Managed care is a kind of insurance that changes the way patients get the care they need.
An HMO (Health Maintenance Organization) is the kind of managed care plan that requires you to use only the health care providers on its network list. PPO (Preferred Provider Organization) is the kind of managed care plan that lets you use providers outside its network, but charges you less if you go to providers who are in their network.
HMOs are the only kind of managed care plan available to most people in New York State covered by Medicaid, Child Health Plus, or Family Health Plus. People covered by their employer, Medicare, or through individual health insurance policies may have additional managed care options, including PPOs.
When you enroll in any managed care plan, you are given a list of a primary care providers or primary care physicians (PCP). You choose a doctor from the list, who becomes your regular doctor, provides most of your care, and coordinates your health care needs.
Although each plan has its own network list of doctors, many doctors are in the networks of more than one plan. Each plan also has a list of its own clinics, hospitals, laboratories, x-ray facilities, and other providers.
If you are in an HMO, you will normally need to get an OK (called a referral) from your PCP before you can see a specialist. Your PCP can also give you a referral to a specialist within the plan's network.
Besides offering medical services, managed care plans also provide customer assistance through a toll-free member services line that explains how the plan works and its benefits. It can also help members find doctors within their plan. Plans even have a 24-hour toll-free number on the back of the plan card that members may call to access or obtain services when their PCP is not available.
For more information about managed care plans, please click on one of the Community Health Advocates resources below:
