What Is Managed Care?

Health Maintenance Organizations, commonly referred to as HMOs, represent one increasingly popular form of managed health care. This is a generic term that applies to different types of health care insurance arrangements. Managed care systems typically combine the financing and delivery of health services. They take care of this by financing, i.e. covering some or all of the cost of health care services and by delivery system. Delivery system means encouraging members to obtain services from the organization's network of providers. Under Managed Care, there are arrangements to obtain services from any provider, even out of network, but the health plan will pay more if the patient obtains care from a network provider.

Some of the most common managed care arrangements are:

• Health Maintenance Organizations (HMOs):   A form of health insurance combining a range of coverage's in a group basis. A group of doctors and other medical professionals offer care through the HMO for a flat monthly rate with no deductibles. However, only visits to professionals within the HMO network are covered by the policy. All visits, prescriptions and other care must be cleared by the HMO in order to be covered. A primary physician within the HMO handles the referrals.
•  Preferred Provider Organizations (PPOs):   A health care organization composed of physicians, hospitals, or other providers which provides health care services at a reduced fee. A PPO is similar to an HMO, but care is paid for as it is received instead of in advance in the form of a scheduled fee. PPOs may also offer more flexibility by allowing for visits to out-of-network professionals at a greater expense to the policy holder. Visits within the network require only the payment of a small fee. There is often a deductible for out-of-network expenses and a higher co-payment. A policy holder will have a primary physician within the network who will handle referrals to specialists that will be covered by the PPO. After any visit, the policy holder must submit a claim, and will be reimbursed for the visit minus his/her co-payment.
• Point-of-Service (POS):   POS plans give members the Opportunity to see providers outside the network.   Members who use a provider in the HMO's network pay less than members who see providers outside the network.    The HMO may still require the use of a gatekeeper to authorize in-network services, but no referral is needed for out-of-network services.
• Primary Care Case Management (PCCM):   Primary care case management programs only operate within the Medicaid program.  In PCCM programs the Medicaid agency pays a primary care provider (PCP) a monthly management fee to manage the member's care.   However, physicians are reimbursed for the services they provide o a fee-for-service basis.   The PCP acts as the patient's gatekeeper and must authorize all non-emergency visits to the hospital and all referrals to specialists.
  What Are the Differences Between an HMO and PPO?

The two main  differences between these two managed care plans is the amount of freedom to choose your physicians and hospitals. The benefit structure will also be a key difference between the HMO and PPO in the form of co-insurance rates, co-payments and deductibles. Frankly, there is no one right answer for the question Which One is better, PPO or HMO. 

Here's just a little of what you need to know about the differences between the two:

The HMO or Health Maintenance Organization
1. HMO Members are required to select their PCP (Primary Care Physician) from a list of network providers.
2. The PCP will select the "first-tier" health care provider.
3. He or she will refer to the Specialists when needed.   These specialists will be part of the HMO network.
4. The HMO plan will have only few out-of-pocket health care expenses - as long as your doctors and hospitals are members of the network.
5. Most of the HMO Plans will not require to pay a deductible.
6. Many HMO's don't require you to pay for visiting an in-network doctor.  Small co-payments will be required for office visits.
7. If you receive specialist care without getting a referral from PCP, or if you receive care from a doctor who is not in the HMO network, you may have to pay the entire bill.

The PPO or Preferred Provider Organization
1. PPO Plan Members are free either to use doctors and hospitals from within their PPO's network or to go outside of that network for their healthcare.
2. Referral is not required to visit a specialist healthcare provider
3. You will be responsible for an annual deductible.
4. Certain PPO's will require you to pay a co-payment for each doctor's office visit or health service.
5. If you take care by a medical provider outside your PPO's network, then you'll have to pay more out-of-pocket for their services.   

How to Choose a Managed Care Plan

The following factors should be considered before selecting a Health Plan.

Health Care Providers: You should see whether your provider is part of the HMO or managed care network.  You should find out what other specialists, hospitals, specialized treatment centers are included in the network.   You should see whether the  network includes the specialist, required to provide the care based on your health-conditions.

Services: You should learn about the services covered or non-covered under the plan.    You should also check where the services are offered and whether they are available in your area of the state.  If there are choice of plans, then discuss with your provider and determine which  plan will best suit your needs.

Quality of Service: There are many ways to judge the quality of health plans.    
You can check few main things like
Disenrollment: Is large number of members, groups or physicians leaving the plan?
Member Satisfaction: Are the members satisfied in the plan.
Utilization Review: How frequently the plan review requests for medical services.  And how often these reviews are denied and appealed?
Inspection: When was the last Department Insurance Inspection and how did the plan do on the inspection?
Grievance Reports: What are the other complaints that members have with the plan
Costs: Check and find out how much you will have to pay for care from the different health plans.   To do this, look at the monthly premiums and out-of-pocket costs in the form of deducts, co-insurance, co-payments, covered and excluded services.

How to Choose your Physician

HMOs gives an Opportunity to choose your own Primary Care Physician (PCP).  Most of the HMOs have their PCP listing in the Internet.  If your current PCP is not a participating provider, then you can have this provider enrolled in the network.

Most HMOs require that you select a Family Physician, General pediatrician or general internist as your PCP.   Some HMOs even allows too choose a Nurse Practitioner (NP) or Physician's Assistant (PA) as PCP.   If you do not choose a PCP, Some HMO's will choose one for you.

After Selecting the PCP from the Participating provider List, you need to call and check whether the accept new-patients.    Some-times if the practice is full, new-patients will not be accepted.   You should also know how long will it take to get an appointment for immediate needs as well general-check-ups.   You should learn about the office-working hours.  When you call the physician's office, you will come to know all these details and also know how easy or difficult it is to approach your physician through telephone.

You should also try to get information through your friends and neighbors about a physician's practice.   Check with them how much time does the physician spends with them and how comfortable will it be when talking to a physician.

Once you have selected a PCP, it is important to set up an initial appointment so that you can develop a care plan.  This first appointment will help you to develop a positive long-term relationship with your physician. 

After all these initial checking and selecting a PCP, if you are not satisfied with the services provided by the PCP then you change the PCP.   Most of the HMOs let you switch PCPs at least once a year.   Some Plans allow you to switch whenever you are dissatisfied.   You can check the handbook Evidence of Coverage about the procedures to switch Physicians.

Assuring Coverage for Health Care Services

Health plans does not cover all the health services that you need.   It depends on the plans we have selected.   For example, some plans exclude mental health services or prescription drugs; some pays only for a limited number of physical or occupation visits.  Health Plans are not required to pay for covered services if you fail to obtain a required referral or Prior authorization.   It is very important to always make sure that the plan's requirements are understood and followed.

Appeal and Grievance Procedures

You have the right to appeal your HMO's decision to deny coverage of health care services.   If the HMO denies the coverage, you can first try to resolve the problem informally.  If you cannot resolve the dispute informally, you can file a formal appeal.   Your Evidence of Coverage will describe the HMO's appeal and grievance procedures, including any time limits for filling appeals and where the appeal should be sent. 

By: B Sugan
Ecare India Private Limited
sugan@ecareindia.com
Phone # 91 44 28462846 Ext: 402
www.ecareindia.com