When Is It Best To Buy A Managed Health Care Insurance Plan?
Health insurance plans today is broadly divided between traditional indemnity health insurance plans (which tend to be quite expensive) and managed health care insurance plans (which tend to be somewhat more affordable). The most well known form of managed care plan is that provided by the Health Maintenance Organizations (HMOs) which are designed to give you a reasonable level of medical care at a relatively low price.
For most of us the idea of being able to get medical care at a relatively low price is attractive, however, this can be very much a case of you "get what you pay for" and, unless you buy a managed care plan with both of your eyes wide open, you could well be disappointed by the quality of the care which you receive.
Managed care operates by tightly controlling costs and this means controlling access to care. Health maintenance organizations are networks of health care facilities whose services are contracted to the HMOs for an agreed fee.
Although it would seem logical that the term managed health care would mean that health care is managed, in fact it is often more a case of plan holders being managed, as they are normally required to seek their health care from within the HMO’s network and access to this health care is controlled by a single doctor to whom the patient is assigned. This frequently means that a patient's choice is severely limited and that a plan holder may have to join a waiting list for treatment.
In some limited circumstances plan holders will be allowed to seek treatment outside of the network but, when this happens, the HMO will usually require the plan holder to pay any costs which are considered to be above those which the HMO considers reasonable and customary for the treatment in question.
So, against this background, why would anyone choose a managed health care plan in preference to an indemnity health insurance plan, other than for reasons of mere cost?
The principle difference between indemnity health insurance and the managed care model is to be found in the cover provided. Indemnity health insurance is designed to cover the plan holder against unexpected, and frequently extremely high, medical bills arising out of an accident or serious illness. Managed care by contrast aims at providing preventative care and focuses its attention on keeping plan holders healthy by helping with the costs of routine medical care including such things as check-ups and vaccinations.
Obviously there are many situations in which one type of insurance would be more suitable than another. For example, if you are married and have a young and growing family then you may feel that focusing your attention on preventative medicine, particularly for your children, would make a managed care plan a good choice.
Conflict of interest: For an MCO board member, a conflict between self-interest and the best interests of the plan.
Edits: Criteria that, if unmet, will cause an automated claims processing sys- tem to "kick out" a claim for further investigation.
Prior authorization: In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical-necessity review.
Quality management (QM): An organization-wide process of measur-ing and improving the quality of the health care provided by an MCO.
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