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Managed Care, by Kathryn Harris

From On Your Mind articles in the Wilmington News Journal



Q.   Is Managed Care useful to me and my family?  And how should I evaluate these options when I look at my health insurance options?


A.  Managed care is meant to provide cost effective guidelines for the delivery of health care services offered through a particular insurance or employee benefit plan.  This may take the form of an EAP (Employee Assistance Plan)within or outside of the company, or a sub-contracted managed care firm.  Either of these plans sets  the standards of the services available for a particular need,  the requirements for professionals (providers), as well as a specific list of local providers the plan will reimburse to provide that service.


            Many of these plans can offer you and your family very important services if you take the time to learn about the services available, how they will best fit your family's needs and what is required for you to best access and use them for your family.           


            In any case you need to look at types of plans available to you and how well they match up to your family's possible service needs and financial resources.  The most inclusive plans with most options tend to cost you or your employer more than less inclusive plans.  If your own choice of professional, and choice about how the service will be delivered is important to you, you will probably choose the plan with most options available for you.    For mental health services you would ask for information about the outpatient, inpatient or substance abuse benefit.  It is important to know the  amount of the annual and lifetime limits of the benefit available to you.  This may be defined in terms of a number of sessions per year, number of days of in-patient stay per year, or total dollar amount available annually or in the lifetime of your benefit.  Once you have this information, it is important to know if there are particular  professionals or providers who are  reimbursed by thie plan for providing this service;  and how you go about making contact with the provider to get the service you need.


            In choosing a plan you may also want to know what information may be available to your employer from your provider and evaluate how important this is for you in how you choose your benefit plan and particular treatment.


            If there is a limited list of providers, the insurance company will give you names and phone numbers of eligible providers whom you can contact.  It is then up to you to contact these professionals and evaluate how well this person seems to fit your needs  in terms of appropriateness for the particular family concern as well as availability of appointments when you can get there.  When you call for an appointment let the provider know what:   your concern is and what you think you need; your insurance coverage and confirm that the provider is accepting that plan;  and when you are available for appointments.  You will probably find that it will take several phone calls to find what you are looking for, so be persistent even though this  is often frustrating when all you want is someone to help you feel better right now.


            Since many managed care plans have specified limits of services for specific issues, it is very important that you know what is available to you and discuss  with the professional of your choice  how you can best use your benefit to meet your needs.  Please remember that the insurance company is  authorizes services they will pay for.  You always have the option of choosing what you need for yourself and exploring whether the provider is willing to negotiate payment for the services if it is not covered by your benefit.


            The bottom line is that the delivery of health care services is currently undergoing major changes which are creating a great deal of uncertainty for consumers and providers alike.  We all need to be informed about our resources and be willing to clearly ask for what we want and need in order to maximize our getting the services and making best use of the plans available to us.


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Contact me at mailto:kathrynPH@aol.com

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