About 1,100 senior citizens use the Aetna HMO plan.
By LAURE CIOFFI
VINDICATOR NEW CASTLE BUREAU
NEW CASTLE, Pa. -- Time is running out for Lawrence County senior citizens who have the Aetna U.S. Healthcare Medicare Health Maintenance Organization plan.
Aetna is pulling its Medicare HMO coverage out of Lawrence and three other western Pennsylvania counties at the end of the year.
Those who deal with the elderly say explaining the changes have not been easy.
"It's been confusing for a lot of folks, even those who don't have Aetna. Many have heard a change is taking place and want to know more," said Ellen Rowley, a community worker for Lawrence County Challenges Options on Aging, an agency that provides services for elderly people to live independently.
Rowley estimates that about 1,100 Lawrence County residents have the Aetna Medicare HMO plan. An additional 3,000 to 4,000 people living in Butler, Beaver and Washington counties are also losing their Aetna Medicare HMO coverage, she said. Aetna does not offer its Medicare HMO plan in Ohio.
A spokesman for the Connecticut-based health-care provider said it can't afford to do business in these counties any longer.
Here's the problem: "Our medical cost ratios are at 100 percent. For every dollar we take in, we pay at least $1 out. It simply does not make business sense for us to continue to offer a Medicare HMO there. It weakens our health system," said Aetna U.S. Healthcare spokesman Walter Cherniak.
Medicare HMO plans are offered by health insurance companies that have contracts with the federal government under the Medicare Choice program. Medicare recipients must use the HMOs' networks of doctors and hospitals.
This differs from traditional health care benefits, called fee-for-service plans, where treatment can be done at any hospital by any physician.
Insurers offering Medicare HMO plans have been pulling out of smaller communities in the last few years, said Michelle Memi, director of managed care analysis for the Hospital and Healthsystem Association of Pennsylvania.
Most have found they can't make money in these communities since the federal government put tighter controls on payments and yearly cost increases for health care providers, she said.
Memi explained that the government bases its fees on past charges made by doctors and hospitals in those areas. Smaller communities have traditionally had lower fees, she said.
Aetna has said it will maintain its Medicare HMO coverage in some of Pennsylvania's larger counties, including Allegheny, Westmoreland and Fayette.
Rawley said Lawrence County residents in the Aetna Medicare HMO plan must now select another HMO plan. Those who do nothing will automatically end up with traditional Medicare -- a more expensive option.
She explained that traditional Medicare covers 80 percent of the cost for health care services and the person must pay the rest or have supplemental insurance in place.
Supplemental insurance costs are often double or triple the monthly premiums for Medicare HMO plans, Rawley said.
Three companies still offering Medicare HMO plans in Lawrence County are Highmark, UPMC and HealthAmerica, she said.
"You need to make that choice sometime before the holidays, sometime before Christmas," Rawley said.