Reimbursements to the patient may be based on the fee negotiated with network providers. While managed care plans will typically allow patients to see a non-network specialist if the plan does not include the needed specialist, the plan usually retains the right to select that specialist. A. Retirees who move away, or dependents who are away at college, may still be covered under the managed care plan. Even employees may live outside the boundaries of the network. The plan should provide for reimbursement equal to that for in-network care for those who do not have reasonable access to network doctors.
Most plans use general practitioners, internists and pediatricians as primary care providers.
A. Most managed care plans require that members obtain a referral to see a specialist. Also, doctors who are not in favor of a particular type of treatment, such as chiropractic care, may hesitate to make referrals, even if the care is covered by the plan. If the plan covers chiropractic or other specialty care, a specified number of visits should be covered without referral. The plan should allow such employees to remain under their current physician s care until that particular treatment has been completed. For such employees, who often have chronic illnesses, the plan should provide for continued treatment for some period of time, phasing out treatment with the current doctor gradually.