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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(Point-of-Service) 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(Preferred Provider Organization) 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. Return to Frequently Asked Questions |
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