Managed Care: Questions and Answers for ESRD Patients

Managed Care: Questions and Answers for ESRD Patients

What is managed care?

There is no standard definition of managed care. But, basically, it is a system which provides quality health care while keeping costs down by coordinating or managing services.

There are many different managed care organizations. A managed care organization may be a group of physicians, a hospital or any organization that is responsible for the delivery of health care to the people enrolled in it.

A managed care plan is a type of insurance policy that covers varying costs of your medical care. There are two main types of managed care plans: HMOs and PPOs. See below to learn more.

What is an HMO?

HMO stands for health maintenance organization. An HMO is one type of managed care plan. An HMO covers health care costs and provides health care services in exchange for a single payment per patient.

Typically, with an HMO plan you choose a primary care physician (PCP) and all your healthcare needs are coordinated through your PCP.  

you need a referral from your PCP to see specialists.

What is a PPO?

PPO stands for preferred provider organization.  PPO plans often offer more flexibility so you can go to any health care professional you want without a referral—inside or outside of your network.  

Staying inside your network means smaller copays. If you choose to go outside your network, you'll have higher out-of-pocket costs, and not all services may be covered.

If I have Medicare, can I also be enrolled in an HMO?

 

That depends. Some HMOs have contracts with Medicare. If you were already enrolled in an HMO before developing ESRD, you are permitted to remain enrolled if your HMO has a contract with Medicare. At present, however, ESRD patients who are not already enrolled may not enroll in HMOs with Medicare contracts.

If I cannot enroll in an HMO with a Medicare contract, how are costs for ESRD treatments covered?

As a U.S. citizen, you are eligible for traditional Medicare coverage if you or spouse have worked and paid into FICA, no matter what your age, on the basis of ESRD. The Medicare ESRD Program pays for 80% of the treatment costs for dialysis patients, and 80% of the cost of immunosuppressant medication for transplant recipients. Medicare will cover 100% minus the deductible of the costs of a kidney transplant.   If you have a transplant, Medicare may terminate after 3 years, unless you are over 65 or have another disability.

If you are also covered by an employer group health plan, that plan may pay for treatment costs initially (30 months) while Medicare covers a part of the remaining costs. Then, after 30 months, Medicare begins to pay 80% and the employer group health plan becomes the secondary payer.

 

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