CID: What Is Managed Care?

What Is Managed Care?

Managed care is a general term used to describe a system of health care delivery that attempts to oversee all aspects of an enrollee’s care. The goal of the system is to deliver quality care in the most appropriate setting, in the most cost-effective manner. Preventative care is promoted, and managed care plans generally require that enrollees choose a primary care physician, who often is required to be the initial contact for care.
How do traditional indemnity plans differ from managed care plans?

Traditional indemnity plans reimburse an enrollee for covered services. There is generally a deductible amount that must be paid by the enrollee before any covered services are paid by the plan. After the deductible is met, there is generally cost sharing by the plan and the enrollee through coinsurance or a percentage of the eligible cost. Enrollees are free to access any licensed health care provider.

Managed care plans are plans that perform utilization review and utilize a network of participating providers. Managed care plans generally require that enrollees seek care from participating providers. Most services are covered in full, although a flat fee or copayment may be required at the time the covered service is rendered. Enrollees must access participating providers in the network, except for emergency services or if the plan offers optional out of network benefits. Such coverage for out of network services is generally on a deductible/coinsurance basis.

Content Last Modified on 8/25/2008 1:06:40 PM