Managed Care

What are managed care plans?

♦ Managed care is all about money.

Insurers try to control health care costs through a process they call utilization management. The most common tool is prior authorization, where your plan has to approve certain care before you get it. The idea is for insurers to pay only for the things really needed and appropriate.

Too many times, this means paying for the cheapest treatment, which may not be what your doctor considers the best option.

♦ Managed care focuses on preventive care.

Checkups and screenings for various diseases are an important part of spotting potential health problems before they become serious and more costly.

Managed care plans often offer incentives for members to control their own health care costs.

Many plans include health education and prevention programs to help their members lead healthier lives.

Some plans even offer free health club memberships to encourage members to exercise.

♦ Managed care plans contract with health care providers and medical facilities to provide care for members at reduced costs.

These providers make up the plan's network.

How much of your care the plan will pay for depends on the network's rules.

♦ There are four primary types of managed care plans:

• Health Maintenance Organization (HMO)

• Preferred Provider Organization (PPO)

• Point of Service (POS)

• Exclusive Provider Organization (EPO)

PPOs are the most common form of managed care offered by larger employers. HMOs are the most common plans bought by individuals.

The trend is clearly toward HMO plans, with cost being the main driving force.

HMOs usually cost significantly less than PPO plans. This is driving more and more companies toward HMO plans as a way to control their expenses.

Rising costs, especially on the Marketplace, have pushed insurers toward HMO plans.

Health Maintenance Organization (HMO)

HMOs are the oldest form of managed care plan.

These plans usually require members to choose a Primary Care Physician (PCP) who will oversee the care they receive.

• These plans require a referral to see a specialist, and that referral comes from the primary care physician.

A few HMO plans don't require a referral to see a specialist, but that's not common. Check your plan's rules.

♦ HMOs can be the least expensive for members, as long as they follow the plan's rules closely. HMOs are the most restrictive of all plans.

HMOs have contracts with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan's network.

As long as you stay within the network, your costs for health care will be lower. Go out of the network for planned care, and you'll be responsible for all costs.

• There are exceptions: emergencies, and out-of-network doctors (like anesthesiologists) who treat you at an in-network hospital. Federal law protects you in both cases.

Emergency

If you have an emergency and the closest hospital isn't in your network, you can go there, and your plan has to cover it.

Your plan will look at the reason for your visit. But under federal law, it has to judge whether it was an emergency by your symptoms, not your final diagnosis. Chest pain that turns out to be heartburn still counts.

♦ Since 2022, the No Surprises Act also protects you from surprise bills for emergency care. An out-of-network hospital can't charge you more than your in-network costs.

One big exception: ground ambulances aren't covered by the law, so an ambulance ride can still bring a surprise bill.

♦ Best Advice

1st: Never pay a bill quickly. Check your Explanation of Benefits first.

2nd: If you think you were wrongly billed, call the No Surprises Help Desk at 1-800-985-3059, or appeal to your insurance company.

3rd: Ask the hospital to discount the bill. Most hospitals would rather receive something than nothing.