COMMITTEE ON CHILD HEALTH FINANCING

 

Managed Care

Many changes have and will continue to occur in how your family will receive health services. One important change is the use of managed care plans, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs), by employers and state Medicaid agencies. Managed care plans are different than traditional "fee-for-service" plans in two major ways:

1. Networks limit the number of doctors who are part of their plans. Few doctors and hospitals are part of all HMO or PPO plans. This is why it is very important for you to know which plans include your pediatrician, pediatric medical subspecialist, and pediatric surgical specialist or which plans your pediatrician, pediatric medical subspecialist, or pediatric surgical specialist has chosen to join.
2. Managed care plans try to keep costs down by requiring your doctor to take more control over the types of health care services you receive. For example, your doctor may need to give his or her approval before you can see a pediatric medical subspecialist and/or pediatric surgical specialist, choose a hospital, or receive emergency services.

So that families are more informed about managed care plans, the American Academy of Pediatrics has prepared this list of commonly asked questions. The questions cover such topics as pediatric primary and pediatric medical subspecialty and/or pediatric surgical specialty services that need prior approval, and cost-sharing requirements. However, this information should not be used as a substitute for the information found in your own health insurance plan contract.

Related Articles

• Managed Care — General Questions
• Managed Care — Primary Care
• Managed Care — Specialty and Emergency Care
• Managed Care — Complaints, Claim Denials and Appeals