Frequently Asked Questions About Managed Care
How does managed care work?
Managed care is designed to keep down the cost of healthcare by coordinating your care through a Primary Care Physician (PCP) who manages your healthcare needs.
What is a primary care physician?
When you join a health plan, the plan will provide you with a list of Physicians from which you can choose your PCP. The PCP is the person you will go to first when you need medical attention. For example, your PCP could be a Pediatrician, General Practitioner, and in some cases an Obstetrician/Gynecologist. Your primary care physician conducts your history and physical examination, provides immunizations, coordinates consults, diagnostic screening, tests and provides preventative care. In an emergency, you should dial 911 or go to the nearest emergency room.
How do I select my primary care physician?
You must pick a physician who is part of your plan’s network. You can call your health plan for help in choosing a PCP (the phone number is on the back of your insurance card), look in your health plan’s provider directory, or access your health plan’s directory online through your plan’s website.
How do I see a specialist?
For most plans, you will need a referral from your PCP. If you go to a specialist without a referral, the plan may not pay for the service provided and you may be financially responsible for the charges. Please check the policies and your benefit plan to understand your Health Plan’s requirements.
For more information on your insurance plan call the phone number on the back of your insurance card or refer to the manual provided to you by your insurance carrier.
What is the difference between an HMO and PPO?
Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) are both forms of managed care. There are differences between the structures of each, but they are typically not important to the average consumer. However, several other important distinctions exist, including the following:
- HMO members must choose a primary care physician (PCP) from among the HMO network’s contracted physicians. The PCP provides general medical care and must be consulted before you can see a specialist, who must also be part of the HMO. Non-gatekeeper HMO plans are available through some managed care organizations. The non-gatekeeper plan requires members to select a PCP but allows members to self refer for specialty coverage. If you are not aware which plan you have, you can call your plan at the number on the back of your card. PPO members do not choose a primary care physician and can refer themselves to specialists.
- HMOs typically provide no coverage for care received from non-network physicians (with exceptions for emergency care while traveling, etc.), unless you have enrolled in a Point of Service Plan, which allows access, at additional out of pocket costs, to physicians who are not in the plan’s network. Point of Service Plans have deductibles and coinsurances that are applied when out of network providers are accessed. The amount of the deductible and the percentage of the coinsurance varies by plan. If you are enrolled in a Point of Service Plan and have questions on your out of pocket costs, contact your plan by calling the number on the back of your card. PPO members are not required to stay within the PPO network, but there is usually a strong financial incentive to do so. For example, the PPO may reimburse 90 percent of costs for care received within the network, but only 70 percent of costs for non-network care.
- HMOs typically do not set deductibles that must be met before insurance benefits begin (e.g., $15 or $20). Instead, HMO members often pay a nominal co-payment for care. In contrast, PPOs sometimes require members to meet a deductible (especially for hospitalization) and may have larger co-payments than HMOs.
So, which is better?
Of course, there isn't one right answer; the best choice depends on your particular needs. If you are fortunate enough to have a choice between HMO and PPO coverage, you will need to take some time to evaluate the coverage offered by each and determine which one best suits the needs of yourself and your family.
As a consumer are there any regulatory agencies I can call if I’m having problems with my health insurance plan?
Yes, below is list of contacts you can call if you are having problems with your health insurance plan.
- New York State Department of Health – for problems related to the quality of healthcare including issues such as difficulties related to getting a referral to a provider or for the care needed call 1-800-206-8125 or write New York State Department of Health, Bureau of Managed Care Complaint Unit, Room 1911, Corning Tower, Empire State Plaza, Albany, NY 12237.
- New York State Department of Insurance – for problems related to payments for benefits contact the Consumer Services Bureau at 1-800-342-3736 or write New York State Insurance Department, Consumer Services Bureau, 25 Beaver Street, New York, NY 10004.
- New York State Attorney General – for problems where you think a law has been broken or fraud might be involved call the Health Care Bureau at 1-800-771-7755. – for problems where you think a law has been broken or fraud might be involved call the Health Care Bureau at 1-800-771-7755.
- External Appeal – is when a plan denies any part of a benefit because the plan says it is not medically necessary or plan says treatment is experimental or a clinical trial call 1-800-400-8882 or visit www.ins.state.ny.us.
- Specific to Medicare
- Rights Center 1-800-333-4114
- New York State Wide Senior Action Council, Patients’ Rights Hotline 1-800-333-4374
- New York State Office for the Aging 1-800-342-9871
- Specific to Medicaid
- Fair Hearings 1-518-474-8781 or 1-212-417-6550
- Legal Aid Society’s Health Law Unit 1-212-577-3575
- NYC Managed Care Helpline 1-800-505-5678
Participating Insurance Plans
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