Could you explain all the managed care and different prescription programs for us?
(Column: Ask the Pharmacist)
Steve Kaufman, RPH
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With Medicaid and other insurance companies trying to force everyone into managed care companies, it is a good idea to discuss the differences in the many types of insurance policies available.

It is important to remember that different people have different needs. A policy that may be perfect for one person might be a nightmare for a different person. So remember it is important to look at your individual needs before deciding which is the best policy for you.

The first policy is the old traditional policy. In this policy the patient may go to any healthcare provider they like as often as they like. Usually referrals to see specialists or to get a second opinion are not required. In this type of policy the insurance company pays all claims less the patient co-payment. In most policies the insurance company pays 80% and the patient pays 20% (this can vary from policy to policy). For example, if the claim is $100.00, the insurance company would pay $80.00 and the patient would pay $20.00. The advantage of this policy is the patient has little or no restrictions as to where they go to get healthcare services. The problem with this type of policy is that it is usually expensive. This type of policy can cost $6,000.-$10,000. a year in premiums and co-payments.

The next policy we will discuss is called a P.P.O. (preferred provider organization). In this type of policy the provider signs a contract with the insurance company and agrees to accept for payment a fee that the insurance company deems appropriate. For example, Dr. Smith's regular fee for an office visit may be $100.00, but he may only receive $65.00 as payment from the insurance company (these figures will vary depending on the doctor and insurance company). In this policy, the patient may see any healthcare provider that is a member of this plan. The insurance company will usually provide a book of all providers who participate in the plan. Referrals are sometimes not needed for specialists or second opinions (you must read the policy to find out for sure). The disadvantage of this plan is you can only use providers who are members of the plan. If you choose to use a provider outside of the network, you are either not covered or must pay the difference between what the doctor charges and the P.P.O.'s contracted price.

The final policy is the HMO (health maintenance organization). This is the type of plan we've been hearing so much about lately. HMO's are usually free standing clinics and the patient must go there for all their medical care (HIP is the most well known one in N.Y.). In this setting, the doctors are on salary from the HMO. They do not get paid based on how many patients they see. They make the same salary whether they see one patient a day or 50 patients a day. Procedures and lab tests are done on site and usually have to be approved by the HMO before the doctor can perform them. The advantage of an HMO is that it is usually the cheapest for the patient. The premium for this type of plan is usually much cheaper than the traditional or PPO plans and most of the time you are not covered if you choose to see a provider outside the HMO network. Also, many times HMO's are local networks and if you leave the area (visiting or vacation) and you need medical services, it may be difficult to find a provider who will accept your insurance.

Lately, many Medicaid patients are being approached by employees of HMO's and other insurance companies as they leave hospitals or clinics, trying to persuade them to sign up with their insurance company instead of using Medicaid. Sometimes these policies offer more benefits than Medicaid, sometimes not. Read the policy carefully before signing. Some questions to ask are: Do I have to change doctors? How large is the network? If I sign up with an HMO in Brooklyn and move to the Bronx, can I get medical services at my new location? Are there any drug or medical restrictions on the plan?

These policies are very confusing. If you have questions, ask your present doctor or pharmacist what they think of the plan (many times they already have patients using the plan).

As a final note, remember it is summertime and many medications can cause reactions with the sun. Check with your pharmacist to see if any medications you are taking can cause sensitivity reactions with the sun.
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