Policies that provide Managed Care Services

ACA compliant policies will often be tied to a provider care network. This affects your choice of doctors and hospitals because not all providers are part of the network. In return for this limited choice, you usually pay less for medical care (i.e., doctor visits, prescriptions, surgery and other covered benefits) than you would with traditional “fee-for-service” health insurance. The managed care network controls health care services in these narrower network options Be sure to review all providers available to you under each type of Managed Care Service network you choose.

If your health care provider is out-of-network, you are responsible for the difference between the allowed amount and the provider’s charge and generally those amounts will not be applied toward your out-of-pocket limits unless there is a change in ACA Federal Law. There are some exceptions depending on the carrier and plan you are covered under. It is imperative that you contact your insurer should you have any question regarding a health provider being an in-network or out-of-network provider. Out- of- network providers can be far more costly as they are not subject to your insurer’s provider contract/s or discounted fee for services, however ACA compliant polices must cover medically necessary emergency services received by an out-of-network provider as if they were in-network.

The types of Managed Care Networks are:

• Preferred Provider Organizations (PPOs) – PPOs offer a provider network to meet the health care needs of an insurance carrier’s insureds. The insurer contracts with a group of health care providers, or with a PPO network, to control the cost of providing benefits to their insureds. These providers charge lower-than-usual fees because they require prompt payment and serve a greater number of patients. Insured’s usually choose who will provide their health care, but pay less in coinsurance with a preferred provider than with a non-preferred provider.
• Health Maintenance Organization (HMO) – HMO members pay a monthly fixed dollar amount (similar to an insurance premium), which gives them access to a wide range of health care services. In many cases, members also pay a predetermined amount, or copayment, for each doctor or emergency room visit and for prescription drugs, rather than paying the provider in full and obtaining a portion of the reimbursement later. Members must use the HMO’s network of providers, which may include the doctors, pharmacies and hospitals under contract with that particular HMO.
• Point of Service plans (POS) – In a POS plan, insured members may choose, at the point of service, whether to receive care from a physician within the plan’s network or to go out of the network for services. The POS plan provides less coverage for health care expenses provided outside the network than for expenses incurred within the network. Also, the POS plan will usually require you to pay deductibles and coinsurance costs for medical care received out of network.