Question

How do Managed Health Insurance plans define the scope of their Risk Management responsibilities differently from Indemnity and Service plans?

Answer 1

In managed health care insurance plans, a person can avail medical services from a network of health care providers and the customer has the option to choose from these health care provider networks. Here the cost of insurance plan is less and the risk management responsibilities of the insurance company are limited to the host of services provided within the network of health care providers. Any patient who wants to avail the heath care services outside this network may have to pay himself/herself for the treatment and the risk gets transferred to the patients only. However in case of Indemnity and Services plans, the patients have the option to choose the services that they want to avail and also from which doctor/health care service provider they would like to avail. Also the risk is higher for the patients in this case since some of the doctors might want upfront fees from the patients and when the patients claim this fee from the insurance companies, the claim for reimbursement might be denied based on the level of coverage and risks covered. Hence before availing services, it is important to clarify your level of coverage from the insurance companies in case of Insurance and Services plans.