WHAT EVERY PERSON WITH A DISABILITY SHOULD KNOW ABOUT MANAGED CARE PLANS

ELLEN GRABOIS, J.D., LL.M.

Introduction

Many individuals with disabilities have complex health care needs that may require frequent medical contacts. This can be a problem in managed health care plans. Certain features work well for persons with disabilities in managed care organizations (MCOs) and others do not. Persons with disabilities enrolled in MCOs must educate themselves so that they can wisely choose the best health insurance plan and advocate for change in the system.

What are managed care organizations (MCO's)?

Managed care organizations such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) control health care costs by paying pre-arranged fees to health care professionals, by reviewing all procedures and tests, and by reducing the amount of health services available to you. You may have a primary care physician (family or general practice physician) who acts as your gatekeeper, and who approves all referrals to specialists and all tests and procedures.

How many people in the United States are in MCOs?

In 1996, it was estimated that 100 million Americans were in managed health care plans. Many individuals with disabilities are included in this number.

What are HMOs and PPOs?

HMOs, or health maintenance organizations, provide health care services to their covered members. Many individuals join HMOs through their employers or other groups. Physicians may be employed by the HMO, or may have a contract with the HMO. They are paid a fixed fee per patient to take care of the covered members' health care needs. Usually patients are limited to choosing only HMO physicians. All health care services are tightly controlled by assigning patients to gatekeeper physicians who must approve all procedures, tests and referrals to other physicians.

PPOs, or preferred provider organizations, are entities in which a group of physicians contracts with employers or health insurance carriers to provide health care services to covered persons on a discounted basis. Enrollees may have more flexibility in picking physicians than in HMOs. Patients who use physicians or providers in the plan get the maximum benefit of the plan and may have to pay only a 10% co-payment. Using a provider outside the plan may mean the enrollee has to pay a 30-40% copayment.

What features do individuals with disabilities like about their MCOs?

Small co-pay for doctors' visits.
Medications at low cost.
Equipment (i.e. wheelchairs and braces) covered in whole or in part.
Preventive health care procedures such as nutritional information, mammograms, pap smears and eye exams.
After-hours clinics.
Some physical therapy and counseling services.

Other important features cited by persons with disabilties included:

Ability to establish a relationship with the primary care physician and to communicate with him or her.
Ability to get second opinions.
Using the gatekeeper physician as an intermediary with specialists.

What features about MCOs are problematic for persons with disabilities?

Their primary care physicians do not know how to treat their disabilities.
Physician office visits are sometimes brief.
Communication sometimes breaks down between patients and their primary care physician and their specialist physicians.

Doctors' offices have inaccessible equipment.
The apprpriate specialist withknowledge about your disability may not be in plan.
The most effective medications are not in the plan formulary (list of medications).
There are limits on physical therapy and counseling services.

What can MCOs do to improve services to persons with disabilities?

Provide training for gatekeeper physicians to treat persons with disabilities.
Use specialists as gatekeeper physicians.
Permit longer doctor visits for persons with disabilities.
Supply more assistive devices to persons with disabilities.
Develop and implement plans to assist doctors and other providers to evaluate their offices for inaccessibility and compliance with the Americans with Disabilities Act.
Have flexible rules concerning their formularies (list of medications), so
that individuals with disabilities can get the most effective medications for their chronic conditions.

What can a person with a disability do in getting what he or she needs from the MCO?

Be an advocate for yourself and speak up when problems arise.
Appeal decisions with which you do not agree.
Be informed and knowledgeable about your disability.
Join support groups to get more information about your disability.

The Center for Research on Women with Disabilities (CROWD) is part of the Department of Physical Medicine and Rehabilitation at Baylor College of Medicine in Houston, Texas. CROWD is committed to expanding the life choices of women with disabilities so they may become more healthy, more independent, and better able to participate in community life. For further information on our programs and publications, please contact:

The Center for Research on Women with Disabilities
3440 Richmond Avenue, Suite B
Houston, TX 77046
(713) 960-0505 voice/TDD
(713) 961-3555 Fax
1-800-44CROWD (1-800-442-7693)
www.bcm.tmc.edu/crowd/

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Center for Research on Women with Disabilities
3440 Richmond Avenue, Suite B - Houston, Texas 77046
Phone: 713-960-0505 Toll Free: 800-44-CROWD Fax: 713-961-3555
email: crowd@bcm.tmc.edu