Tip: This is important because knowing the type of plan you are in will give you an idea of how much flexibility and control you have over the providers you can see and the types of services you receive.

Tip: While most HMOs require primary care providers to coordinate patients’ care ("gatekeepers"), some HMOs have open access plans. These plans allow the patient to choose any PCP or specialist in the network without a referral.

Tip: Some health plans allow members to seek care from non-network providers–often at an increased cost (e.g., POS, PPO. HMOs on the other hand, generally require that you obtain your care from a network provider (with limited exceptions). If the plan allows you to seek care from non-network providers, find out if there are any restrictions or additional costs.

Tip: Clinical protocols are guidelines a managed care plan uses in deciding whether a person with your condition should receive certain health care services or treatments. These will help you anticipate how a particular condition may be treated by the managed care plan as well as assist you with an appeal and/or grievance. Managed care plans are required upon request to give you a copy of their clinical protocols or utilization review criteria. If you don’t understand what it means, ask a health care professional who you trust to help you decide if the guidelines are adequate to meet your health care needs.