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Managed care

Are you covered?
If you or a family member needed mental healthcare, would your insurance policy cover the costs? Benefits for physical and mental health problems are often different and the rules for using these benefits are often different, too.

Frequently, a managed care organization acts as a "gatekeeper" over insurance benefits. Managed care is a means of providing healthcare services by limiting access to a defined network of healthcare providers who have contracts or agreements with the managed care organization (MCO). The MCO is given the responsibility to manage the payments that are made to it "up front" to provide quality, cost-effective healthcare within those dollar limits.

Insurance used to be almost exclusively on a "fee for service" basis, providing the insured with complete freedom to choose their doctors, hospitals and other healthcare providers. Managed care was introduced as a means of controlling the rising costs of healthcare. To control costs, MCOs limit consumer choice to those providers who have entered into a contract or agreement with the managed care organization. The contracts require providers to follow certain rules and to discount fees in return for being listed as providers with that organization. One such rule is the requirement that a doctor or hospital receive preauthorization before services are provided.

Three out of four insurance plans through employers are managed care plans, rather than traditional insurance.

It is important that you, as a consumer, understand your insurance policy. The services and terms of your care depend on the particular policy you have. It is very important that you have accurate information on what your benefits are and what you need to do to get services when you need them.

Stay informed
Here are some tips to help you better understand just what your health insurance covers and what it doesn't:

  • Read your health insurance policy and member handbook. Make sure you understand them, especially the information on benefits, coverage, and limits. Sales materials or plan summaries cannot give you the full picture.
  • Most insurance or health benefit cards have a telephone number on the back that you can call for more information. When you do that, be sure to get the name of the person with whom you speak so that you can call again if necessary.
  • Talk to your health benefits officer at work to learn more about your policy.
  • Ask how the plan will notify you of changes in the network of providers or covered services while you are part of the plan.
  • See if your plan has a magazine or newsletter. It can be a good source of information on how the plan works and important policies that affect your care.

What you need to know
As you learn about your health insurance coverage, make sure you find the answers to these questions:

  • Do I have coverage under a managed care or a fee-for-service type of plan?
  • Am I in a Health Maintenance Organization (HMO)?
  • How do I know who the doctors and other providers are under my contract?
  • Can I go to providers other than the ones listed in my plan? If so, is there an additional fee charged to go "outside the network?"
  • What do I need to do before making an appointment for mental health services?
  • Do I need prior approval or precertification?
  • What should I do in case of an emergency?
  • What are the benefits and limitations under my contract for inpatient, outpatient, substance abuse and other mental healthcare?
  • Do I pay anything at the time of service?
  • What if I am taking or am prescribed a medication that is not on my plan's formulary (list of medications approved for payment)?
  • What happens if my policy or managed care organization changes? Can I stay with the same doctor or therapist?
  • What if I have problems getting the care I need? Is there a grievance procedure or other means of recourse?

If you have a complaint about your insurance carrier or cannot get anyone to answer your questions, you can call the Kentucky Department of Insurance at 1-800-595-6053.

It is very important to understand the benefits available within your insurance policy. When a health issue arises, the main concern is getting better, not insurance coverage. However, financial health must also be considered and it makes sense to use the insurance coverage that is available to you.

Baptist Health Louisville can help
When a mental health issue arises, knowing where to go, what to do and how to access insurance can be very important. To make finding help easier and less stressful, Baptist Health Counseling has an Access Center. The Access Center is open 24 hours a day, 7 days a week and can answer your questions about mental health. A psychiatric nurse or therapist is always available and can suggest the best course of action for receiving care. Specially trained professional staff within the Access Center are very knowledgeable about insurance coverage and can advise you on how to access benefits. The Access Center can be reached at (502) 896-7105 or toll-free 1-800-478-1105.