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BASICS OF MANAGED CARE

Funded by a grant from the federal Maternal and Child Health Bureau, Department of Health and Human Services Administration (

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BASICS OF MANAGED CARE

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    1. BASICS OF MANAGED CARE by Center for Advancement of Distance Education University of Illinois at Chicago, School of Public Health

    2. Funded by a grant from the federal Maternal and Child Health Bureau, Department of Health and Human Services Administration (#MCJ-17R804-01)

    3. Quality Community Managed Care

    4. Moderator - Faye Manastar Eldar, MEd Family Coordinator for Quality Community Managed Care Project Mother of Maya who is 18 years old and deafblind

    5. Karen Gugliuzza Community Care Manager for Midland Management Company, LLC Registered Nurse with 14 years experience in managed care

    6. Lynn Doolittle Parent of 3 children, one with special health care needs Coordinator for Child and Family Connections in the Rockford, Illinois area

    7. Early Intervention Program to support children, ages 0 - 3, who have developmental disabilities or delays Provides family education, support, therapy, education, and resources

    8. Child and Family Connections Statewide agency which handles intake and referral for early intervention services in Illinois

    9. What is managed care? A system of delivering and paying for health care using networks of preapproved providers

    10. What does manage care “manage”? Cost of health care Quality of health care Access to care

    11. What is a Health Maintenance Organization? (HMO) Oldest type of managed care Members receive health services, including preventative care for a fixed monthly cost from an approved provider

    12. What is a Point of Service Plan? (POS) Characteristics of a HMO and Traditional health insurance Member can use either an in-network provider at a low cost or

    13. Point of Service Plan allows member to use an out- of network provider, one that does not have a contract with your managed care organization, at a higher cost

    14. What is a Preferred Provider Organization? (PPO) Organized group of doctors, hospitals, or other providers that arranges contracts to provide services generally, at a reduced rate Called preferred providers or in network

    15. Preferred Provider Organizations Plan allows covered person to use a network provider at a lower cost Traditional insurance, HMO’s, and POS plans have preferred providers

    16. What is Traditional Insurance? Also known as indemnity plans or fee-for-service A type of health insurance where the health care provider is paid for each service

    17. Traditional Insurance Usually has co-payments, deductibles, and out-of-pocket costs Member has a choice of any doctor, hospital, or other health provider

    18. Traditional Insurance May have preferred provider relationships with hospitals

    19. Capitation A method of payment in managed care. Primary care providers are paid a set amount for each person per month.

    20. What are covered benefits? What your insurance plan will pay for - is dependent on your benefit plan Includes both the type of service your plan will pay for and the amount it will pay

    21. Read your insurance plan or booklet. Look for: What specific services are covered? How many times are they covered? Per month, per year, or per lifetime

    22. Look for: What is not covered? These are called exclusions Who are the network or preferred providers?

    23. Resource for families Family Voices - network of families/friends of children with special needs that offers information and resources Has a brochure on Managed Care

    24. Family Voices P.O. Box 769, Algodones, New Mexico 87001 Tel: 505/867-2368 or toll free 888-835-5669 www.familyvoices.org

    25. What is a referral? The recommendation of your primary care physician that you see another physician or provider.

    26. Another view of a referral The written approval from your physician or managed care organizations for you to receive treatment from another provider

    27. About referrals Generally given to providers who are in the network Are within the guidelines of the insurance plan

    28. More about referrals Process or steps you must follow are different for each company Check with your primary care physician, insurance company, or your employer for more information

    29. Out-of network referrals If there is not a provider within the network that can give the necessary health service, you may be referred to an out-of-network provider

    30. How to find out what is covered? Read the booklets that your employer or agent has given you Ask your human resources or personnel representative for assistance

    31. How do I find out what is covered? Call the insurance company or managed care organization Ask the insurance company or MCO for a case manager Ask your physician or hospital

    32. Referrals and families Families may have difficulties finding specialized care in the network Managed Care Organizations try to refer you to network providers to contain costs

    33. How long do referrals last? May be for only one visit May be for a set amount of time: 1, 3, or 6 months May be open ended (called a “standing referral”)

    34. What are the Benefits of Managed Care? Lower out-of pocket costs Well-child and preventative care is covered (visits to the doctor, shots for your child, physical exams)

    35. Benefits of Managed Care No claim forms to fill out Low deductibles or no deductibles

    36. More Benefits Better coordination of care for a child with special needs Improved care from a parent perspective

    37. What are the Challenges of a MCO? Limited choice in providers Must have a referral from your primary care provider to see a specialist

    38. Challenges Finding a physician within your network to meet your child’s special needs Getting a referral to an out-of-network provider

    39. Challenges Accessing needed therapies, equipment Finding services close to home

    40. Referrals If you do not follow the rules of you health plan, you may have to pay the entire bill yourself or a larger portion of the bill.

    41. How are decisions made? Family selects physician and other provides based on who is in their plan Primary Care Physician makes decisions based medical needs and guidelines of the plan

    42. How are decisions made? Managed Care Organization considers medical necessity and what is covered by members plan

    43. Who makes decisions? Managed care organizations have governing bodies that include physicians. All decisions can be reviewed by an MD

    44. What is an appeal? A request by a member of provider that a decision be reconsidered All MCO’s have an appeal process

    45. How do you appeal? Look in your insurance booklet for information about appeals Call the Managed Care Organization and ask how to appeal

    46. How to learn about appeals Talk to your employer Talk to your primary care physician

    47. What we all need to do: Read the insurance information that you receive from your employer or agent Find out about your covered benefits Find our which providers are in your network

    48. Thank you for joining us for our first webcast.

    49. For further information on managed care, return to our website and click on resources. http://www.uic.edu/sph/cade/kidsmco

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