Understanding the Provisions of Your Managed Care Plan
The type of plan you have can affect who directs your medical plan of care (the healthcare
provider), where that care can be delivered (the facility providing services), the
length of time certain services can be administered (precertification/predetermination),
and any additional cost of treatment to you (coinsurance).
Managed care, by definition, is a comprehensive method of managing and coordinating
medical care you receive. The goal of case management is to coordinate and facilitate
access to medical care, while adhering to the guidelines and provisions of your health
benefit plan. A wise course of action is to be proactive by finding out what your
policy covers, how to access medical care services, and how to get a case manager
assigned to monitor and help you access care. The case (or in some settings "care")
manager can be your advocate and help you understand both your health issues and how
to navigate the healthcare system.
Questions about your coverage
Whether you are newly diagnosed with cancer or facing choices of new or additional
treatment recommendations, review your policy for clarification of benefits available
regarding health care providers. Providers of medical care mean the doctor managing
your medical plan, as well as the facility where that care is delivered. Review all
of your covered benefits. Obtain the most current copy of the Provider Membership
Directory and read it thoroughly to be sure the providers you want to use are included
The following questions and points of discussion are areas for your review and may
serve as a guide to help you solve potential problems.
What do the words usual, customary, and reasonable mean? Is there a limit to the coverage for my particular type of cancer or its treatment?
Usual, customary, and reasonable, often abbreviated on insurance forms as UCR, is
a method of determining payment the insurance company will allow for a claim. UCR
is determined by the insurer by comparing charges of providers of care to those of
like providers of service in the same region or community.
The extent of benefits the insurance company will cover for your particular type of
cancer is defined under Limitations. They are important to understand:
Limitations are restrictions placed on a benefit. Usually this refers to the number
of times for use or the circumstances of use for a particular service or treatment.
Exclusions are those services not covered at all. Excluded services can not be accepted
as within the scope of medical practice, conditions not considered related to health or illness, or may be specific services
excluded from the plan by request of the plan contract parties (generally the insurance
group health agent and the group or employer). Experimental Procedures as defined by the insurance company may be found in the list of exclusions.
How is experimental care defined and funded?
When selecting a plan, look closely at the marketing materials supplied by your plan
and your employer to see how the plan defines experimental care, and under what conditions
the plan might cover such care. This is very important for cancer patients who are
joining a new insurance plan, or consumers who believe they are at high risk for the
disease (for example, because of a strong family history of cancer). If the plan's
materials do not clearly define the term, and how the plan uses it, consumers can
ask their employers to let them see the contract with the plan. Consumers also can
call the plan and ask plan administrators to provide them with information on the
plan's coverage of experimental care, such as use of off-label medicines and care
in clinical trials, which are discussed in greater detail below, and guidelines on
how the plan decides what care is experimental.
Some consumers in managed care plans have reported problems getting access to care
because their plan considers a particular product or service experimental. When plans
deny coverage for a service on this basis, the plan will not pay for the care. Most
managed care plans routinely exclude experimental care from coverage in their contracts.
While there is no widely accepted and utilized definition of experimental care, plans
typically regard it to mean that the medical benefit of a particular service has not
been proven to the plan's satisfaction. Thus, each plan defines the term as it wishes
and may apply it differently from contract to contract. Some of the things that plans
commonly exclude from coverage as experimental are the following:
Off-label use of some medicines. In some cancers, healthcare providers and patients want to use a medicine for a diagnosis
other than what the medicine is approved for by the FDA. Plans make case-by-case decisions
on whether to cover off-label use of the medicine and may deem some off-label uses
experimental, if the plan believes there is insufficient scientific basis to justify
New tests or treatments. As medical technology produces new services for cancer patients, managed care plans
evaluate these new services to make policy decisions about what they will cover and
pay for. They review published medical studies of the new test or procedure and government
approvals (where applicable), and consult with leading oncologists. After this review,
if the plan's administration believes that a new test or procedure has not been sufficiently
evaluated, or its effectiveness is uncertain, the plan may designate the service as
experimental and refuse to provide coverage and payment.
Clinical trials. Plans may refuse to cover the costs of having their patients treated in clinical trials.
Because clinical trials are research studies, some plans may conclude that care in
a clinical trial is, by definition, experimental, and therefore, excluded from coverage.
For many cancer patients, clinical trials offer state-of-the-art treatment.
The issue of whether something is or is not experimental is not black and white. There
is often disagreement among plans, patients, and healthcare providers about whether
a service, such as a bone marrow transplant, is an experimental treatment for a particular
diagnosis. There have also been many state and federal court cases in which patients
and healthcare providers have challenged plans' decisions not to cover and pay for
care of a plan labeled experimental, but which the patient and healthcare provider
believed appropriate. The courts have ruled that whether a service is or is not experimental
may depend not only on published medical studies, but also on whether the healthcare
providers in a community believe it is appropriate for a particular diagnosis, as
well as expert opinion. Thus, standards of care vary around the country. If a managed
care plan refuses to cover and pay for a treatment or test on the grounds that the
service is experimental, consumers and their healthcare providers need to work closely
together to challenge the decision.
When consumers and their managed care plan disagree over whether a test or treatment
is experimental, consumers can appeal the plan's decision. This process starts with
notifying the managed care plan. All managed care plans have an appeal process for
reviewing denials of care. Consumers should file an appeal by writing a letter to
the plan, and get a letter supporting their position from their healthcare provider.
The healthcare provider also should submit to the plan copies of medical studies and
expert opinion that support the appeal.
If a consumer and a plan cannot resolve their differences, the consumer may want to
consider filing a complaint with a state regulatory agency, such as the state health
department, insurance department, or attorney general's office. A complaint to these
agencies should include copies of all correspondence with the plan and copies of relevant
medical studies. The state agency may be able to help mediate a resolution to the
complaint, or it may intervene directly on the consumer's behalf if it discovers that
the plan is not adhering to the terms of its contract with you or is violating a provision
of state law. State laws vary in how much authority these agencies have over managed
In some cases, consumers need legal help, and might consider filing a lawsuit against
the plan to get the care they need. Consumers in a self-insured plan (employers or
plans can identify if they are self-insured) cannot turn to state regulatory agencies
for help. They need to speak with a lawyer who has experience helping consumers pursue
complaints against self-insured plans. Self-insured plans are regulated by the federal
Department of Labor, which generally does not help consumers with complaints over
a denial of care on the grounds that it is experimental.
An ethics committee is now part of the formal review system in many managed care organizations.
These committees may have medical and legal representatives, ethicists and other healthcare
providers as members. One of the functions of an ethics committee is to review cases
in order to develop coverage policies and criteria for benefit application.
What questions need to be answered to define breast cancer coverage?
If you have breast cancer, the following questions may be of particular interest to
you. Are the following covered as part of my benefits:
Treatment for recurrence of the primary cancer
Wigs and hair pieces, breast prosthesis
Surgical repair of both breasts even if single mastectomy covered (breast reconstruction)
Coverage for new/innovative therapies and biologies
Genetic testing for inherited breast cancer, such as BRCA 1 and BRCA 2
Contralateral prophylactic mastectomy
Molecular/special testing on the tumor to determine recurrence risk (Oncotype DX,
Is the healthcare specialist you want available?
Some policies limit your access to medical care to healthcare providers listed in
the Provider Membership Directory. This publication should be available from the customer
service department of the insurance company. Obtain the most current copy available.
Be sure the specialists listed in the directory are ones with expertise in the treatment
of your particular problem and that they are available to you at the time you need
them. Confirm with your employer's benefit manager and with the customer service department
of the insurance company whether this specialist is included with your plan. Call
the healthcare provider's office directly to verify what you have been told by the
plan representative and make your appointment. Once you are receiving treatment from
the specialist, be sure to periodically check that he or she remains a participating
provider in the network. Do not assume the Provider Membership Directory remains current
or accurate for any length of time.
What is the procedure if you need to have tests, to see a specialist or to be hospitalized?
Most health maintenance organization (HMO) plans require you to obtain a referral
from your primary care physician to see a specialist or receive special tests and
procedures. Plans may vary in the process. HMOs, preferred provider organizations
(PPOs), and most fee-for-service plans require approval before admitting patients
to the hospital; this is known as precertification. Precertification has a predetermined
set of guidelines for hospital admission and length of stay in the hospital. You may
want to ask the plan representative what those guidelines are and how many days are
approved for a planned hospitalization. Emergency hospitalizations generally have
additional or different guidelines. Check your plan.
If you are approved to have a certain type of procedure or treatment, ask where it
can be performed. HMOs may use only certain hospitals or a designated medical center
as the only place you may go to have a specific treatment.
What if the primary care physician or the plan will not give approval for a referral
to a specialist you request?
If your primary care physician or the plan administrator refuses to allow the referral
or services you believe you need, find out how you may appeal the decision. The appeal
or grievance process is defined in your health plan.
What questions do you need to ask your employer if you become totally disabled?
If you become totally disabled from cancer and cannot return to work, check for answers
to the following questions from your employer benefits manager:
How long will the policy stay in effect during a medical leave of absence?
How much of the premium must you pay?
Are benefits changed or reduced while on disability?
If you become eligible for medical disability, will the managed care plan agree to
become your secondary insurance?
What are the short-term benefits available through the company disability coverage?
What are the long-term benefits available through the company disability coverage?
Are there specific services or benefits excluded from coverage through the disability
Is there a case manager who can work with you to help with your insurance and with
the healthcare system?
What is the role of utilization review?
Utilization review, or UR, is a process by which an insurer reviews the care a patient
receives to assess whether it was appropriate and provided in a cost-effective manner.
UR is most often associated with indemnity insurance plans, but also is used in other
forms of managed care, such as HMOs and PPOs. In all these cases, UR is a means of
controlling the use of services by patients, and thus, the costs of care. Managed
care plans use UR in a number of ways:
Assess hospital lengths of stay, and keep patients in the hospital no longer than
Limit the number of visits a patient makes to a particular healthcare provider, for
example a specialist,
Choose the setting in which a patient receives care, such as inpatient versus outpatient
Manage catastrophic illness, to help coordinate the care provided and to move the
patient along from one phase of care to the next.
Ideally, UR should help a consumer get the best care at the best price in the right
setting. Consumers in managed care plans can appeal decisions by the plan's UR departments
that they believe are inappropriate. They should work with their doctor to document
for the UR department their disagreement with the decision and outline why another
treatment option is preferable. In fact, under the Affordable Care Act, when treatment
is denied, you have the legal right to ask for an internal review and, if this appeal
is denied, an independent, external review. This right applies to plans created after
March 23, 2010. Finally, if necessary, consumers can also file a complaint with the
state agencies, such as the health or insurance departments, or the attorney general's