Managed Care Frequently Asked Questions?

What is a managed care organization?

In Connecticut a managed care organization (MCO) is defined as a company that offers a health plan that includes a network of providers and utilization review.

Which MCO is right for me?

Think about what is most important to you in an MCO: low cost; availability of a specific physician, clinic, or hospital; freedom to see any physician you want; or convenient location facilities.

In completing the application, I had to choose a primary care physician. What does that mean?

Your primary care provider is responsible for managing your health care needs. Many MCOs require its members to receive all care from the primary care physician or with a referral from the primary care provider.

What can I do if I want a different primary care physician?

Every plan has its own procedures for changing primary care providers. Some plans will only allow you to change primary care providers once during the plan year. Others allow you to change as often as you like. This should be explained in your member handbook or your employer may be able to assist you.

What happens if I need immediate care?

If you need emergency care, most plans will allow you to go to the nearest provider. If you need immediate care which is not life-threatening, you may be required to go to an urgent care facility or other participating provider. You should always contact your primary care physician or MCO as soon as possible if you need emergency care. Some plans will not cover services for a nonplan provider if you do not contact them within 24 hours after receiving the care.

Does it matter if the specialist to whom I am referred is a plan provider?

Yes. Most managed care plans will require you to see a specialist who is a plan provider if one is able to provide the services you need.

My primary care provider referred me to a nonplan provider. Do I have to contact the insurance company before my appointment?

Yes. Most managed care plans require a referral to a nonplan provider be authorized by the MCO before the appointment. In some cases, your primary care physician may submit the referral request to the MCO for you, and the MCO will send you a notice letting you know if the referral has been approved. In some cases, you may be required to contact the MCO directly. In any case, if you have not received the authorization from the MCO prior to your appointment, you should contact the company to determine if the service will be covered.

How are students or dependents living out of the service area covered?

Dependents who live out of the area are generally covered for emergency medical problems. The dependent would be required to receive all follow-up care and routine care from participating providers in the service area.

Will I incur any liability if I fail to follow the preauthorization requirements?

Yes, if you fail to follow the required preauthorization procedures, you may be required to pay a larger portion of the claim. In some cases, the MCO may determine that the service is not covered under the contract and completely deny the claim.

What is a drug formulary?

Many managed care organizations establish a list of prescription drugs which the plan considers medically appropriate and cost effective. This formulary often requires a generic form of a drug to be used unless there is a valid medical reason to use a drug not on the formulary.

What if I have a complaint?

You should contact the MCO’s customer service department. Many problems can be resolved on an informal basis. You can also file a written grievance. All managed care organizations are required to have a grievance procedure to resolve a member’s problems. This procedure is explained in your member handbook. Grievances are generally resolved within 30 days. If you believe your medical condition needs immediate attention, you may wish to ask that the grievance be considered an urgent grievance

You may also file a complaint with the Consumer Affairs Division of the Insurance Department at any time during the grievance procedure.

My doctor told me he was no longer with the MCO, but I want to stay with him. What can I do?

The agreement between the MCO and your doctor is a separate agreement that may terminate any time during the year. The MCO may require you to choose another doctor. If you are in the middle of a treatment plan, you may ask the MCO if it would negotiate an agreement with your doctor until the treatment is completed. However, the MCO is not required to do this.

If your employer offers other plans, you may wish to consider changing plans during your employer’s open-enrollment period.

My doctor never told me he was no longer with my MCO and the MCO did not tell me either. Now I have all these bills the MCO will not cover. What can I do?

MCOs are required to notify you if it terminates its relationship with your primary care physician within 30 days of the termination

I disagree with my doctor and want a second opinion. Will the MCO pay for it?

While there is no requirement that MCOs pay for a second opinion, most are willing to provide this coverage. You will probably be required to go to a participating provider for the second opinion.