Managed Care

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Managed Care


Managed care plans focus on managing the health care of members.

Managed Care

What are managed care plans?

♦ Managed care is all about money.

Insurers try to control healthcare costs through a process they call utilization management. The idea is for insurers to pay only for the things really needed and appropriate.

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

♦ Managed care focuses on preventive care.

Check-ups and screenings for various diseases are an important part of identifying potential health problems before they become serious and more costly.

Managed care plans often offer incentives for members to control their own healthcare 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 member 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 purchased by individuals.

The trend is clearly toward HMO plans. 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 means to control their expenses.

The Affordable Care Act and instability in the Marketplaces has accelerated the shift toward HMO plans.

Health Maintenance Organization (HMO)

HMOs are the oldest form of managed care plan.

These plans usually require plan members to select 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.

Ambetterwas offering a few HMO plans in some markets that did NOT require a referral to see a specialist. This not common.

♦ HMOs can be the most inexpensive for the member 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 reduced. Go out of the network and you will be responsible for all costs.


If you have an emergency and the hospital closest to you is not in the network you are permitted to go to that hospital and the plan should cover the services.

However, your plan will scrutinize the reason for your visit. It must be a TRUE emergency.

Unfortunately, the plan decides what a true emergency is or is not.

As a rule, anything that a reasonable person would consider life-threatening or a serious injury.

♦ Unfortunately, a hospital outside your plan’s network is not required to accept what your plan decides is reasonable to pay for the service you received during the emergency.

The hospital can and probably will bill you for the difference. This is called balance billing, which has led to a huge increase in ‘surprise billing.

♦ Best Advice

1st Never pay a bill quickly.

2nd Appeal to your insurance company and try to get them to pay more.

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

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