To evaluate a managed care plan, get a complete written explanation of its coverage, costs and procedures. These are usually contained in a printed brochure called a Summary of Benefits. Also, get a chart showing premiums and copayments. Compare that written information with each important category discussed in this article.

If you do not understand exactly what the coverage, costs and procedures are, ask a plan representative to point out where they are explained in the written information. If you can’t get an important piece of information in writing, don’t join the plan.

Look at a number of specific factors when evaluating a managed care plan.

Choice of Doctors and Other Providers

For many people, the most important factor in choosing a Medicare plan is whether the doctors, hospital and other providers they already use and trust are in the plan’s network of providers. If the people and places you prefer for care are in the network, the tight restrictions of HMOs and PSOs may not have much effect on you, at least for the foreseeable future. But if not, you would be faced with finding new doctors, which is never an easy or comfortable process. And you might have to use a hospital that is more distant from your home, leaving you a little less secure.

The problem is not quite as great with PPOs, or HMOs with a Point-of-Service Option. These plans permit you to use providers who are not in the plan’s network. So, if you want to continue with a particular doctor or provider who is not in the network, you may do so, but with a higher copayment each time you use the non-network provider. If you are treated by non-network doctors very often, the extra payments may wind up canceling out the cost advantage of managed care.

Access to Specialists and Preventive Care

The requirement that you must visit your primary care physician to obtain specialist referrals is one of the main objections to managed care. Try to learn how difficult it is to get a referral to a specialist with any plan you are considering.

Total Cost

Many managed care plans charge no premium to members. Other plans charge a relatively small premium-especially PPOs, and HMOs with point-of-service option or deluxe coverage, such as unlimited prescription drugs. Usually, these premiums are lower than for medigap policies. But premiums don’t tell the whole story. You must add up other costs-particularly required copayments for doctor visits and prescription drugs-to see whether a plan is worth your dime.

Review Process

About 30% of Medicare managed care patients report having been denied coverage for treatments their plans deemed to be medically unnecessary or experimental. And if you are denied coverage for a treatment or service, Medicare will not help you. The appeals procedure is run by the plan. The prospect of having your wishes and those of your doctor overruled by the insurance company is always enraging. And when the treatment is for a serious illness, the plan’s rejection can be devastating.

Before joining any managed care plan, explore its appeal or review process. The procedures should be explained in the Summary of Benefits booklet the plan gives to potential members. If the review process is not fully explained, request written information from a plan representative.

Extent of Service Area

Consider the extent of a plan’s service area, particularly if you live in a rural or spread-out suburban area. If the service area is not broad enough to include a good selection of specialists, you may find your future care choices limited.
Also, see if the plan has what are called extended service areas. Some plans permit you to arrange medical care far from your home if you travel frequently or spend a regular part of the year away from its primary service area. This allows you to take care of non-urgent medical needs, even if you are not at your primary residence.

Other Plan Features

In addition to the key features of managed care plans, many plans offer a variety of other features beyond basic Medicare coverage. These extra benefits are either minor services provided by some plans or major medical expenses for which some plans pay a small portion. If you are likely to use any of these benefits, the plan that offers them may be more attractive to you. Such benefits include: short-term custodial care, medical equipment, chiropractic care, acupuncture, acupressure, routine physical exams, foreign travel immunizations and emergency coverage, eye examinations and glasses, hearing tests and hearing aids, dental work, after-hours advice and treatment, chronic disease management and wellness programs.

See also…

Healthcare Law Forum

Insurance Issues