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Managed care is one type of health care insurance for providing
you with the medical care you need. There are many varieties of
managed care plans, but each generally has its own list (called
a network) of health care providers.
HMO (Health Maintenance Organization) is the kind of managed care
plan that requires you to use only the health care providers on
its network list. PPO (Preferred Provider Organization) is the
kind of managed care plan that lets you use providers outside its
network, but gives you a financial incentive to stay in.
HMOs are the only kind of managed care plan available to people
in New York State covered by Medicaid, Child Health Plus, or Family
Health Plus. People covered by their employer, medicare, or through
individual heath insurance policies may have additional managed
care options, including PPOs.
When you enroll in any managed care plan, you are given a list
from which to choose a primary care provider or primary care physician
(PCP). This person becomes your regular doctor who will provide
most of your care and coordinate the rest.
Although each plan has its own network list of doctors, many doctors
are in the networks of more than one plan. Each plan also has a
list of its own clinics, hospitals, laboratories, x-ray facilities,
and other providers.
If you are in an HMO, you will normally need to get an OK (called
a referral) from your PCP before you can see a specialist. Your
PCP can also give you a referral to a specialist within the plan's
network.
For an in-depth description of the types of managed care plans,
read our Managed
Care News quarterly newsletter issue # 1 and Chapter
3 of the Advocate's Guide to Managed Health Care.
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