Kids and Health Care: Switching to Managed Care

If you switch your coverage from traditional insurance to a managed care plan -- and your personal physician isn't in the managed care plan's network -- you probably can't continue to go to the same doctor. And, even if he or she is a member, your office visits still may be restricted, especially if your doctor is a specialist.

Most managed care plans require you to choose a primary care doctor from their list of doctors. This doctor, also called a gatekeeper, controls your access to medical care. And unless your primary care doctor decides your medical problem is outside his own realm of expertise, you cannot see a specialist.

The principal objective of managed care is cost control. The plans control costs by:

• stressing preventive medicine -- physical exams and diagnostic procedures;
• reducing the number of unnecessary hospital admissions;
• reducing the average number of days per hospital visit;
• reducing duplication of benefits; and
• saving on administrative costs.

A federal employee benefit law passed during the 1970s requires employers who offer health care benefits to offer enrollment in a managed care plan as an alternative to indemnity insurance. Employers falling under this Act are those that:

• have 25 or more employees and are within the service area of a federally qualified HMO;
• are paying at least minimum wage; and
• offer a health plan to their employees.