The term Managed Care means that certain structures are in place in order to reduce the cost of health care to your employer and ultimately, the insurance company. There are only two ways to do this: either lower the reimbursement to various providers of care, and/or limit services, procedures, visits to providers, treatments, etc. Part of this may mean simply making it harder for you to comply with all the requirements of your plan.
Here are a few tips on how your policy may be written, and what to look for when you have a choice.
Somewhere in your policy may be the word "necessary." Perhaps it will be called "necessary medical treatment" or "medical necessity." The red flag here is that someone needs to make the decision as to exactly what is considered necessary. Is it your doctor? Or is The Plan? When you read the definition of medical necessity, is it clear? Is it based on science, customary medical practice? Or some un-named administrator? You may find that your doctor is named in one place, but elsewhere the policy states that the guidelines of the plan are the ultimate arbitrars. If you need to file an appeal at some point, you may find that the guidelines are frequently considered proprietary and are difficult for a patient to find out.
Another important element of the plan is to know who decides when you need to see a specialist? Do you need a referral each time you see one, or can you get a standing referral? Under what circumstances can you see one? What are the guidelines for seeing a physician if you have a chronic condition that really needs to be followed by a specialist?
A question you m ay want to ask your doctor is whether there are there any incentives for him not to send you to a specialist. What are the financial arrangements between the health plan and your doctor? Some health plans pay their doctors a bonus if they control the number of referrals they grant to their patients. Others pay their doctors a set amount each month per patient called capitation. Capitation may encourage some doctors to treat a time consuming patient more hastily that he would otherwise. It is good to ask your general physician what circumstances would persuade him or her to over ride those structures?
Look in the exclusion section for answers about who determines what is excluded? Again, determine if it is according to accepted standards of care, and/or whose criterion is used (see necessity above). Is the standard neutral and based on research? Are these standards in a document that you can read, or is it proprietary?
What standard is used for determining if you need to go to the emergency room? Are there any restrictions? Do you need to "pre-approve" your emergency? A better standard would be emergency care based on what a "prudent layperson" would do in a similar circumstance. I had a client whose son broke his arm in school, but didnŐt tell anyone for five hours. When she saw the arm it was clearly broken - but should she take him to the nearest ER or should she take him to a hospital on her plan although it was farther away? The arm had been broken for five hours - could it still be an emergency? What is the out-of-pocket expense for a visit to the emergency room?
Is there a Point of Service Option (POS)? A POS means that if you elect to see a provider who is not on your insurer's panel, that provider can still be reimbursed. The reimbursement will not be their entire fee; you will pay the difference, at least 20% of the cost. Preferred Provider Organizations (PPOs) have similar financial arrangements. If you purchase such a plan, premiums will be higher than a standard HMO. Be aware that the POS option may be subject to the same standards of necessity and other managed care structures as a more restrictive plan, but it does offer a more flexible choice of provider. Before you pay the extra costs, decide if the premium is worth it to you. If there is a particular provider you need to see who is not on your plan's restricted panel, or you are particular about who your doctors are, the extra charge may be valuable to you. Remember, in the world of Managed Care, you will still have to play by the plan's rules.
What is covered? Generally, doctor visits and hospitalizations are covered. There may be additional co-insurance, co-payments, and/or deductibles. Find out what kinds of preventive care and diagnostic tests are encouraged and under what circumstances; especially if you have children. Are all childhood immunizations covered? up to what age? What kinds of additional therapies are offered such as speech or physical therapy, and what are their limitations? Are any other services offered or excluded, such as vision and hearing care and their corrective devices, dental services, hospice care, etc. If, for instance, you are thinking about having children, you might want to explore their maternity benefit, or if they offer fertility treatment.
After you understand your plan structure, you can begin to make some informed choices about what is best for you. While you are making this decision, remember that the single most important choice you can make for your medical care is the choice of your personal physician. A good working relationship with a doctor you trust is really the best way to take care of your own and your family's health.
