What is a managed care plan?
A managed care plan is an insurance plan where the insurance carrier has contracted with certain providers to provide care to enrolled members at a reduced rate based on volume. There are different types of managed care plans offering a wide selection of benefit designs and degree of freedom.
An HMO (Health Maintenance Organization) is the most restrictive type of managed care plan. Members are usually required to select a primary care physician, and receive a referral from that physician if other services are needed. In addition, claims will not be paid if the member uses a provider that is not contracted with the HMO. An open-choice HMO (like the plan offered by United HealthCare) allows members to choose freely from a list of contracted providers and to receive benefits from a non-contracted provider for a reduction in benefits.
A POS plan usually requires that members choose a primary care physician and receive a referral from that physician if other services are needed. In addition, members are allowed to receive services from a non-contracted provider for a reduction in benefits.
A PPO plan is usually not as rich in benefits, but offers more freedom to members. Members in a PPO must use a contracted provider to receive the highest level of benefits but never have to select a primary care physician or gain a referral. Members always have access to non-contracted providers.
What is the difference between “In-network” and “Out-of-Network” services?
In-network services are covered services which are provided or authorized by a contracted provider. Out-of-network services refer to services which are not provided or authorized by a network provider. It is important to note that for out-of-network services, you will be required to pay the difference between the billed charges and allowable charges.
What is the HIPAA law?
The Health Insurance Portability and Accountability Act (HIPPA) was signed into law on August 21, 1996. This law requires all group insurance carriers to accept every eligible individual without regard to health status for groups with 2 – 50 employees. The carrier can impose a 12 month penalty for pre-existing conditions if the member has not had 18 months worth of prior coverage without a 63 day gap in coverage. If the employee and dependents can supply proof of at least 18 months of prior coverage via one or more certificates of creditable coverage from carriers, all pre-existing conditions must be covered by the carrier.
It is important to note that the pre-existing condition exclusions have been eliminated for pregnancy. A pre-existing condition limitation cannot be applied for a newborn, an adopted child or a child placed for adoption under the age of 18 if the individual becomes covered under creditable coverage within 30 days of birth, adoption, or placement of adoption.
What is the COBRA law?
The Consolidated Omnibus Budget Reconciliation Act (COBRA) was passed in 1985. This law requires employers that have at least 20 employees and provide an employee health plan to offer identical coverage to covered employees or qualified beneficiaries if coverage is lost due to certain qualifying events.
If group health coverage will end when an employee is terminated or hours of work are reduced, the covered employee and qualified beneficiaries must be given the option of electing COBRA continuation coverage for up to 18 months. This 18 month continuation period can be extended under certain circumstances if a covered family member is determined to be disabled for Social Security purposes at any time during the first 60 days of COBRA coverage. When the qualifying event is the employee’s death, divorce, legal separation, or Medicare entitlement; or loss of dependency status; either initially or subsequent to an 18-month event, the qualified beneficiary must be allowed to elect COBRA coverage for up to a maximum of 36 months from the first qualifying event.
My employer has less than 20 employees. Can I continue my coverage after my termination?
Yes. There is a state law that addresses continuation of coverage for employers with less than 20 employees. This law (#23-86-114) allows covered individuals to continue group coverage for a maximum of 120 days.
What do I do if I have an emergency and am enrolled on a managed healthcare plan?
Members are covered world-wide for life and limb threatening emergencies. Members should go to the nearest medical facility for care. Present your insurance identification card. Once your condition is stable, call your health insurance company and your primary care physician within 24 hours. Examples of emergencies when you should seek immediate attention include: heart attack, uncontrollable bleeding, broken bones, poisoning, unconsciousness, etc.
What should I do if I have a non-emergency after regular physician office hours?
Many health insurance plans including United HealthCare and Qual-Choice offer a 24-hour nurse line where you can call and discuss your illness with a registered nurse 24 hours a day. The number for this service will be listed on the back of your insurance card. If your health plan does not offer this service, call your primary care physician or the physician on call. He or she will instruct you on what to do. Remember to use a contracted network provider for all services in a non-emergency. Examples of non-emergencies when your Primary Care Physician should be contacted include: vomiting, diarrhea, sore throat, minor burns, earaches, rashes, etc.
What is a prescription drug formulary?
Many carriers are now offering members a three-tier drug copay option. This program allows members to receive generic prescriptions at a much lower copay. However, for prescription drugs that do not have a generic alternative, a formulary (or list) of preferred name brand drugs that are covered is offered. This formulary is different for each insurance carrier. Brand name drugs not listed on the formulary are covered by most carriers, but for a much higher co-payment.
What if I lose my I.D. card?
Contact our office or your carrier’s member service department. You should receive a new card within seven to ten days at your home address. Until you receive your card, our office can assist you.
How is your agency paid?
In most all cases, carriers charge the same monthly premium if you use an outside consultant or agent. Therefore, our service fee is automatically built into the proposed monthly premium and we are paid by the insurance carrier. Our staff provides on-going employee education, assistance with claims issues, billing issues, enrollment issues, and a full market evaluation each year at renewal. Most importantly, we provide prompt, accurate responses to your questions. We will be here when you need us.
What is the best health plan for me?
Choosing a health plan can be a confusing experience. Although there is no one “best” plan, there are some plans that will be better than others for you and your family’s health needs. We will try to guide you in simple terms. However, rather than just giving you answers, the best thing we can do is to make sure you are equipped with the right questions.
There are three major things to consider, each with their own unique set of questions. By considering the questions thoroughly, you will arrive at the right plan for you and your family.
How affordable is the cost of health care?
- How much will it cost me on a monthly basis?
- Should I try to insure just major medical expenses or most of my medical expenses?
- Can I afford a policy that at least covers my children?
- Are there deductibles I must pay before the insurance begins to help cover my costs?
- After I have met the deductible, what part of my costs are paid by the plan?
- If I use doctors outside a plan’s network, how much more will I pay to get care?
- How often do I visit the doctor and how much do I have to pay at each visit?
Do the included services match my needs (access of care)?
- What doctors, hospitals, and other medical providers are part of the plan?
- Are there enough of the kinds of doctors I want to see?
- Where will I go for care? Are these places near where I work or live?
- Do I need to get permission before I see a medical specialist?
- Are there any limits to how much I must pay in case of a major illness?
- Is the prescription medication which I need covered by the plan?
- Does the plan cover the expenses of delivering a baby?
Have people had good results when covered by a specific plan (quality of care)?
- How do independent government organizations rate the different plans?
- What do my friends say about their experience with a specific plan?
- What does my doctor say about their experience with a specific plan?
