Tip #26
CONSUMER GUIDE
TO HEALTH CARE PLANS

As a health care consumer, the rapid changes in health care may have made it difficult for you to know how to make the best choices for you and your family. Many Americans feel that health care is a right -- a right which should not be taken away because they are sick or have a pre-existing condition. The American Academy of Allergy, Asthma and Immunology is also very concerned about this changing climate.

One of the basic components of the managed care plan is the notion that your primary care provider (PCP) can effectively treat almost all of your medical needs. However, PCPs are not always trained to treat specialized problems in the same way that medical specialists, such as the allergist/immunologist, are trained. The best medical care for many people involves a team approach by a PCP and a specialist.

Potential Challenges of Managed Care
Managed care is designed to provide quality health care at a lower cost. However, possible difficulties include:

Types of Managed Care
Individual Practice Associations (IPAs) - Physicians are prepaid a capitation rate by a managed care organization on a monthly basis for service to members. The physician receives the same rate whether members see the doctor that month or not. A co-payment for patients may be required in some cases.

Group Model HMO - An HMO contracts with a group of physicians to provide health care services. Physicians continue to practice in their own offices, but pool and distribute income based on an agreed-upon plan.

Network Model HMO - An HMO contracts with several physician groups and physicians that may share in savings but also may provide care to other patients who are non-HMO members.

Staff Model HMO - A form of an HMO in which physicians are employees of the HMO.

Preferred Provider Organization (PPO) - An HMO contracts with a selected group of physicians who agree to abide by a certain reimbursement and payment structure. You may be able to see a physician outside of the PPO structure, but you usually must pay co-payments or deductibles in order to receive that care.

Patients seeking treatment from a non-participating health care provider may be allowed to do so on approval if they are willing to pay a fee for the service in addition to the usual premium (often called a point of service option).

In many plans, patients must first be seen by a PCP who acts as a gatekeeper who decides whether or not a patient can see a specialist.

What Does Managed Care Mean to Me and My Family?
Managed care may mean:

What Questions Should I Ask When Choosing a Health Care Plan?
Ask your employer to provide materials that can help you make this important decision. Identify coverages, effective dates, co-payments, deductibles, preexisting condition limitations, point-of-service options including the additional amount you will be expected to pay, limitations on devices, drugs, and access to an allergist/immunologist or other specialists.

Take the time to study the plan. Do not sign up for a plan until you are satisfied that it is the best one for you and your family. Try to plan for and consider unforeseen medical needs. The cheapest plan may cost you and your family more in the long run.

You should be able to review a list of participating physicians, covered services, formulary lists (medicines), and other rules before you sign up for a plan. This includes information about your right to contest the gatekeeper's decision on referral to an allergist/immunologist or other specialists if you feel that this is not in the best health interests of you or your family. Request information about the point-of-service option which will allow you to see the doctor or allergist/immunologist of your choice, who may not be a part of your health care plan.

What Can I Do If I Cannot See the Physician Who Can Best Treat My Condition or Receive a Prescription for the Specific Drug Which Works Best for Me?
Managed health care plans are driven by customer satisfaction as well as costs. In order for the insurance company to remain competitive, it must achieve the reputation of taking good care of its members. If you have difficulty seeing the physician of your choice or if you are dissatisfied with any part of your health care, contact the customer service representative for the plan. This individual may be reached by calling the main office of the health care plan.

What If I Have a Problem with My Managed Care Plan and Am Dissatisfied with Their Answers?
If your medical insurance is provided through your employer, talk to the personnel or benefits manager at work. Managed care organizations often listen to employers as they compete to be the health plan carriers for businesses. If your problem is still not resolved to your satisfaction, contact the Insurance Commissioner's Office in your state capitol. Remember that sufficient demands from consumers can increase accessibility to appropriate specialist care without raising premiums.

Helpful Terms to Know

Allergy/Immunology Specialist - A physician who has completed specialty training in the diagnosis and treatment of asthma and allergic and immunologic diseases in addition to general medical training.

Capitation - Method of reimbursement in which a physician is paid a fixed amount of money per each member enrolled in a health care plan.

Co-payment - A fixed dollar amount paid by the patient at the time services are rendered. Typical co-payments are for office visits, prescriptions, or hospitalizations.

Deductible - The portion of your health care which must be paid by the patient before insurance coverage applies.

Direct access - Situation in which a patient may consult a specialist of their choice for a specific medical problem without the requirement of obtaining prior approval of the gatekeeper.

Fee-for-service - Traditional health care payment system under which providers receive a fee for each service rendered.

Formulary - Medications which have been chosen by a particular health care plan for its enrollees.

Gatekeeper - The primary care physician or other provider whom a patient must see for all initial medical visits. For referrals to all specialists, diagnostic, therapeutic, or hospital services, the patient must see the gatekeeper first.

Health Care Payers - Insurance companies, hospitals, some physician groups, and employers who are responsible for paying the cost of health care for enrollees.

HMO - Health Maintenance Organization.

Managed Care - A health care insurance plan which is designed to provide high quality care at the lowest cost possible. This includes a detailed plan with a set of rules to be followed by the patient.

Point of Service - Will allow you to see your personal doctor or allergist/immunologist who may not be a part of your insurance network; the doctor may be compensated at a lower rate and the patient may be charged a portion of the expense.

Preexisting condition - An illness, disease, or condition which an individual has at the time of enrollment in a health care plan.

Primary Care Provider (PCP) - A generalist physician -- pediatrician, internist or family physician.

Your allergist can provide you with more information on your health care options related to allergies and asthma.

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