The term managed care refers to a team of activities designed to lower the costs of providing health care and yet delivering high-quality American health care while improving the overall quality of the care. The ultimate goal is to provide optimal health care at an affordable price, using the greatest possible resource mix. Managed care plans fall into a number of categories, including:
Managed care plans are generally supported by health insurance companies, though they sometimes provide their own doctors and specialists. Most Managed care plans focus on keeping health costs down by contracting with health care providers who provide the least expensive services. Managed care providers participate in a network, so when one person in the network requires specialized treatment, the provider making the call gets payment. This form of “networkship” allows managed care plans to offer more options and coverage than health insurance companies alone could do.
There are several different types of managed care plans, including: fee-for-service; fee-for-service plus managed care plans; and Medicare Advantage, also known as Medigap. Fee-for-service plans are generally the most common type of managed care plan in the United States. These allow the health care provider to set the amount they are paid for services and the types of services covered. The health care provider and the insurance company jointly agree on a dollar amount for each service. Some managed care plans allow a choice of out-of-network doctors, although Medicare does not.
Managed care plans may also include hospitals within the managed care plan's network. This provides the added benefit of skilled doctors and the ability to treat more patients. Many health insurance plans limit the number of hospitals, a patient can see under their health plan, which limits the freedom of the patient in terms of where they receive their care. Health care providers and health insurance companies use these limits as part of their marketing strategy.
Part D and Health Insurance: Managed care plans also cover many other extended health care benefits, including: prescription drugs, dental plans, hearing aids, vision care, hospital rooms, and physician visits. The U.S. Department of Health and Human Services (HHS) recommends that all individuals who are 55 or over receive coverage through a managed care plan. Most health insurance providers offer some or all of these extended health care benefits, so it is not always necessary to purchase additional health insurance to meet extended health care needs.
When choosing a managed care policy, it is important that you choose one that gives you the freedom to select the healthcare providers and physicians that meet most of your personal healthcare needs. It is also important that you get a health insurance plan that pays the agreed upon amount (based on the family's income and medical history) at the time of service instead of a payment that is made after the service has taken place. Your health insurance provider should be able to give you the paperwork you need to legally claim the services as being medically necessary. If you do not have a primary care physician or you are not receiving routine medical exams, your provider may refer you to a hospital for care, which can mean an additional cost. Therefore, if you have had a prior health crisis, you may want to take control of your medical care by immediately contacting your primary care physician or any other doctor, as soon as possible, in order to prevent medical bills from accumulating.
Some managed health care providers provide a health management program, also known as a PPO, to their clients. With this type of managed health care, your health care providers select the medical professionals to participate in your managed health care plan's managed care plan. Your PPO would likely require annual or bi-annual wellness check-ups and a referral from your primary care physician. However, the cost for this type of managed health care would likely be significantly less than what you would pay for routine medical exams and care.
If you do not already have a primary care physician, it is important to choose one before enrolling in a managed care plan. By doing so, you would ensure that you receive routine medical care and that you would always have an opportunity to see a specialist if needed. By choosing a primary care physician, you would also reduce the number of medical visits to hospitals, doctors offices, and specialists. In addition, your primary care physician could recommend an individual health trainer, a dietitian, and even a home health aide to accompany you in your everyday activities. If your health is already very good, you would also reduce your monthly premiums because you would get more years of low-cost coverage. Make sure to talk with your primary care physician for more information about enrolling in a managed care plan today.