Managed Care Insurance

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• QHow do managed care health plans work?

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  A Dr. Michael Roizen, MD , Internal Medicine, answered

  Managed care plans are the least expensive variety because they’re generally the most restrictive, and most directive as to what your doc and you can do. (That’s why it’s referred to as managed care.) Many different versions exist now: health management organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans. In the traditional HMO, you must pick a primary care doctor who is in the HMO network of physicians, and this doctor coordinates all of your care. That doctor must refer you to specialists who are generally also in the HMO network; you can’t just go see them (or any out-of-network doc) on your own whim and expect the services to be covered. You pay next to nothing (or nothing) for in-network care, meaning the care or services you receive from one of the hospitals or doctors who have agreed to accept greatly reduced payments from the HMO’s members. But if you see a doctor outside the HMO network, or break the rules, you pay 100% of the costs. PPOs and POS plans give you a little bit more freedom. You can see a doc out of network, but you have to pay a higher co-pay than you would ordinarily, but it’s not like an HMO where you have to cover the entire bill.  These plans are pricier, though, since they give you more of a choice. Unlike HMOs, with PPOs and POS plans, you also may not necessarily have to choose a primary care physician (PCP) to give you referrals and serve as the ringleader for your care.

  No matter what managed care plan you select, it’s important to read the Summary Plan Description (SPD), which gives you all the info, ins and outs, and juicy details of your plan before you purchase it. You want to make sure you know exactly what you’re getting so you can find the plan that fits as well as your favorite pair of jeans.

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• QHow does preferred provider organization (PPO) health insurance work?

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  A Dr. Michael Roizen, MD , Internal Medicine, answered

  PPOs were created for people who still wanted economical coverage, but more freedom of choice than HMOs offer. They allow you to use doctors and hospitals outside of the PPO network as you wish (Princess Bride anyone?), but at a higher cost. For the mixture of freedom and relative economy, these plans are the most popular in the U.S.

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• QWill I choose my own doctors with managed care insurance?

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  A Dr. Michael Roizen, MD , Internal Medicine, answered

  These days it’s hard to find anything that doesn’t charge you more for simple benefits like going to any location of the sports club you joined or even choosing your own docs. 

  If you have a managed care plan, you can choose any primary care provider (PCP) that’s in-network. Your PCP can then give you a choice of in-network specialists he or she can refer you to, but if the doc you want isn’t on the list, you’re going to have to cough up extra dough. How much extra you need to pay depends on what type of managed care plan you have. So you still have some say in who provides your care, but not as much as you would have if you did not have a managed care plan.
• QWhat kind of benefits does managed care insurance have?

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  A Dr. Michael Roizen, MD , Internal Medicine, answered

  The main types of managed care plans are the HMO, PPO, and POS, each plan offering different benefits. That being said, many plans offer the following benefits free or at a very low co-pay:

  - free annual physical exams

  - cancer screenings such as pap smears, mammography, PSA tests, and colonoscopy

  - lab to check blood glucose for diabetes

  - immunizations

  - blood pressure and blood cholesterol checks

  - counseling for weight loss, drug use or quitting cigarettes

  But you’ll have to invest in a set of quality magnifying glasses and scrounge up every ounce of patience you have, to find the details in your Summary Plan Description (SPD) or over the phone from your insurance provider.

• QWhat kind of benefits does a Point of Service (POS) plan have?

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  A Dr. Michael Roizen, MD , Internal Medicine, answered

  The point-of-service (POS) health plan has many benefits for people who enjoy some flexibility and freedom of choice in health care. If you review the Summary Plan Description (SPD), which you may need a quality set of magnifying glasses to examine, you hopefully will see the many choices that are available for preventive care, cancer screenings, testing for diabetes and other diseases, prenatal and newborn care and more. The POS plan also provides members with choices in mental health therapy, ER care, and home health care.

• QWhat is a Preferred Provider Organization (PPO)?

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  A Dr. Michael Roizen, MD , Internal Medicine, answered

  A PPO (preferred provider organization) is an evolutionary step just a sliver closer to the proud and noble indemnity plan. PPOs were created for people who still wanted economical coverage, but more freedom of choice than HMOs offer. They allow you to use doctors and hospitals outside of the PPO network, but at a higher cost. For the mixture of freedom and relative economy, these plans are the most popular in the U.S. About 40% of people with employer-sponsored health insurance have a PPO plan.

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• QWhat is a point-of-service plan?

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  A Dr. Mehmet Oz, MD , Cardiology (Cardiovascular Disease), answered

  With a point-of-service health insurance plan, you have the choice of using any physician and getting any service without needing a referral from your primary care doctor (like in an indemnity plan). However, the insurance carrier has a network of doctors, hospitals and other care providers that it has negotiated discounts with, and you have a financial incentive to use those "in-network" providers. You'll pay more (usually, a lot more) for using out-of-network doctors and hospitals.
  
  The premiums usually run a little less than traditional indemnity plans, and there may be less paperwork because your doctor's office will likely have frequent (if not daily) contact with the insurance company.
• QWhat is a managed care plan?

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  A American Diabetes Association answered

  Under managed-care plans, you or your employer pay a fixed premium and you typically receive a comprehensive care package, ranging from routine office visits and preventive care to hospitalization. The three main types of managed care plans are preferred provider organization (PPO), health maintenance organization (HMO), and point of service (POS).

  Basics of Managed-Care Plans

  • Your cost is generally lowest if you seek care from the network of participating providers and hospitals.
  • You generally have lower deductibles to satisfy and limited paperwork to process.
  • You also may not be expected to pay large out-of-pocket amounts for services.

  Types of Health Care Plan

  PPO: The insurance company has a contract with hospitals or doctors to provide care at a discounted rate. You may have more flexibility in your choice of in-network providers or specialists without the need for a referral from a primary care provider. However, if you choose to see an out-of-network provider, you may pay more.

  HMO: The insurance company has a contract with a network of providers that will provide your care. Generally, you’ll need to see a primary care provider first for a referral before seeing specialists, and your choice in doctors may be limited. The HMO may not pay for care from out-of-network providers or if you see a doctor without a referral.

  POS: You’ll see a primary care provider first, just like an HMO, but you may have more flexibility about seeing providers out of network. However, if you see an out-of-network provider, you may pay more in the form of a separate deductible, copayment, or portion of the total bill.

• QWhat is a Health Maintenance Organization (HMO)?

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  A Dr. Michael Roizen, MD , Internal Medicine, answered

  A health maintenance organization (HMO) insurance plan is the most maligned insurance plan on earth, and the one that made us accustomed to the utterance of “managed care.” They’re way back at the monkey’s uncle end of the evolutionary scale. About a third of all Americans who get their insurance through their employers have HMOs. An HMO is usually the least expensive variety because they’re generally the most restrictive, and most directive as to what your doc and you can do. And sometimes they provide the most preventive care. The plans set up a network of doctors and hospitals that will provide care for you at a very low (or no) cost as long as the plan guarantees a steady stream of patients.

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• QWhat is a gatekeeper?

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  A Dr. Michael Roizen, MD , Internal Medicine, answered

  When I think of a gatekeeper, those giant lion-sphinx-like creatures hovering outside the gates of ancient Egyptian temples come to mind. While those particular gatekeepers did control who came into those sacred places, the term has come to mean something fairly different in the insurance world.

  For those with traditional HMOs, your primary care physician (PCP) is your gatekeeper. This doc oversees and coordinates all of your medical care. The gatekeeper must approve medical tests and treatments and even refer you to specialists for additional medical care.

  Sometimes, point-of-service (POS) plans have gatekeepers, but YOU usually decide whether to have one or not.