Managed Care Health Plans

Managed care is a method of delivering health care through a system of network providers. The State's managed care plans include Health Maintenance Organizations (HMOs) and Open Access Plans (OAPs). There are differences in the premiums and copayment amounts among the managed care health plans offered; however, these plans provide comprehensive medical benefits at lower out-of-pocket cost by utilizing network providers. Managed care health plans coordinate all aspects of a plan participant’s healthcare including medical, prescription drugs and behavioral health services. An annual $100 prescription deductible is applied for each individual covered on the plan each plan year.

Members who enroll in a managed care health plan must select a Primary Care Physician or Provider (PCP) from the managed care health plan provider directory or website. Always contact the physician’s office or managed care health plan administrator to find out if the PCP is accepting new patients. Special attention should be given to these participating physicians and hospitals, which Members are required to use for maximum benefits.

If the designated PCP leaves the HMO network, there are three options:

• Choose another PCP with that plan,
• Change managed care health plans, or
• Enroll in the QCHP indemnity plan.

This opportunity to change health plans applies only to the PCP leaving the network. It does not apply to hospitals, specialists or women’s healthcare providers who are not the designated PCP.

Members are notified in writing by the managed care health plan administrator when a PCP network change occurs. Members have 60 days to select a new PCP or make a health plan change.

There may be managed care health plans that are self insured and administered by the State of Illinois, meaning all claims are paid by the State of Illinois even though managed care health plan benefits apply. The plans are not regulated by the Illinois Department of Insurance and are not governed by the Employees Retirement Income Security Act (ERISA).

In order to have the most detailed information regarding a particular managed care health plan, you may ask to receive a plan’s Summary Plan Description (SPD) which describes the covered services, benefits levels and exclusions and limitations of the plan’s coverage. The SPD may also be referred to as the Certificate of Coverage or the Summary Plan Document.

Pay particular attention to the health plan’s exclusions and limitations. It is important that you understand what services are not covered under the plan. If you decide to enroll in a managed care health plan, it is essential that you read your SPD before you need medical attention. It is your responsibility to become familiar with all of the specific requirements of your health plan.

In most cases a referral for specialty care will be restricted to those services and providers authorized by the designated PCP. In some cases, referrals may also require pre-approval from the managed care health plan. To receive the maximum hospital benefit, your PCP or specialist must have admitting privileges to a network hospital.

For complete information on specific plan coverage or provider network, contact the managed care health plan and review the SPD.

NOTE: Managed care health plan provider networks are subject to change. Always call the respective plan administrator for the most up-to-date information.­

HMO Members must choose a Primary Care Physician or Provider (PCP) who coordinates the medical care, hospitalizations and referrals for specialty care.

HMOs are restricted to operating only in certain counties and zip codes called service areas. There is no coverage outside these service areas unless pre-approved by the HMO. When traveling outside of the health plan’s service area, coverage is limited to life-threatening emergency services. For specific information regarding out-of-area services or emergencies, call the HMO.

Like any health plan, HMOs have plan limitations including geographic availability and limited provider networks. Most managed care health plans impose benefit limitations on a plan year basis (July 1 through June 30); however, some managed care health plans impose benefit limitations on a calendar year basis (January 1 through December 31). Contact the managed care health plan for additional information.

NOTE: When a managed care health plan is the secondary plan and the plan participant does not utilize the managed care health plan network of providers or does not obtain the required referral, the managed care health plan is not required to pay for services. Refer to the plan’s SPD for additional information.

The Open Access Plan design combines similar benefits of HMOs and traditional health coverage. OAP plans offer two managed care networks, referred to as Tier I and Tier II. Enhanced benefits are available by utilizing providers in Tiers I and II. In addition, Tier III benefits (out-of-network) are available so plan participants can have flexibility in selecting healthcare providers. The provider and tier selected for each service determine the level of benefits available.

The OAP plans allow plan participants to mix and match providers. For example, the plan participant can utilize a Tier II physician and receive care at a Tier I hospital. The OAP plan administrator can provide a directory that contains listings of the Tier I and Tier II networks. The benefit level for services rendered will be the highest if selecting Tier I providers.

• Tier I is often a 100% benefit after a copayment.
• Tier II is generally a 90% benefit with a 10% coinsurance after the annual plan deductible is met.
• Tier III (out-of-network) is generally paid at 60% of the Usual and Customary (U&C) charges after the annual plan deductible is met.