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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.
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