What You Should Know About Vermont Managed Care

What Is "Managed Care"?

Managed care plans are offered through employers and as individual policies, as well. Most of the time care is managed by HMOs (health maintenance organizations) or PPOs (preferred provider organizations), but some, including indemnity insurers, "carve out" some of their benefits and administer them through contracted managed care companies. For example, you may choose among the insurer's network providers for most of your services, but in certain cases such as for mental health benefits or prescription drug benefits, service approval must be obtained from a contracted managed care company. Be sure to check your plan's rules on how to get those services because they may be different than getting other services and from whom you could get them.

Each managed care plan will provide you with a listing of their contracted providers, called a Provider Directory. In most managed care plans, you must choose a primary care doctor (or other health care provider) as your primary care provider from the plan's contracted provider network. Your primary care provider (PCP) coordinates most decisions about the medical care you will get from your plan. Usually you will need to call your primary care provider's office first to get a referral before going to another provider or to the hospital. In most cases, pre-admission authorization will be required for hospital admissions and prior authorization will be required for certain outpatient procedures in order to receive benefits. Read the plan's contract and benefits handbook for more information about these requirements.

Vermont's "Patient Bill Of Rights"

Vermont has a broad set of consumer protections for people insured through managed care plans. Known as "Rule 10," these protections includes your right to quality health care, information about how your plan works, the right to covered services under the terms of your contract and the right to appeal if benefits are denied. Other areas covered by Vermont's patient bill of rights include:

• The right to emergency services. If you have a medical problem that you reasonably believe poses serious risks to your health, managed care plans have to pay for your visit to an emergency room, even if it later turns out there was no emergency.
• Reasonable access to the plan's providers. Managed care plans are required to have enough providers, both primary and specialty care, to care for all of their members. This means that you should be able to see providers relatively close to your home and without having to wait an unreasonable time to get an appointment.
• Access to specialty services. Plans must allow you to see specialists as necessary. This includes the use of "standing referrals" to specialists if you have a condition requiring ongoing care. Plans must also allow specialists to coordinate your care if you have life-threatening, degenerative or disabling conditions.
• Direct access by women to gynecological health care services. Plans must allow women to see their network gynecological health care providers (OB/GYNs or Planned Parenthood, for example) at least twice a year without a referral from their primary care provider for reproductive and gynecological health care services, plus any necessary follow-up services.
• Continuity of care. If you are pregnant and in your second or third trimester when you join an HMO, or if you have a life-threatening, disabling or degenerative condition, the plan must allow you to continue using your out-of-network provider for up to 60 days after your enrollment. You get the same 60-day transition period if your provider is in the plan's network, but decides to leave.
• Consumer information. When you enroll, or upon request, plans must give you basic information about how their plans work and what services are covered. You will also get a handbook that clearly describes in detail what you need to do to get services.
• Confidentiality of medical records. Managed care plans must ensure the confidential handling of your personal health care information. They must also allow you to see your medical records, and to copy them for reasonable fees.

Because federal laws prohibit the state from regulating certain types of employer-sponsored health benefit plans, not every person with comprehensive health coverage in Vermont benefits from Rule 10 or other regulatory protections. If your employer's plan is "self-insured" you will not necessarily have these protections.

The Division of Health Care Administration can give you detailed information and publications about Rule 10 and what to expect if you are insured by a managed care plan. It can also help you find out whether Rule 10 and other Vermont laws and regulations affect your health insurer. Call Consumer Assistance at 800-631-7788 or visit our website at www.bishca.state.vt.us.