Managed Care Questions
What is managed care and what is the difference between it and the health plan I have been covered by previously by my employer?
A managed care plan provides health care services through participating physicians, hospitals and other health care providers. If you were given a list of providers to review and choose from and a benefit description of which services are covered, you are probably enrolled in a managed care plan. You might have been covered previously by an "indemnity" type insurance plan in which you were reimbursed, for covered expenses for services to any doctor or hospital of your choice, after the application of deductibles and co-insurance requirements (the amounts you are responsible for before the plan pays).
Iím considering joining a managed care plan. What areas should I find out about before I choose a plan?
These are the basic items that you may want to find out about:
- Participating physicians and hospitals
- Out of pocket expenses such as premiums and co-payments
- Preventive care and health screening
- Specialist care Ė with or without a referral
- Hospitalization and Emergency Services
- Prescription Drug Coverage
- Vision Services
- Ongoing Care for Chronic Illnesses Ė Disease Management Programs
- Rehabilitative Therapy
- Care for Mental Health
- Alcohol & Substance Abuse Services
- Home Health and Nursing Home Care
- Experimental Treatments
I am a new enrollee in a managed care plan and read in the documentation received that I must get a referral before receiving specialty care. What does that mean and what do I have to do?
Most managed care plans require enrollees to visit their primary care physician to discuss the need to receive care from a physician who provides specialty care. A primary care physician provides, arranges, authorizes and coordinates care for his/her patients. Upon joining a managed care plan an enrollee chooses a primary care physician from a list of network physicians provided by the plan to manage their medical care. The primary care physician can provide the referral (or approval) necessary for you to visit a specialist.
What should I do about a bill I am receiving that I think my plan should pay?
First, read the bill carefully. Check to see if it is an actual bill and not just a statement from the provider saying that your insurance company has been billed or an Explanation of Benefits from your plan stating that a bill has been paid to your provider.
If it is a bill from your provider, contact your managed care health plan Member Services department (toll free number on your membership card) to find out if they have been billed and if they have paid the bill.
I am unhappy with the denial of services from my health plan. How do I proceed to try to have the decision overturned?
State law requires that each managed care plan establish and maintain an internal grievance procedure to assure that enrollees may seek a review of any grievance that may arise from the planís action or inaction. Whenever the plan denies coverage they must send a letter detailing their appeals process. As the internal appeals and grievance process differs from plan to plan, it is important you read your planís membership book to understand your rights and responsibilities.
State law does dictate that your appeal must be reviewed and resolved within 15 days from the date you submit the request for review, unless an extension is granted by the carrier. If your requested medical treatment or service is determined to be "not medically necessary" (doesnít meet the standards of medical need as established by the plan) by the internal appeals process, you may qualify for an external appeals review through the CT Insurance Department. You must file an external appeal within 120 days of receiving written notification that the internal appeal process has been exhausted. If your plan is not regulated by the state of CT, you may qualify for an external review process through your employer or out-of-state carrier. Call OHA for assistance.
Prescription Coverage Questions