Managed Care

Managed care health insurance plans involve a group of medical providers that offer comprehensive medical services.

In some managed care plans a primary care physician or gatekeeper is chosen by the patient from a list provided by the plan. There may be no primary care physician requirement in some managed care plans.

There are basically three managed care options:

• a Health Maintenance Organization or HMO
• a Preferred Provider Organization or PPO
• a Point of Service feature or POS

The HMO Plan

Typically, HMOs have two recognizable features. First, a provision usually exists for you to select a primary care physician from the plan's list of medical service providers. This physician usually coordinates your care, and, therefore, will see you first. If necessary, your primary care physician will refer you to a specialist. There is usually no deductible when this provision is followed. Secondly, in an HMO, emphasis is usually placed by the plan on preventive care through routine checkups and health screenings. These may be available for a flat out-of-pocket fee, also referred to as a co-payment.

The PPO Plan

PPOs are formed to provide a large medical care network that offers its services to insured members for a set fee an allowable charge. PPO members receive a list from which they choose medical care providers. A gatekeeper is usually not required. A PPO generally allows its members to receive care outside its network of providers, although usually at a somewhat higher cost.

The POS Feature

Some HMOs offer a feature in their plans called point of service (POS.) A POS may allow you:

• to select a non-network provider and/or
• to receive coverage for some preventive care services (see POS in comparison chart.)

Typically, however, using this option could result in higher costs.