Managed Care & Medicare Issues

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Managed Care Issues

Managed Care Health Insurance Plans

Managed Care Health Insurance plans (also known as an HMO - Health Maintenance Organization, or EPO - Exclusive Provider Organization) most often are plans that require members to choose a Primary Care Physician (PCP), and often require that referrals are initiated from the selected PCP to see a Specialist. The referrals are usually within the Plan's selected network of providers. 

What is a PCP?

A Primary Care Physician (PCP) is a doctor who will provide and coordinate all of your medical care. PCP's have specialties in:

  • General Internal Medicine
  • Family Practice/General Practice
  • Pediatrics

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Many health insurance plans have pre-certification or prior authorization requirements for specific services. In some cases referrals are required. Information about these requirements is usually listed on the back of your health care insurance card. Please refer to your card, your benefits handbook, or contact the member responsibility to complete these requirements.

Some important items to remember when obtaining an authorization or referral include:

  • Be certain the referral is for a service covered by your Health Plan.
  • The referral should be to a Provider within your Health Plan's network.
  • Check for limitations on the referral. For example, number of visits allowed, or expiration date.
  • Contact your PCP about a referral prior to your specialty appointment 

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Medicare Information

2015 Medicare Deductibles and Coinsurance

Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2015 = $1,260) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.

For each benefit period you pay:

  • A total of $1,260 for a hospital stay of 1 to 60 days.
  • $315 per day for days 61 to 90 of a hospital stay.
  • $630 per day for days 91 to 150 of a hospital stay LRD (Lifetime Reserve Days).
  • All costs for each day beyond 150 days

Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services, durable medical equipment)

  • $147.00 per year.
  • (Note: You pay 20 percent of the Medicare-approved amount for services after you meet the $147.00 deductible.)

Additional information about the Medicare premiums, deductibles, and coinsurance rates is available at

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Important Information for Medicare Patients Concerning Non-covered Services

What is "Medical Necessity"?

Medicare covers only those services which are reasonable and necessary for your treatment. Medicare requires all providers to report information regarding the patient's diagnosis when seeking payment so that they can determine whether the services ordered were medically necessary.

What are my rights as a patient?

As a Medicare beneficiary, you have certain guaranteed rights. These rights protect you when you receive health care services. Your rights include, but are not limited to:

  • The right to information about what services are covered and how much you will have to pay.
  • The right to information about all treatment options available to you.
  • The right to appeal decisions by Medicare to deny or limit payment for medical care.

What is an ABN?

An Advanced Beneficiary Notice (ABN) is a written notice (the standard government form CMS-R-131 ), that you may receive before a service or item is furnished to you. The form is to notify patients covered by Medicare that Medicare may deny payment for that specific service or item.

Medicare patients may also be issued an ABN for services or items that are covered by Medicare, but that are only covered up to a certain number of times within a specified amount of time (once every 12 months for example). Examples of so-called "frequency limited" services include laboratory tests, some preventive screening tests, and vaccinations. If you receive an ABN that gives a frequency limit as its reason, it means that Medicare will not pay if you exceed that limit on the service. Otherwise, Medicare may pay. 

  • The ABN protects you from unexpected financial liability in cases where Medicare denies payment. This allows you the opportunity to choose whether or not to receive the service or item.
  • The ABN helps you to make an informed consumer decision about whether to obtain the service or item and be prepared to pay for it (that is, either out of your own pocket or by your other insurance coverage) or to choose not to receive it.
  • The ABN allows you to have your claim reviewed by Medicare if you do receive the service or item. This also means that you will have the right to appeal Medicare's decision.

Additional questions about Medicare ABNs can be answered by the local Medicare Contractor that handles your Medicare Claims. Please contact your Medicare Carrier (for Part B or physician related claims), Fiscal Intermediary (for Part A or hospital related claims). Or, please call (800) MEDICARE (1-800-633-4227) for additional information.

Do I need the service if Medicare will not pay?

Your physician bases decisions on a wide range of factors including your personal medical history, any medications you might be taking and generally accepted medical practices. Even if your physician believes a particular test/service is "good medicine" and useful information to have in order to provide the best care for you, it is possible Medicare may not consider the service to be medically necessary for patients with your diagnosis.

What if I have questions?

Additional information on ABN's, non-covered services and your rights as a Medicare Beneficiary is available on Medicare's website or by calling (800) MEDICARE (1-800-633-4227).

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