2000-10-14 / Columnists

Managed Care Update Plans For You And The Family

If you are given a choice between different managed care plans, here are some issues you will want to consider before you join:
By Zandra Myers

Managed Care Update
Plans For You And The Family

  • If your whole family needs to be covered by one health plan, consider the health needs of each family member individually. You may want to choose a plan based on the needs of the sickest family member.
  • Consider your long-standing relationships with current providers. If you and your family want to stay with your current doctor, you should ask the doctor which plans he accepts.

You may want to ask the plan you are thinking of joining:

  • Are there primary care doctors near my house who don’t have a waiting list?
  • Which hospitals can I use if I join the plan?
  • How long do I have to wait to get appointments?
  • If I am already getting care for a special condition, will I be able to get the same treatment or services that I have now?
  • If I use special supplies or prescription drugs, can I get them with the plan?
  • What happens if I get sick while out of town?

Q. What type of information does the managed care plan have to give you to help you make your choice?

A. Managed care plans are required to provide the following information to enrollees and prospective enrollees upon request:

  • How to choose a PCP (primary care provider) and how to get care from the plan’s PCP’s and specialists;
  • How to change your PCP;
  • How providers are paid by the plan;
  • What you need to do to get emergency services whenever you need them, 24-hours a day;
  • What benefits covered by the plan, including any limits on benefits and a definition of "medical necessity";
  • When you will need "prior authorization" or other plan requirements before you can get treatments or services;
  • How to get permission to see (a "referral" to) a non-plan provider when your plan does not have a provider with the right training and experience to meet your needs;
  • How much of your medical bill you will have to pay if you go to a doctor outside of your plan’s network, or go to a provider without prior authorization, or use a non-covered benefit;
  • How to complain either through "grievance" procedures (for most problems) or through "utilization review" (for denials of medically necessary care).

If you need assistance in making your choice, or have any questions or concerns, you may contact me at Jewish Community Council of the Rockaway Peninsula, or e-mail me at zkmyers@hotmail.com.

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