FOREWORD
This is a time of tremendous change in the delivery
of health care. In the private sector, a growing number of traditional health
care indemnity insurers are designing and offering a wide variety of managed
care products. In Medicaid, States are aggressively pursuing Medicaid waivers
to develop health delivery programs that provide greater flexibility and
enhance the state's ability to act as a prudent purchaser of health care
for its vulnerable population groups. Within the Medicare program, over eleven
percent of all Medicare beneficiaries have chosen to enroll in
Medicare-contracting managed care plans. In turn, managed care plans desiring
to contract with Medicare to provide services to our customers grew at a
rate of over 25 percent during 1995.
As the new Director of the Office of Managed Care,
and former legal aid attorney and patient advocate, you may be interested
to know how I plan to enable this organization to meet the new challenges
posed by the needs of a growing Medicare managed care population, the
Medicare-contracting managed care plans, and those who are concerned about
the interaction between the two.
We will improve our operational efficiency in areas
which will enable us to serve as a catalyst for positive changes within this
evolving managed care population. The kinds of changes that I believe will
help to guide the program through this new era include; (1) health plan
accountability, (2) quality improvement, monitoring and enforcement, and
(3) beneficiary information and empowerment.
We want to provide a broader array of information
about participating plans to help make health care decision making less
burdensome and more beneficiary-friendly. In this document, you will find
information about the new Out-of-Network/Point-of-Service option
being offered by some managed care plans and an expanded section on
Appeals. Please let us know if the information is helpful and what we
can do to make this document a better resource for you.
Managed care can be a quality health care choice
for many Medicare beneficiaries. We encourage the use of this document in
that process. Additional resources are available from the local Health
Insurance Counseling Programs, which are listed elsewhere
in this document.
I hope that this directory assists Medicare beneficiaries in getting the best possible health care.
WHAT'S NEW IN THE 1996 DIRECTORY?
The 1996 Directory includes information about a new product, program changes
and responds to many of the inquiries and suggestions we have received over
the past several years. The Directory includes:
SECTION I: An expanded Beneficiary Rights
and Information section - providing additional information to assist
beneficiaries in becoming better informed consumers, to understand a greater
number of managed care related issues and to provide support for the most
effective health care decision-making process.
The Medicare SELECT information has been
updated to reflect the expansion of the product which some plans may offer
beginning in 1996.
We have included information about the new
Out-of-Network/Point-of-Service product which some plans may offer beginning
in 1996.
We have expanded the Appeals, Complaints and
Grievances section to provide more information about appeals where the
beneficiary has requested a reconsideration of an unfavorable decision by
the managed care plan.
SECTION II: WHERE TO OBTAIN HELP - contains
information to assist you in contacting HCFA Regional Offices, Health Insurance
Counseling Programs, State Insurance Departments and Peer Review Organizations.
TIPS FOR USING THIS DIRECTORY
The information in this Directory has been developed to assist SSA workers
and other Directory users in locating Medicare-contracting coordinated or
managed care plans near the residence of potential enrollees. The directory
is updated through January 1996 and provides information in the following
manner:
All plans are listed within Regions.
Regions are broken into States and the plans are
listed in alphabetical order.
All counties (full and partial) included in the plan's
service area are listed. Some plans provide services only in specific zip
codes within a county. For more information about the plan, services provided,
limitations or the zip codes in the counties serviced by the plan, please
call the plan directly.
Plans which provide services in counties across two
or more State lines are listed in each State. However, only the counties
for a particular State are listed in the State. Plans which have more than
one type of contract or agreement with HCFA may be listed one or more
times.
USING THE KEY: The various types of managed
care plans may be identified by the Key which follows each plan address.
The Key is constructed to indicate the State in which the plan is
located and what kind of contract or agreement the plans has with HCFA.
The five digit number in
parenthesis at the end of the Key is the HCFA-assigned number for
a particular plan. Multiple numbers are provided in instances where more
than one HCFA contracts exists.
Just a reminder.
We have not separately identified partial counties in the plan listing.
Therefore, it is important to remember that some plans may not provide
or arrange for services to be provided in all parts of the counties listed.
The plan's representative can tell any potential enrollee whether he or she
lives in the plan's service area.
We have included supplemental information in this document which may be useful
in assisting individuals with various health care and insurance-related needs.
This additional information includes HCFA Regional Office contacts and a
listing of State Insurance Commissioners and telephone numbers for Insurance
Counselors.
(For more information about the differences among managed care plans, SSA
workers may consult POMS HI 00208.070. Other interested individuals
may wish to review HCFA publication #02195, Managed Care Plans.
NOTICE: The annual update of the Directory
will be available around the spring of each year from the Health Care Financing
Administration. If you have corrections, additions or suggestions for making
this a more useful document, please use the form at the back of the Directory
to address those issues. Also, this Directory is available on 31/2 inch
diskettes, WordPerfect for Windows 6.1 format. Requests for diskettes should
be forwarded to :
ATTN:
Margie Sharif/Office of Managed Care
Health Care Financing Administration
7500 Security Boulevard, Rm
S3-02-1
Baltimore, Maryland 21244-1850
The
Medicare Managed Care Resource Information Directory is on the World Wide
Web and can be found under the Medicare button of the home page at:
HTTP://WWW.HCFA.GOV/
Source:>
Department of Health
and Human Services
Health Care Financing Administration
Office of Managed Care
Health Care Financing Administration
Office of Managed Care
Baltimore, Maryland 21244-1850
May 1996
Donna E. Shalala, Secretary
Bruce C. Vladeck, Administrator
Bruce M. Fried, Director
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