Managed Care Plan Questions to Ask

Fee-For- Service Questions:

What is the monthly cost? How much does this total annually? Are

there variations of rates depending on individual or group/family

status?

What does the plan cover and not cover? Does it include

prescriptions (brand or generic), in and out-patient care,

rehabilitation, disability care, surgery, and other core services?

What pre-existing conditions are automatically barred? What waiting

period or probation window is involved for new members?

Does the plan include capitations, ceilings, premiums, and/or

deductibles? Is the deductible an adjustable amount? Is it per

incident or does it have aggregate or lifetime amounts? Are there

copayments and costs that are covered only partially?

HMO Questions:

Is the list of allowable network doctors and providers expansive or limited? Are they open to new members or mostly closed?

Does the member choose which doctor or is the assignment determined by the HMO?

What limitations or restrictions exist on changing doctors? What is the process for getting a recommendation to a specialist

from general care?

How impacted are the services in terms of waiting for an appointment? What is the expected calendar delay from the time of

call to actually having an appointment? If emergency room care is needed, what costs and restrictions apply?

What services are not covered by the HMO? Which ones are partially covered? Which ones are fully covered?

What is the exact territory and coverage area of the local HMO network? Are these locations clustered in urban areas or

generally accessible to rural areas as well? What are the restrictions to getting care covered when out-of-town or travelling?

What prescriptions, brand and/or generic, are covered?

Questions for a PPO

Is the approved medical provider list expansive or small? Which ones are preferred provider status? Are the locations

practical or impractical? What is needed to get seen by a specialist?

Which medical facilities are included and are they reasonably located? What happens when emergency room care is

necessary?

Which services are fully-covered, partially-covered, and not covered? What sort of prevention programs are included in the

PPO managed care plan? Are there deductions, premiums, capitations and/or limits?

What is the monthly and annual cost for the PPO plan? What variations exists between preferred providers and providers

who are out of network?

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