Understanding the Provisions of Your Managed Care Plan

The type of plan you have can affect who directs your medical plan of care (the doctor), where that care can be delivered (the facility providing services), the length of time certain services can be administered (precertification/predetermination), and any additional cost of treatment to you (coinsurance).

Managed care, by definition, is a comprehensive method of managing and coordinating medical care you receive. The goal of case management is to coordinate and facilitate access to medical care, while adhering to the guidelines and provisions of your health benefit plan. A wise course of action is to be proactive by finding out what your policy covers and how to access medical care services.

Questions about your coverage

Whether you are newly diagnosed with cancer or facing choices of new or additional treatment recommendations, review your policy for clarification of benefits available regarding health care providers. Providers of medical care mean the doctor managing your medical plan, as well as the facility where that care is delivered. Review all of your covered benefits. Obtain the most current copy of the Provider Membership Directory and read it thoroughly to be sure the providers you want to use are included in it.

The following questions and points of discussion are areas for your review and may serve as a guide to help you solve potential problems.

What do the words usual, customary, and reasonable mean? Is there a limit to the coverage for my particular type of cancer or its treatment?

Usual, customary, and reasonable, often abbreviated on insurance forms as UCR, is a method of determining payment the insurance company will allow for a claim. UCR is determined by the insurer by comparing charges of providers of care to those of like providers of service in the same region or community.

The extent of benefits the insurance company will cover for your particular type of cancer is defined under Limitations. They are important to understand:

  • Limitations are restrictions placed on a benefit. Usually this refers to the number of times for use or the circumstances of use for a particular service or treatment.

  • Exclusions are those services not covered at all. Excluded services can not be accepted as within the scope of medical practice, conditions not considered related to health or illness, or may be specific services excluded from the plan by request of the plan contract parties (generally the insurance group health agent and the group or employer). Experimental Procedures as defined by the insurance company may be found in the list of exclusions.

How is experimental care defined and funded?

When selecting a plan, look closely at the marketing materials supplied by your plan and your employer to see how the plan defines experimental care, and under what conditions the plan might cover such care. This is very important for cancer patients who are joining a new insurance plan, or consumers who believe they are at high risk for the disease (for example, because of a strong family history of cancer). If the plan's materials do not clearly define the term, and how the plan uses it, consumers can ask their employers to let them see the contract with the plan. Consumers also can call the plan and ask plan administrators to provide them with information on the plan's coverage of experimental care, such as use of off-label drugs and care in clinical trials, which are discussed in greater detail below, and guidelines on how the plan decides what care is experimental.

Some consumers in managed care plans have reported problems getting access to care because their plan considers a particular product or service experimental. When plans deny coverage for a service on this basis, the plan will not pay for the care. Most managed care plans routinely exclude experimental care from coverage in their contracts.

While there is no widely accepted and utilized definition of experimental care, plans typically regard it to mean that the medical benefit of a particular service has not been proven to the plan's satisfaction. Thus, each plan defines the term as it wishes and may apply it differently from contract to contract. Some of the things that plans commonly exclude from coverage as experimental are the following:

  • Off-label use of some drugs. In some cancers, health providers and patients want to use a drug for a diagnosis other than what the drug is approved for by FDA. Plans make case-by-case decisions on whether to cover off-label use of the drug and may deem some off-label uses experimental, if the plan believes there is insufficient scientific basis to justify it.

  • New tests or treatments. As medical technology produces new services for cancer patients, managed care plans evaluate these new services to make policy decisions about what they will cover and pay for. They review published medical studies of the new test or procedure and government approvals (where applicable), and consult with leading oncologists. After this review, if the plan's administration believes that a new test or procedure has not been sufficiently evaluated, or its effectiveness is uncertain, the plan may designate the service as experimental and refuse to provide coverage and payment.

  • Clinical trials. Plans may refuse to cover the costs of having their patients treated in clinical trials. Because clinical trials are research studies, some plans may conclude that care in a clinical trial is, by definition, experimental, and therefore, excluded from coverage. For many cancer patients, clinical trials offer state-of-the-art treatment.

The issue of whether something is or is not experimental is not black and white. There is often disagreement among plans, patients, and doctors about whether a service, such as a bone marrow transplant, is an experimental treatment for a particular diagnosis. There have also been many state and federal court cases in which patients and doctors have challenged plans' decisions not to cover and pay for care of a plan labeled experimental, but which the patient and doctor believed appropriate. The courts have ruled that whether a service is or is not experimental may depend not only on published medical studies, but also on whether the doctors in a community believe it is appropriate for a particular diagnosis, as well as expert opinion. Thus, standards of care vary around the country. If a managed care plan refuses to cover and pay for a treatment or test on the grounds that the service is experimental, consumers and their doctors need to work closely together to challenge the decision.

When consumers and their managed care plan disagree over whether a test or treatment is experimental, consumers can appeal the plan's decision. This process starts with notifying the managed care plan. All managed care plans have an appeal process for reviewing denials of care. Consumers should file an appeal by writing a letter to the plan, and get a letter supporting their position from their doctor. The doctor also should submit to the plan copies of medical studies and expert opinion that support the appeal.

If a consumer and a plan cannot resolve their differences, the consumer may want to consider filing a complaint with a state regulatory agency, such as the state health department, insurance department, or attorney general's office. A complaint to these agencies should include copies of all correspondence with the plan and copies of relevant medical studies. The state agency may be able to help mediate a resolution to the complaint, or it may intervene directly on the consumer's behalf if it discovers that the plan is not adhering to the terms of its contract with you or is violating a provision of state law. State laws vary in how much authority these agencies have over managed care plans.

In some cases, consumers need legal help, and might consider filing a lawsuit against the plan to get the care they need. Consumers in a self-insured plan (employers or plans can identify that ones are self-insured) cannot turn to state regulatory agencies for help. They need to speak with a lawyer who has experience helping consumers pursue complaints against self-insured plans. Self-insured plans are regulated by the federal Department of Labor, which generally does not help consumers with complaints over a denial of care on the grounds that it is experimental.

An ethics committee is now part of the formal review system in many managed care organizations. These committees may have medical and legal representatives, ethicists and other health care providers as members. One of the functions of an ethics committee is to review cases in order to develop coverage policies and criteria for benefit application.

What questions need to be answered to define breast cancer coverage?

If you have breast cancer, the following questions may be of particular interest to you. Are the following covered as part of my benefits:

  • Treatment for recurrence of the primary cancer

  • Wigs and hair pieces, breast prosthesis

  • Surgical repair of both breasts even if single mastectomy covered (breast reconstruction)

  • Counseling/supportive services

  • Coverage for new/innovative therapies and biologies

  • Genetic testing for inherited breast cancer, such as BRCA 1 and BRCA 2

  • Contralateral prophylactic mastectomy

  • Molecular/special testing on the tumor to determine recurrence risk (Oncotype DX, Mammoprint)

Is the specialist doctor you want available?

Some policies limit your access to medical care to doctors listed in the Provider Membership Directory. This publication should be available from the customer service department of the insurance company. Obtain the most current copy available. Be sure the specialists listed in the directory are ones with expertise in the treatment of your particular problem and that they are available to you at the time you need them. Confirm with your employer's benefit manager and with the Customer Service Department of the insurance company whether this specialist is included with your plan. Call the doctor's office directly to verify what you have been told by the plan representative and make your appointment. Once you are receiving treatment from the specialist, be sure to periodically check that he remains a participating provider in the network. Do not assume the Provider Membership Directory remains current or accurate for any length of time.

What is the procedure if you need to have tests, to see a specialist or to be hospitalized?

Most health maintenance organization (HMO) plans require you to obtain a referral from your primary care physician to see a specialist or receive special tests and procedures. Plans may vary in the process. HMOs, preferred provider organizations (PPOs), and most fee-for-service plans require approval before admitting patients to the hospital; this is known as precertification. Precertification has a predetermined set of guidelines for hospital admission and length of stay in the hospital. You may want to ask the plan representative what those guidelines are and how many days are approved for a planned hospitalization. Emergency hospitalizations generally have additional or different guidelines. Check your plan.

If you are approved to have a certain type of procedure or treatment, ask where it can be performed. HMOs may use only certain hospitals or a designated medical center as the only place you may go to have a specific treatment.

What if the primary care physician or the plan will not give approval for a referral to a specialist you request?

If your primary care physician or the plan administrator refuses to allow the referral or services you believe you need, find out how you may appeal the decision. The appeal or grievance process is defined in your health plan.

What questions do you need to ask your employer if you become totally disabled?

 If you become totally disabled from cancer and cannot return to work, check for answers to the following questions from your employer benefits manager:

  • How long will the policy stay in effect during a medical leave of absence?

  • How much of the premium must you pay?

  • Are benefits changed or reduced while on disability?

  • If you become eligible for Medical Disability, will the managed care plan agree to become your secondary insurance?

  • What are the short term benefits available through the company disability coverage?

  • What are the long term benefits available through the company disability coverage?

  • Are there specific services or benefits excluded from coverage through the disability plan?

What is the role of utilization review?

Utilization review, or UR, is a process by which an insurer reviews the care a patient receives to assess whether it was appropriate and provided in a cost-effective manner. UR is most often associated with indemnity insurance plans, but also is used in other forms of managed care, such as HMOs and PPOs. In all these cases, UR is a means of controlling the use of services by patients, and thus, the costs of care. Managed care plans use UR in a number of ways:

  • Assess hospital lengths of stay, and keep patients in the hospital no longer than is necessary,

  • Limit the number of visits a patient makes to a particular health care provider, for example a specialist,

  • Choose the setting in which a patient receives care, such as inpatient versus outpatient care, and

  • Manage catastrophic illness, to help coordinate the care provided and to move the patient along from one phase of care to the next.

Ideally, UR should help a consumer get the best care at the best price in the right setting. Consumers in managed care plans can appeal decisions by the plan's UR departments that they believe are inappropriate. They should work with their doctor to document for the UR department their disagreement with the decision and outline why another treatment option is preferable. In fact, under the Affordable Care Act, when treatment is denied, you have the legal right to ask for an internal review and, if this appeal is denied, an independent, external review. This right applies to plans created after March 23, 2010. Finally, if necessary, consumers can also file a complaint with the state agencies, such as the health or insurance departments, or the attorney general's office.

© 2022 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare provider's instructions.