Managed Care Health Plans Frequently Asked Questions

How do I select a health plan?

Think about what is most important to you in a health plan: low cost; availability of a specific physician, clinic, or hospital; freedom to see any physician you want; or convenient location of facilities. If you like the physician you are currently seeing, check to see if he or she is a provider in the plan you are considering. If you or a dependent has special medical needs, check that the plan you are considering has adequate medical services and providers for that specialty.

In completing the application, I had to choose a primary care provider. What does that mean?

Your primary care provider is responsible for managing your health care needs. Many HMOs require its members to receive all care from the primary care provider or with a referral from the primary care provider.

What can I do if I want a different primary care provider?

Every plan has its own procedures for changing primary care providers. Some plans will only allow you to change primary care providers once during the year. Others allow you to change as often as you like. This should be explained in your member handbook or your employer may be able to assist you.

What happens if I need immediate care?

If you need emergency care, most plans will allow you to go to the nearest provider. If it is not an emergency but you need care sooner than a routine doctor's visit, you may be required to go to a plan provider. You should always contact your primary care provider or the insurance company as soon as possible. Some plans require you to pay an additional portion of the charges if you do not contact them within 48 hours of receiving care in an emergency room.

Does it matter if the specialist to whom I am referred is a plan provider?

Yes. Most closed panel plans will require you to see a specialist who is a plan provider if one is able to provide the services you need.

My primary care provider referred me to a nonplan provider. Do I have to contact the insurance company before my appointment?

Yes. Most closed panel plans require a referral to a nonplan provider be preauthorized by the insurance company before the appointment. In some cases, your primary care provider may submit the referral request to the insurer for you, and the insurer will send you a notice letting you know if the referral has been approved. In some cases, you may be required to contact the insurer directly. In any case, if you have not received the authorization from the insurance company prior to your appointment, you should contact the company to determine if the service will be covered.

How are students or dependents living out of the service area covered?

Dependents who live out of the area are generally covered for emergency or urgent medical problems. The dependent would be required to receive all follow-up care and routine care from plan providers in the service area.

May I use any provider I choose under the plan?

If you are covered under an HMO or other closed panel plan, you will need to receive all services from your primary care provider or other plan providers. If you are covered under a preferred provider plan or point-of-service plan, you will be able to choose any provider. However, you will be required to pay a larger portion of the bill if you use a nonplan provider, and may be required to have some services preauthorized by the insurance company. Your member handbook should explain the requirements specific to your plan.

Will I incur any liability if I fail to follow the preauthorization requirements?

Yes. If you fail to follow the required preauthorization procedures, you will be required to pay a larger portion of the claim. In some cases, the plan may determine that the service is not covered under the contract and completely deny the claim.

What is a drug formulary?

Many managed care plans establish a list of prescription drugs which the plan considers medically appropriate and cost effective. This formulary often requires a generic form of a drug to be used.

What if I have a complaint?

You should contact the plan's customer service department. Many problems can be resolved on an informal basis. You can also file a written grievance. All managed care plans are required to have a grievance procedure to resolve a member's problems. This procedure is explained in your member handbook. Grievances are generally resolved within 30 days. If you believe your medical condition needs immediate attention, you may wish to ask that the grievance be considered an expedited grievance. Expedited grievances must be resolved within 72 hours after receipt.

You can also file a complaint with OCI at any time during the grievance procedure.

The Plan's grievance committee denied my appeal. What can I do now?

You may have the right to appeal to an independent review organization if your dispute involves a medical necessity or experimental treatment decision. A medical expert who is not connected to your plan will review the appeal and has the authority to determine whether the treatment should be covered by your plan. If you need immediate medical care, you may be able to bypass your plan's grievance process and go directly to independent review. Your member handbook should explain the independent review process.

My doctor told me he was no longer with the HMO, but I want to stay with him. What can I do?

The agreement between the managed care plan and your doctor is a separate agreement that may terminate any time during the year.

If the provider is your primary provider, the plan must cover your care for the remainder of the plan year.

If you are in your 2nd or 3rd trimester, the plan must cover your care through postpartum care.

If you are seeing a specialist, the plan must cover your care for the lesser of 90 days or through the current course of treatment.

If the provider leaves the plan because he or she no longer practices in the plan's service area or is terminated for misconduct, the foregoing provisions do not apply.

If your employer offers other plans, you may wish to consider changing plans during your employer's open-enrollment period.

My doctor never told me he was no longer with the HMO and the HMO did not tell me either. Now I have all these bills the HMO will not cover. What can I do?

If your doctor leaves the HMO in the middle of the plan year, there are notice requirements. The HMO is required to notify you at least 30 days in advance if its contract with your primary care provider is terminated. If it terminates its contract with a specialist, it must either notify you at least 30 days in advance, or require the specialist to post a notice in the provider's office.

If you are receiving bills, you should file a grievance with the plan to explain the extenuating circumstances. You should also file a complaint with OCI.

I disagree with my doctor and want a second opinion. Will the HMO pay for it?

Yes, so long as you go to a plan provider or, if necessary, obtain a referral from your primary provider for the second opinion.

I live in a different county from where I work and my employer only offers an HMO. It is too far for me to go to see the doctor. What can I do?

If you enroll in the HMO, you must follow its procedures. This means that you will be required to receive your care from plan providers.

You should ask your employer to consider offering other coverage.

What is a defined network plan?

A defined network plan is the term used in Wisconsin insurance law to refer to any health benefit plan that creates incentives for its enrollees to use network providers. Some defined network plans will provide coverage only if the enrollee uses network providers. Other plans will pay a larger portion of the charges if the enrollee uses network providers. HMOs and preferred provider plans are examples of defined network plans. Some people refer to these plans as managed care plans.

I received a provider directory when I enrolled in my health plan. How do I know whether I'm in an HMO, a preferred provider plan (PPP), or some other type of managed care plan? What difference does it make?

When you enroll, you should have received a certificate of coverage or other written information that explains how your health plan works. This material should describe the benefits covered by your plan and explain any procedures that you must follow in order to receive coverage. It is very important to review this information. It will explain all of your coverage, all of the limitations to the coverage, and whether you must use plan providers or whether you can choose any provider. It will also explain when you need a referral from your primary care provider and when you need to contact the health plan for authorization before receiving care.

If you have questions about your coverage, call the health plan's customer service department. If you have coverage through your employer, the employer's human resources department may also be able to answer your questions.

I am covered by a group health plan through my employer. I would like to receive a copy of the certificate of insurance. How do I go about obtaining a copy?

Under Wisconsin insurance law, health insurers are required to provide insureds with a copy of the health insurance certificate. As an alternative to providing each employee with a copy, the insurer may make certificates available electronically through the internet or through your employer's network Web site. Your employer should provide you with information that explains how to access the certificate and also how to request a copy of the certificate if you prefer a paper copy.

Can I get a list of Preferred Provider Plans (PPPs) doing business in Wisconsin?

No, our office does not maintain a list of insurers offering PPPs. Many insurers that offer standard health insurance policies also offer some type of preferred provider plan. You should ask an agent to provide you with information on preferred provider plans in your area.

What do the Medical Expense Ratio and Administrative Expense Ratio tell me?

The Medical Expense Ratio represents the percentage of premiums that are used to pay for the delivery of health care. The Administrative Expense Ratio depicts the percentage of total revenue used to administer the plan. In theory, a company with a low administrative expense ratio would be operating more efficiently than a company with a high ratio. Caution should be used in interpreting the results, however, since too low of a ratio may be indicative of an understaffed plan and certain activities such as accreditation of the plan’s quality improvement and assurance program is expensive and would increase the ratio. The accreditation program is considered by many to be in the member’s best interest. The ratio results could raise questions that should be addressed by the plan.