Q. Where can clients go to get information comparing managed care plans?

A. Each managed care plan is required to make certain information available to plan members and prospective purchasers. (See the Managed Care Consumer Bill of Rights in Appendix B.) There are also two helpful resources from the New York State Insurance Department:

• Premium Rates for HMO Standard Individual Health Plans by County This page has a very brief explanation of how direct pay insurance works, and has links to the monthly prices and the contact numbers for various plans. It is available on-line at the Department’s website, www.ins.state.ny.us/ihmoindx.htm
  
• The New York Consumer Guide to Health Insurers and The New York Consumer Guide to HMOs compare plans by the proportion of consumer complaints upheld, the proportion of utilization review decisions reversed, the plan’s success at various health measures, etc. Clients can order this booklet by calling the Department’s Consumer Services Bureau, 212-480-6400, or 1-800-342-3736. They are also on-line at the Department’s website, www.ins.state.ny.us.

Q. How can clients choose between managed care plans by looking at the doctors and hospitals they can use?

• Doctors in the Managed Care Plan’s network:
  Find out which doctors and hospitals are in the managed care plan’s network. Ask each plan for a “provider directory,” the list of the doctors, hospitals, skilled nursing facilities, home health agencies, pharmacies and other providers who are in their network. See page 15 for suggestions on how to choose a doctor.
  
  
• Going outside the managed care plan’s network:
  Clients should also find out what services are covered when they go outside the managed care plan’s network. All managed care plans are required to cover emergency care outside of their service area.
  
• For a Point-of-Service (POS) or a Preferred Provider Organization (PPO) plan, clients will want to know:
  
  • What is the co-insurance (what part of the bill do they pay)?
    
  • Is there a deductible each year (an amount client’s must pay themselves before the plan starts to pay any part of your bills)?
    
  • Is there a maximum number of visits or dollar amount that is covered?
    
  • Will the plan cover all types of doctor visits? Will it cover non-doctors, such as mental health providers or therapists?
    
• Does the managed care plan let clients go to doctors for non-emergency care when the client is outside the service area? Some managed care plans have agreements with plans in other areas to provide non-emergency care for enrollees in other regions of the U.S.

Q. What are some other questions clients can ask about the differences between managed care plans?

A. If clients need to take certain drugs on an ongoing basis:

• Are those drugs on the plan’s formulary (list of drugs covered)?
  • If not, what would be required to have the plan agree to coverage?
  • Is the client’s medication recognized by the plan as a “maintenance drug” that he/she can get by mail order?
    
• What are the plan’s monthly premiums? Current monthly premiums for all individual plans in a county are available from the State Insurance Department, both in a written rate sheet and on its web-site.

Q. What type of information do managed care plans have to give the client to help him/her choose between them?

A. Managed care plans are required to provide the following information to prospective enrollees:

• how to choose a primary care provider (PCP) and how to get care from the plan’s PCPs and specialists;
  
• how to change a client’s PCP;
  
• how providers are paid by the plan;
  
• what clients need to do to get emergency services whenever he/she needs them, 24 hours a day;
  
• what benefits are covered by the plan, including any limits on benefits and a definition of “medical necessity”;
  
• when will a client need “prior authorization,” or other plan requirements, before he/she can get treatments or services;
  
• how to get permission to see (a “referral” to) a non-plan provider when the plan does not have a provider with the right training and experience to meet the client’s needs.
  
• how much of a client’s medical bill will he/she have to pay if he/she goes to a doctor outside of the plan’s network, or go to a provider without prior authorization, or use a non-covered benefit;
  
• how to complain either through “grievance” procedures (for most problems) or through “utilization review” (for denials of medically necessary care)