Managed Care Insurance

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• QHow do managed care health plans work?

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  A LIVESTRONG answered

  Managed care plans have arrangements with certain physicians, hospitals and health care providers to serve patients who are plan members at a contracted reduced rate. Managed care plans usually offer a lower premium and require less paperwork. However, the choice of physicians, drugs and treatment are restricted.
  
  With managed care plans, such as a Health Maintenance Organization (HMO), you may be required to select a primary care physician (PCP), who is a member of the plan network, to take care of your general medical needs. General medical needs may include treatment for common illnesses, preventive care and annual exams. Your PCP must make the determination to refer you to a specialist, such as an oncologist. Under an HMO, you cannot have coverage for services through a specialist without a referral from the PCP.
  
  The premium cost for managed care health coverage is generally less than an indemnity plan (fee-for-service plans). You also pay a co-payment (such as $10 or $25 per visit) each time you meet with your PCP or other medical provider who is a member of the plan network.

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

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  A LIVESTRONG answered

  A preferred provider organization (PPO) plan may recommend but not require that you work with a primary care physician (PCP). Instead, you can work with a large number of medical providers who participate as a member of the plan network. There is also an opportunity to receive health care services with providers who are not in the network, but you may be required to pay the difference between the amount billed and the amount allowed by your insurance company. This is likely to result in increased out-of-pocket expenses for you, such as a higher co-payment.

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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 LIVESTRONG answered

  A health maintenance organization (HMO) contracts with certain health care providers to provide prepaid services to plan members. There is usually a set fee or co-payment for office visits and other medical services. This type of plan requires a primary care physician (PCP) and referrals are required to receive care from specialists within the HMO network of providers. Some HMOs may allow you to see certain commonly used specialists, such as an obstetrician-gynecologist, without a referral from the PCP.

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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.