QUESTIONS YOU SHOULD ASK YOUR MANAGED CARE PLAN

By: Pam Silberman, JD, DrPH and Laura Sutton Elsberg, MSPH

The best way to ensure that your health care needs are met is to take an active role in your own health care. You can improve the care you receive by understanding managed care and how it works, being proactive in your health care, and establishing positive relationships with your providers. Learn all that you can about your health plan choices, the services that are covered or excluded (and any limitations), participating providers, quality, and costs. This document was designed to help you ask the right questions to help you become an informed health care consumer.

Over the last ten years, there has been a significant change in the way that the health care system is financed and delivered. Managed care has slowly gained support as a possible solution for containing costs without sacrificing quality of care. Managed care is a generic term that applies to different types of health care arrangements. Managed care systems typically combine the financing and delivery of health services. They do this by covering some or all of the costs of health care services (financing), while encouraging enrollees to obtain services from the organization’s network of providers (delivery system). There are three primary types of managed care arrangements: Health Maintenance Organizations (HMO), Point-of-Service plans (POS), and preferred provider Organizations (PPO).

• Preferred Provider HMOs have exclusive provider networks and may also use primary care providers as "gatekeepers." Gatekeepers are responsible for arranging the patient’s referral to a specialist or admission to a hospital. enrollees usually can not obtain care from providers that are outside the HMO’s network of providers.
  
• POS plans give the patient the opportunity to see providers outside of the network. Patients who use the HMO network of providers pay less than patients 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.
  
• PPOs seek to manage medical costs by contracting with a network of providers who are willing to accept lower reimbursement rates. In addition, PPOs usually use other methods, such as utilization review, to control unnecessary utilization. Patients can choose any health care provider. But they will have to pay additional money if they use a provider who is not part of the network. PPOs are frequently used by traditional insurance companies.

This document starts with some general advocacy tips, followed by a list of important questions and tips related to the health plan selection process. We recognize that you may not have time to ask every possible question about health care when you are faced with a choice of health care plans. You should tailor the questions to meet address your family’s health care needs.

The questions fall into the following general topic areas:

• Key plan elements
• Selecting a primary care physician
• Access to specialists
• Access to hospitals and specialized treatment centers
• Covered services
• Costs
• Member services
• Appeals and grievances
• Quality assurance
• Provider Payment Systems

Most of the questions listed here can be asked of any type of managed care organization. However, there are some questions that are more appropriately asked of HMOs and point-of-service plans. For example, questions dealing with the adequacy of the provider network are most important for HMOs that limit providers to the HMO network. Similarly, questions about a health plan’s referral process are most appropriate for HMOs and POS that require the primary care provider (PCP) to refer the member to specialists or other services. We have tried to indicate the questions that have more limited applicability by listing the type of managed care system in parenthesis.

REMEMBER, you are your best advocate: be an educated consumer!

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