COSTS

QUESTIONS TO ASK
YOUR PLAN:
PEOPLE WITH SPECIAL HEALTH NEEDS

General Information
about Managed Care
Advocacy Tips
Key Plan Elements
Selecting a Primary
Care Physician
Access to Specialists
Access to Hospitals and Specialized
Treatment Centers
Covered Services
Costs
Appeal and Grievance
Member Services
Quality Assurances
Provider Payment Systems
Glossary

INDEX

UNDERSTANDING
MANAGED CARE

CONSUMER PROTECTIONS

MEMBER RESPONSIBILITIES

QUESTIONS TO
ASK YOUR PLAN

QUESTIONS TO
ASK YOUR PLAN:
PEOPLE WITH
SPECIAL HEALTH NEEDS

BACKGROUND
INFORMATION: NC HMOS

HOW TO INTERPRET
THE INFORMATION

HMO COVERAGE OF SPECIFIC SERVICES

COMMON EXCLUSIONS

ENROLLMENT TRENDS

DISENROLLMENT TRENDS

UTILIZATION REVIEW INFORMATION

FINANCIAL DATA

GLOSSARY

INTERNET RESOURCES

INTERNET RESOURCES:
INDIVIDUALS WITH DISABILITIES

STATE FUNDED HEALTH PROGRAMS FOR
YOUNG CHILDREN
AND THEIR FAMILIES

NC DEPARTMENT
OF INSURANCE

NC STATE EMPLOYEES
HEALTH PLAN

NC DEPARTMENT OF MEDICAL
ASSISTANCE (MEDICAID)

NC HEALTHCHOICE

NC COUNCIL ON DEVELOPMENTAL
DISABILITIES

MEDICARE

YOUR COMMENTS

NORTH CAROLINA
INSTITUTE OF MEDICINE

COSTS

• What is the monthly premium for the managed care plan? For an individual? For a parent with child(ren)? For a couple? For a family?

• Are there any cost sharing requirements (such as co-payments or deductibles)?

• Does the health plan have an individual or family out-of-pocket limit?

Tip: The individual out-of-pocket limit is the maximum that you will be required to pay in copayments and other cost sharing for covered services. The family out-of-pocket limit is the maximum that your family will have to pay for copayments or coinsurance. Once you or your family reaches the out-of-pocket limit, the health plan will pay 100% of the costs of covered services.

• Does the health plan have annual or lifetime limits for covered services?

Tip: Some health plans have annual or lifetime limits, which is the maximum amount they will pay for health care services in a particular year or over the lifetime of the individual. Other plans have annual or lifetime limits for specific services. It is important to find out if the health plan has any maximum limit on covered services.

RETURN TO HOMEPAGE