Tips
to Remember:
Guide to Health Care Plans
December 1998
Constant changes in health care may make it more 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 that
should not be taken away because they are sick or have a
pre-existing condition.
Managed care plans are designed to provide health care to all
members at a relatively low cost. One basic component of managed
care plans is the notion that your primary care provider (PCP) can
effectively treat almost all of your medical needs. However,
studies have shown that patients with asthma or allergies
experience a better outcome when their care is directed by an
allergist/immunologist. The best medical care for many people with
asthma and allergy involves a team approach by a PCP and an
allergist/immunologist.
Potential challenges of a managed care plan may include:
- being restricted to physicians who are chosen by the plan;
- being denied certain medical devices or medications;
- having a PCP limit your access to the allergist/immunologist
or other specialists;
- being penalized for pre-existing health conditions.
Types of managed care
Risk Contracted Individual Practice Association (IPA)—Physicians
are prepaid a monthly capitation, which is a fixed amount per
enrolled member. The physician receives the same rate whether
members see the doctor that month or not. A co-payment from
patients may be required in some cases.
Group Model Health Maintenance Organization—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 Health Maintenance Organization—An HMO
contracts with several physician groups. Physicians that may share
in savings but also may provide care to other patients who are
non-HMO members.
Staff Model Health Maintenance Organization—A form of an
HMO in which physicians are employees of the HMO.
Preferred Provider Organization (PPO)—An HMO or other
managed care organization contracts with a selected group of
physicians who agree to abide by a certain reimbursement and
payment structure. Patients may be able to see a physician outside
of the PPO structure, but usually must pay higher co-payments or
deductibles in order to receive that care.
Point of Service Option—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.
In many plans, patients must first be seen by a PCP who acts as
a gatekeeper, deciding whether or not the patient can see a
specialist.
What you should know
So, what does managed care mean to you and your family?
Your freedom to choose an allergy/immunology specialist may be
curtailed or denied, or you may have difficulty obtaining such
medical aids as a peak flow meter, home nebulizer, skin tests, or
allergy shots. Additionally, you may have difficulty getting a
particular medication that works best for your condition, such as
a prescribed bronchodilator, anti-inflammatory medications,
self-administered adrenaline, antihistamines or gamma globulin.
When choosing a health care plan, make sure to ask the
appropriate questions. Ask your employer to provide materials that
can help you make this important decision. Identify coverages,
effective dates, co-payments, deductibles, pre-existing condition
limitations, point-of-service options—including the additional
amount you will be expected to pay, limitations on devices or
drugs, and access to an allergist/immunologist or other
specialists.
Take time to study the plan, and 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
least expensive plan may end up costing 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 denial
of referral to a specialist if you feel the decision 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
allergist/immunologist or other specialist of your choice, who may
not be a part of your health care plan.
Taking action
What can you do if you cannot see the physician who can
best treat your condition, or receive a prescription for the
specific drug that works best? Managed health care plans are
driven by customer satisfaction as well as costs. To remain
competitive, the insurance company 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, you should contact the customer service
department for the plan at the company’s main office.
However, the employee benefits manager at your workplace will
be your strongest ally. Managed care organizations listen to
employers, as they compete to be health plan carriers for
businesses. If your problem is still not resolved to your
satisfaction, you may contact the Insurance Commissioner’s
office in your state capital. Sufficient demands from health care
consumers can increase accessibility to appropriate care without
raising premiums.
Helpful terms
Allergist/immunologist—A physician who has
completed specialty training in pediatrics or internal medicine,
and has elected at least two additional years of training in the
diagnosis and treatment of allergic and immunologic diseases.
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 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 health care which must be
paid by the patient before insurance coverage applies.
Direct access—Patients may consult the specialists of
their choice for a specific medical problem without being required
to obtain prior approval of the gatekeeper.
Fee-for-service—Traditional health care payment
system under which providers receive a fee for each service
rendered.
Formulary—Prescription medications that have been
approved 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 or 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.
Managed care—A health care insurance plan designed to
provide high quality care at low cost. This care includes a
detailed plan with a set of rules to be followed by the patient.
Point of service—Allows patients to see their
personal doctors who may not be a part of the insurance network.
The doctor may be compensated at a lower rate and the patient may
be charged a portion of the cost.
Pre-existing condition—An illness, disease or
condition that an individual has at the time of enrollment in a
health care plan.
Primary care provider (PCP)—A generalist physician
such as a pediatrician, internist or family physician.
Your allergist/immunologist can provide you with
more information on health care plans.
The content of this brochure is for
informational purposes only. It is not intended to replace
evaluation by a physician. If you have questions or medical
concerns, please contact your allergist/immunologist.
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