Helen has been seeing the same doctor for years. Her doctor is a gem: a good listener, kind, patient, and up-to-date on current medical literature. He knows her medical history well and gives her helpful ideas about how to take care of her health. She doesn't want to change doctors. But Helen has just started a new job that offers health care through a different managed care plan.
Her new plan may have different rules and Helen isn't sure she is going to be able to keep seeing her doctor. She has so many questions, but most of all she wants to make sure she can keep getting the best medical care possible.
Sound familiar? Many people have faced this situation over the last ten years. In the United States, our health care system has changed greatly. We have moved away from traditional fee-for-service health care to managed care. This change came about, in part, because of high health care costs. In fact, most people who are under 65 get their health insurance through a managed care plan.
What is Managed Care?
In managed care, insurance companies contract with doctors and hospitals to provide health care services. If you get your managed care health insurance through your job, as many people do, your employer pays the managed care plan a set amount of money in advance to pay for all your health care. You pay only a small amount called a copayment.
In most managed care plans, you choose doctors or hospitals from the plan's network. Some managed care plans will let you see doctors outside the plan, but you may pay more. You also usually must get the plan's okay before you can be admitted to the hospital or see a specialist.
These changes in the health care system mean that you need to be active and learn about your managed care plan to get the best care possible.
Types of Managed Care Plans
There are many kinds of managed care plans. You've probably heard of the most common plans: health maintenance organizations (HMOs) and preferred provider organizations (PPOs). As the health care system continues to change, so may the types of managed care plans. The most important thing to know about your plan are the rules and how they apply to you.
You can join a managed care plan through your employer's health benefits program or as an individual by buying your own insurance policy.
Once you join a plan, you are called a "member" of that plan. Each plan has rules you need to follow. In some plans, such as HMOs, you can usually only see doctors that are part of their "network," or group. In other plans, such as PPOs, you may be able to see doctors outside their network but you usually pay more.
If you want more detail about these plans, see articles in the Medicare section of this site.
Four Key Things to Know
- The best managed care plans focus on keeping you well or keeping a chronic condition under control. The plans encourage you to eat right, get lots of exercise, and use your prevention benefits to find an illness early.
- Managed care plans are businesses. When you get sick, the plans try to keep health care costs low. For example, they might not pay for the latest or highest-cost treatment if they believe a less costly treatment will work just as well.
- You need to play an active role in your health care. This means you will need to be a partner with your plan and doctor, working closely with them to get the best health care.
- You need to stand up for yourself. Be ready to appeal a plan's decision if it denies or stops treatment you feel you need.
AARP Resources
Managed Care Enrollees Gain Ground
AARP reports on how states are protecting people in managed care plans.
Additional Resources
U.S. Agency for Healthcare Research and Quality (AHRQ)
Read “Checkup on Health Insurance Choices” and “Choosing and Using a Health Plan,” from this federal agency.
HealthCareCoach.com
Learn the basics about HMOs and PPOs.
