always get to choose my own doctor, and there is high turnover, but, I don't care. As long as there is someone there to treat me, I'm okay with it.
  2. They do all my paperwork for me, so I don't have to keep up with my own receipts
  3. They have classes, special events, and a nurse on-call line I can call anytime of the day or night. They even have after hour clinics I can go to.
HMO's, like every other kind of health care service, is not for everyone. You have to determine the personality of the person, and based on that, you would either suggest they go into an HMO system, or stay clear of it. For someone who has been going to several specialists their adult life, unless those specialists are in the HMO network, they would be the wrong people to put into an HMO, no matter how much money it is saving them.

They have built a relationship with that physician, and moving them, strictly based on money is harming them, and your reputation.

Now, the Horrors of Part C: Part C of Medicare has taken on many incarnations - Part C, Part C+, Part C Plus Choice, and now Medicare Advantage. Basically, it's the anti-MedSupp. Just as with Medicare Supplement plans, the federal government is privatising the administration of the medicare part C.

CMS did a horrible job of educating the Medicare Beneficiaries, the Physicians who accept Medicare, and the FMO's and agents who are out selling the products. These are government employees, who never had to offer a service to an end user, and make them satisfied, in their lives. These are mirmidons, who just go in and out of their respective offices and cubicles everyday, with no sense of cause and effect.

Medicare Advantage Plans are nothing more than another option for Medicare Beneficiaries to take advantage of. Simply put, MA's are nothing more than Major Medical Plans for seniors. The big mistake is not the plans themselves, but the poor, inadequate, or non-existent training required to properly sell these plans.

Because there are no medical questions, other than ESRD, people are assuming that they are being taken out of Medicare. Actually, what is happening is they are being "transferred" to another provider in the Medicare system, and that paperwork is nothing more than authorization to do so. Because it is made that easy, agents, FMO's, and to a certain extent, insurance companies, are a bit laxidasical (sp?) in moving Medicare Beneficiaries into these plans.

That's a shame.

They feel that since there is no premium to collect (in most cases), that it's a no-brainer, and best for the Medicare Beneficiary.


Where Medicare Supplement plans ask for payment now to cover costs later, Medicare Advantage Plans ask for no money now, and offer you "predictable" costs on the tail end. You know how much your doctor visits are, your dental visits are, your frames for your glasses. You know you have to buy your own hearing aids, but you know how much the tests are.

If they were not a viable option, I seriously believe that CMS would not have approved them for sale. Unlike the Zero Premium Life insurance scam, Medicare Advantage Plans were approved on a state by state basis, so that CMS could see what is and is not working. It's not an easy process these insurance companies have to go through to get their products approved in certain states.

Bottom line: As long as unethical agents bait and switch, misrepresent, and arm-twist, then you will always hear horror stories. If it is something you can believe in, and would sell to your mother and father, without losing sleep five years from now, then sell it. Otherwise, move on to another product.
If it was up to the Democrats, we would have a single pay health system that would work great according to them. I too think it would work great so long as you do not get sick or have any type of accident that requires medical treatment.


HMO you have a primary doctor who refers you to specialists. You have to stay with-in the network.

PPO you do not have a primary doctor and you can go out of the network.

So, if your doctors and hospitals are in network, then the HMO could be a good fit.

Network and costs. That is what it all boils down to. Can I afford it (both in premium and if they get sick considering co-pays) and are my doctors in network.
Bob, Wow, thank you for the detailed reply; I greatly appreciate it. It helps me understand this aspect of Medicare much more.

Also, Midwest, I thank you too!

So, let's say I have somebody who is open to swithing doctors, would this then be a better fit b/c of that premise and the fact I'd be saving her money?

Also, I am a bit unclear here and sorry for the stupid question. The doctors do evidently make the decisions for patients and not anybody else from business point, is that right? And last, if that's so, is it the PCP or the specialist - if a specialist would apply here? (ie, I have a lady who needs some back surgery. Who makes the call? The PCP or the back doctor; or both? or other?)

I'm just trying to get a feel for how these plans so, just as you said, if I'd consider selling.

Also lastly, do you know if this operates similarly to regular hmos under employee group plans?

Thanks again guys.
Why the premium is lower?

I forgot to ask that. Sorry.

Why is the premium so much lower on an HMO plan?

Do you know what the reason or reasons are for this?

I thank you in advance. Yes somebody asked me and I could not answer. Hence my querry. Thanks again.
Hmo's are less because the insurance carrier has a better control over the costs.

If their current doctor is a HMO doctor already, then it usually a non issue. If they want to change doctors, then they will have to have a primary that will refer them to specialists. If they are ok with that, then the HMO may be a good fit.

The PCP would refer to a specialist, but then the specialist would determin the next step in treatment.

If they cannot afford a supplement or cannot pass underwriting, then a MA plan in general could work.