February 13, 1998
The Honorable Nancy-Ann Min DeParle
Dear Ms. DeParle:
Patients in HMOs often find that the medical services of their choice are not available from their prepaid providers. They have been accustomed to seeking care outside the HMO, paying directly out of pocket, for such services.
Are Medicare HMO patients still able to buy services out of network from physicians who have not completely withdrawn from Medicare? I understand that there is a policy memorandum on this point, referenced in the February 9, 1998 Coding Bulletin for Ophthalmic Administrators by the American Academy of Ophthalmology.
One might think that since HMO subscribers have turned over all their Medicare benefits to the HMO, they are no longer beneficiaries whenever they are outside the network, and that out-of-network services they receive are not covered. However, physicians are very fearful of violating a law or regulation, incurring ruinous penalties, should they serve such a patient. Therefore, they would like to have an official policy statement.
Please respond promptly. Certain patients may have to go without needed medical service pending your response.
Jane M. Orient, MD
cc Senator Jon Kyl