BC Advantage - 2006 Issue 6
UNDERSTANDING MANAGED CARE - HMO's
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Article Overview
This article explains the basic structure of managed care and compares common plan types such as HMOs, PPOs, POS plans, and PCCM programs. It is written for readers trying to understand network use, referrals, coverage limitations, costs, and the practical factors involved in selecting a plan and a primary care physician. The article also touches on coverage review, prior authorization, and the appeal or grievance process.
Why This Topic Matters
Understanding managed care is important for patients, providers, and billing staff because plan structure can affect access, coverage, referrals, and out-of-pocket costs. A clear grasp of these terms helps readers evaluate benefits and avoid surprises when services are obtained inside or outside a plan network.
Article Sections
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What Is Managed Care?
Introduces managed care and describes the major plan categories discussed in the article. It outlines general network-based coverage concepts and plan administration.
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What Are the Differences Between an HMO and PPO?
Compares the two plan types at a high level, focusing on access, cost-sharing, and network use. The section also summarizes major differences in how members interact with providers.
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How to Choose a Managed Care Plan
Reviews broad factors to consider when evaluating plan options, including providers, covered services, quality measures, and costs. It presents a consumer-oriented checklist for plan selection.
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How to Choose your Physician
Discusses selecting and working with a primary care physician within a managed care arrangement. It covers general considerations such as availability, access, and changing physicians.
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Assuring Coverage for Health Care Services
Explains that plan coverage can vary and that authorization requirements may affect whether services are paid. The section emphasizes reviewing plan requirements and coverage limits.
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Appeal and Grievance Procedures
Describes the availability of review processes when a plan denies coverage. It notes the role of plan documentation in outlining appeal and grievance steps.
What You Will Learn
- How managed care is generally structured
- The basic differences among common managed care plan types
- Key considerations when comparing health plans
- How primary care physician selection works in an HMO setting
- What factors can affect whether services are covered
- How appeals and grievances are generally handled under a health plan
Who Should Read This
- Patients and plan members
- Medical office staff
- Billing and coding professionals
- Healthcare administrators
- Anyone comparing health insurance options
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