At divorce, if you are the dependent spouse and are looking at health coverage options, you need to know the difference between traditional insurance and managed care plans that may be available.
If you are covered by traditional fee-for-service insurance, you are free to choose any doctor and to use any hospital or other health care facility to provide services covered by your policy. People with traditional health insurance find that the payment of premiums are only one part of the cost structure since they also must pay deductibles, coinsurance, and the cost of services that are not covered by the policy, such as physicals. In short, traditional Indemnity plans means you have unrestricted choice of providers, but preventive care is usually not covered. There are claim forms to file, and these plans are generally more expensive than managed care plans. There is little, if any care coordination.
But if you are enrolled in a managed care program, your care will either be provided by or authorized by the plan. You will be given the opportunity to choose your primary care physician from a list made available by the plan. If you don't choose, the plan will assign a doctor to you. The majority of plans allow you to change your primary care physician. And with managed care plans, the out-of-pocket costs are generally lower, and there is far less paperwork for enrollees to contend with. If you enroll in a Medicare managed care plan, you will not need a Medigap policy.
There are several types of managed care plans:
The HMO Staff Model is a centralized facility where care is provided and coordinated. Your copayments are low, there is preventive care available, and you will not have to be bothered with claim forms. However, you will be required to use doctors who are in the HMO, and your plan will be required to approve treatment and make referrals.
The HMO Individual Practice Association (IPA) is a managed care plan where health care providers use their own offices and are not part of a centralized facility. Your copayments will be low, you will be able to receive preventive care, and there will be no claim forms; however, you will be required to use physicians from a designated list and the plan must first approve treatment and make referrals.
HMO Point of Service (POS) will allow you to receive preventive care, will not bothered you with claim forms, and will be low in cost so long as you stay within the network. However, if it is necessary for your to go outside the network, you will face higher costs, and the plan must approve treatment and make referrals. Treatment outside of the network may be severely limited.
Preferred Provider Organization (PPO) gives you a choice of staying inside or going out of network for care. Your costs will be lower if you use providers within the network, while there will be a higher cost outside the network -- not to mention additional paperwork to get approval for some services. Coordination of care is limited.
That's why, if you are part of a managed care plan, choosing a primary care physician is important because he or she will become your personal doctor, will coordinate your care, and will act as a "gatekeeper" -- that is, will either treat you directly or authorize you to have tests, see a specialist, or enter a hospital. Managed care plans use the gatekeeper arrangement to provide necessary care at the lowest cost and to avoid giving unnecessary care.
Doctors who practice under traditional health insurance plans are independent and are not assessed by their peers or by government regulators. On the other hand, managed care plans generally have internal and/or external quality review procedures. And those managed care plans that are federally qualified or provide health care to Medicare recipients require quality assurance programs.
Today, a large number of states have similar requirements, meaning that overall plan performance is monitored by use of government oversight, patient surveys, grievance procedure data, and other types of independent reviews.
To cope with the expansion of managed care, both the federal government and private quality assurance organizations are developing more ways to measure the quality of care provided by managed care and to then communicate that information to consumers who will then be able to use that information to make informed health care choices.
In addition to quality control, managed care plans use what is called "utilization review" -- that is, a review of the medical care which is proposed by your physicians in order to determine whether or not the course of care is appropriate and necessary. Your primary care physician is an important part of the utilization review procedure, and when hospital care is suggested, the following are used as part of the utilization review process:
Preadmission Certification which is advance approval for care. Without this, a managed care plan may not pay for non-emergency services.
Concurrent Review is the monitoring of your hospital stay by the plan to make sure that the stay is not longer than needed and that all tests and procedures ordered for you are medically necessary.
Discharge Planning helps arrange post-hospital care -- such as nursing home or home health or rehabilitation -- to keep your hospital stay as short as appropriate.
Case Management includes the development of care plans are for those complicated cases in order to make sure that your care is not only coordinated, but also provided in the most cost-effective manner. This could include 24-hour home care instead of an expensive hospital stay.
Second Surgical Opinions are generally required before elective surgery. In this procedure, the second physician may be asked to judge whether the surgery is necessary and to give an opinion about the most cost-effective and appropriate place to do the surgery -- such as in the hospital, at an outpatient clinic, or at a doctor's office.
Some managed care plans have what are known as "gag clauses" in the contracts they have with their doctors. These clauses prevent doctors under contract with the plan from discussing with the patient all of the treatment options, whether covered by the plan or not. This type of non-disclosure has come under fire, and some states have passed laws that prevent managed care plans from using these clauses.
A number of managed care plans give gatekeeper physicians certain financial incentives to keep them from making unnecessary referrals to specialists; however, since these incentives could discourage doctors in the network from providing needed care, it is imperative that these plans be monitored by outside organizations to make sure that those enrolled receive the care they need. For example, Medicare managed care plans are monitored by HCFA, the Health Care Financing Administration.
© 1997 Flying Solo
