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Managed Care Mississippi Health Insurance Plans

Managed Care Plans

Every managed care plan must have enough providers so that you can get the care you need without unreasonable delay.

Every managed care plan must file a description of its network of providers and how it makes sure the network can provide health care services without unreasonable delay.

Sometimes, a doctor, hospital, or other health care facility leaves a managed care plan's network. When this happens, a managed care plan must notify you if you saw that provider on a regular basis.

As a covered person, you and your doctor have the right to a complete list of providers that are part of the managed care plan's network. You must get this list when you enroll, re-enroll, or upon request.

Every managed care plan must keep close track of the quality of the health care services it provides.

Managed care plans should not use rewards or penalties that encourage less care than is medically necessary. If you want to know more about how your plan pays its providers, you should ask.

Your managed care plan should notify you if it refuses to pay for a health care service based on a decision that is not medically necessary, efficient, effective or appropriate. The notice should include the main reasons for the denial and instructions on how to appeal.

Every managed care plan should follow certain procedures if it determines that a health care service was not medically necessary, efficient, effective or appropriate. The procedures must be fully described in the certificate of coverage or member handbook.

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