Health Insurance and Managed Care Plans

Managed care health plans are a crucial part of the US healthcare industry which are meant to cut costs of providing quality services. If you have healthcare through your employer, you are probably enrolled in some form of a managed care plan. The type of plan you have will impact how you access healthcare and what you may have to pay out of pocket.

In general, managed care plans cover a variety of services including preventive care and immunizations, regular checkups, diagnosis of illness and its treatment (hospital care, necessary tests, doctors’ visits and prescription drugs). It will also include prenatal as well as newborn care. Most managed care plans out there also cater to patients with mental illness and substance abuse issues.

Advantages of managed care plans

The one main benefit associated with enrolling in a managed care plan is that all plans try to save money by providing preventive services in order to help their beneficiaries to avoid serious healthcare problems. For example, many conditions that can become chronic like diabetes, high cholesterol, and high blood pressure can be avoided or prevented from getting worse if they are diagnosed and treated early.

Another advantage of managed care plans is that they contract with clinics, hospitals, and healthcare centers in your area in order to control the premium you pay.

In some types of managed care plans, it is mandatory to receive all services from within your network provider while in other plans, you may be able to receive care from out-of-network providers but you may have to pay a larger share of the cost. Normally, in all types of managed care plans, you have to pay an annual deductible as well as a copayment for each doctor’s visit or prescription drug received. Any managed care plan that requires you to go to a network provider will have lower premiums and high deductible and copayments while plans that allow you to use any provider will have higher premiums but lower deductibles and copayments.

Another benefit of being part of a managed care plan is that accessing prescription drugs becomes easier as they have a list of drugs they cover. However, your copay for each prescription drug will depend on whether you are getting a generic medication, a medicine that your network prefers or one that it does not prefer.

Types of Managed Care Plans

Normally, three types of managed care plans are offered by health insurance companies across the country:

  1. Health Maintenance Organizations (HMOs)

Within this plan, you will have to receive most, if not all, of your healthcare from within the network. This requires that you select a primary care physician who takes care of all of your healthcare needs. In case you need to see a physician specialist in the network or a diagnostic service, your primary care physician will provide you with a referral. Without this referral, you will have to pay a huge portion of the cost yourself.

  1. Preferred Provider Organizations (PPOs)

This plan has contracts with a particular network or ‘preferred’ providers to choose from in which case you don’t need a primary care physician or referrals. If you stay within this network, you will only be paying for an annual deductible and a copayment for each visit.

  1. Point of Service Plans (PSP)

This is a combination plan involving a health maintenance organization and a preferred provider organization. The network for this plan is a lot like the HMO where you pick a primary care physician but you are allowed to go out-of-network as well, in which case you pay more.

John Adams is a freelance expert medical article writer and working for different health related blogs. Most of his articles are contributed to where you can read articles on introduction to back pain and asthma overview.