Managed Care - HMOs and PPOs are managed care plans. Any plan that requires pre-approval for treatment, authorization for continued treatment, or limited access to health care providers is a managed care
plan. These plans are called managed care because the insurance company "manages" or oversees access to health care treatment, and controls the costs of treatment through this management process. The
company determines whether you require treatment based on their assessment of your problem. The company controls access to providers, telling you who you can see for treatment. The company controls what type of
treatment you can receive, by limiting payment for authorized services only. The company controls length of treatment and frequency of treatment appointments, by authorizing only those services it feels are
necessary.
Point of Service or Indemnity coverage - This is the traditional insurance coverage that was, until recent years, most common. The insurance company determines what types of services are covered under your
health care plan, and the credentials required of providers. Typically, health care providers must be licensed to practice their specialty in the state in which they practice, and their profession must be
qualified to provide the services rendered (based on their license). You may choose any licensed provider in your community. You may choose a specialist out of your area for treatment. Coverage is based on a
percentage of the usual customary fee for that service in your area. You are responsible for part of the fee, and usually also have to pay an annual deductible. Sometimes there is an annual maximum dollar amount
of coverage, or a maximum fee per service, or a lifetime maximum coverage for services. If the insurance company feels that treatment is not necessary, they can request a review by the state licensing board, or
use other acceptable practices for reviewing treatment necessity.
