Questions on Managed Care Health Insurance Plans in Virginia

How do I select a managed care health insurance plan (e.g. HMO, PPO)?

Consider what is most important to you in a health plan: cost, availability and location of providers, or freedom to see any doctor. If you like the physician you are currently seeing, check to see if he or she is a provider in the plan that you are considering. If you or a dependent has special medical needs, check that the plan you are considering has adequate medical services and providers for that specialty.

In completing my application for insurance, I noticed that I needed to choose a primary care physician. What does that mean?

Your primary care physician (PCP) is responsible for managing your health care needs. Many managed care plans require their members to receive care from the PCP or obtain a referral from the PCP to receive care from a specialist.

May I use any provider that I choose under the plan?

If you are covered under an HMO, in most cases you will need to receive all services from your PCP or other participating plan providers. Generally, if you are covered under a PPO or POS, you will be able to choose any provider. However, you will be required to pay a larger portion of the bill if you use a non-participating (or non-preferred) provider, and you may be required to have some services preauthorized by the insurance company. Your member handbook or EOC should explain the requirements specific to your plan.

What can I do if I want a different primary care physician (PCP)?

Follow the plan's procedures for changing primary care providers. Consult your member handbook or EOC, or your employer may be able to assist you.

What can I do if my doctor says I need a medical procedure and my managed care health insurance plan says it's not medically necessary?

If you are a participant in a Managed Care Health Insurance Plan (MCHIP), you have the right to request a copy of any utilization-review policy and procedures your plan uses to determine medical necessity for a medical condition. You have the right to file an appeal requesting reconsideration. Consult your doctor and submit any additional important information with your appeal. Your insurance company must have a medical doctor determine if a treatment is not covered due to medical necessity. You have the right to seek assistance from the Bureau of Insurance, Office of the Managed Care Ombudsman, and your situation may be eligible for further consideration through the Independent External Appeals process.