FL Adjuster Claim Professional Exam: Managed Care Plans

Fast Facts

Characteristics of Managed Care Plans

Medical services provided on a pre-paid basis.
Insureds are members or participants.
Emphasis on preventive care (e.g., annual physicals, labs).
Members select a primary care physician (PCP) to oversee medical care.
Cost containment through preventive care and negotiated rates.

Types of Managed Care Plans

Health Maintenance Organizations (HMOs): Use a network of providers; members need PCP referrals for specialists. Providers paid via capitation (set amount per member, regardless of care sought).
- Closed Panel HMO: Covers only network providers.
- Open Panel HMO (POS): Covers non-network providers at agreed rates.
Preferred Provider Organizations (PPOs): Contract with non-employee providers; no PCP referral needed for specialists.
Blue Cross/Blue Shield Plans: Offer hospital (Blue Cross) and medical/surgical (Blue Shield) care; include traditional and HMO plans.

Health Maintenance Organizations (HMOs)

HMOs deliver prepaid health care through a network of doctors, hospitals, and clinics, funded by member premiums. They operate in specific service areas and are state-regulated. Providers receive capitation payments (fixed amount per member).

Members must use network providers for covered care, limiting provider choice. HMOs emphasize preventive care (e.g., annual physicals, immunizations, dental/vision care) to reduce costly treatments.

Key Point: Unlike indemnity policies, HMOs have no deductibles; members pay a small copay (e.g., $15-$30) per visit.

Closed Panel vs. Open Panel

Closed Panel HMO: Covers only network providers.
Open Panel HMO (POS): Covers non-network providers at negotiated rates.

Primary Care Physician (PCP)

Members select a PCP who coordinates care and acts as a "gatekeeper," managing specialist referrals to control costs.

Emergency and Hospital Care

Nonemergency hospital stays/surgeries require prior HMO approval. For emergencies, members must notify the HMO within 24-48 hours if treated outside the network.

Coinsurance vs. Copayment

Coinsurance: Percentage of total charges paid by the insured (used in major medical insurance).
Copayment: Flat dollar amount paid by HMO members per service (e.g., $15/visit).

Members don’t submit claim forms for in-network services; only copays are required. Claims may be needed for out-of-network emergency care.

Test Your Knowledge: What is the difference between coinsurance and copayment?

Coinsurance is a percentage of charges paid by the insured in major medical plans, while a copayment is a flat fee paid by HMO members per service.

Preferred Provider Organizations (PPOs)

PPOs contract with non-employee providers at negotiated rates. Members can visit specialists without PCP referrals and may seek out-of-network care (with a deductible). Providers benefit from more patients and prompt payments.

Point-of-Service (POS) Plans

POS plans blend HMO and PPO features. Members choose a PCP but can access out-of-network providers with deductibles and coinsurance, offering more provider choice.

Exclusive Provider Organizations (EPOs)

EPOs are stricter PPOs, covering only in-network providers. They are less expensive than HMOs or PPOs but limit member flexibility.

Blue Cross/Blue Shield Plans

Blue Cross (hospital care) and Blue Shield (medical/surgical care) offer prepaid plans, including HMOs and traditional coverage. They use community rating (same premium for all in an area) and manage Medicare and group plans. Members pay no claim forms for in-network services.

Cost Containment in Managed Care

Managed care plans control costs through:

Limiting provider access to networks.
Coordinating care via PCPs.
Requiring preauthorization for services.
Emphasizing preventive care and negotiated rates.
Conducting utilization reviews (prospective, current, or retrospective) to ensure appropriate care.

Insurers use usual, customary, and reasonable (UCR) charges to set benefits, adjusting for regional cost differences.