Managed care is a form of health insurance. It is a health or long term care delivery system in which a managed care organization is responsible for providing health or long term care to the individuals enrolled in their organizations. Managed care plans as health insurance options are present in every area of the health care system, including the private insurance market, as well as Medicare and Medicaid.
To participate in a managed care plan, an individual must enroll. By doing so, the individual agrees to terms and conditions, including participation in a provider network. Enrollment is usually allowed only during a specific period each year. Once enrolled, the individual receives their health or long term care, within the network of providers participating in the plan, usually for a reduced rate or a specific monthly premium.
To create a provider network, the managed care organization contracts with a variety of care providers and medical facilities that provide specific services to the enrolled members. The managed care organization pays the providers based on a negotiated contract. Providers are usually paid a reduced rate to provide services to those individuals participating in the plan.
Individuals enrolled in the managed care organization receive their health or long term care through only the network providers. Their care is usually coordinated or managed through a primary care physician who can act as a “gatekeeper” regarding access to specialists, testing and treatment options. A managed care organization can set criteria that enrollees must meet to receive certain services. These restrictions can include prior authorization requirements or limits on the number of visits to a specialist within the network. Services provided by companies outside the managed care organization’s network are usually not paid for by the managed care organization and are the responsibility of the individual.
Many employers, including the State of Florida, offer managed care plans as options for their employees. Medicare recipients can also enroll in managed care plans referred to as Medicare Advantage Plans. Finally, many states require certain Medicaid recipients to enroll in managed care organizations to receive Medicaid covered health or long term care services. Florida is currently transitioning its Medicaid program to a managed care system.
Do you have experience with managed care? Are you concerned about how managed care may affect you or a loved one, especially whether private managed care organizations might put profits ahead of quality of care? Is our state more concerned with saving money than caring for our most vulnerable citizens? Feel free to post your concerns right here! As someone who is advocating for seniors on a daily basis, I want to hear your voice.
