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State Health Insurance

Managed Care Plans (MCP)

Managed Care Plans (MCP) are health plans designed to offer cost-effective medical care with lower out-of-pocket costs. Individuals receiving care under a MCP are encouraged to have annual preventive physicals and seek early treatment if they become ill. When considering an MCP, special attention should be directed to the participating physicians and hospitals that you are required to use for maximum benefits.

MCPs contract with a network of physicians and hospitals to deliver or arrange for the delivery of covered services. There are two types of MCPs: Health Maintenance Organizations (HMOs) and Open Access Plans (OAPs). Employees enrolling in an OAP do not need to select a Primary Care Physician (PCP). Employees enrolling in an HMO must choose a PCP from a list of contracted physicians who will coordinate and manage your care.

If your designated PCP leaves the HMO network, within 60 days of the event you may:

  • Choose another PCP within that plan;
  • If the health plan network experienced a significant change in the number of medical providers offered, as determined by CMS.
    • Change to a different managed care plan; or
    • Enroll in the Quality Care Health Plan.

Depending on your geographical location, you can choose either a Health Maintenance Organization (HMO) plan or an Open Access Plan (OAP). Please view the FY 2018 Health Care Plan map (as of July 1, 2017) for the available plans in your area.

Prescription drug deductibles and copayments you pay apply to your out-of-pocket maximum; therefore, when you reach your out-of-pocket maximum, eligible medical, behavioral health and prescription drug charges will be covered at 100 percent for the remainder of the plan year.

Points to consider in making this choice:

  • There is little, if any, paperwork with an HMO.
  • HMOs have restricted service areas. When traveling outside of the plan's service area, coverage is for life-threatening emergency services only. For specific information regarding out-of-area services or emergencies, contact the HMO.
  • The PCP selected from the list of participating physicians will coordinate all care in an HMO plan.
  • Referrals for specialty care are restricted to those services and providers authorized by the designated PCP under the HMO plan. In some cases, referrals may also require pre-approval from the HMO.
  • The use of hospitals is restricted to those affiliated with that HMO and with which the designated PCP or approved specialist has admitting privileges under an HMO plan.
  • Contact the plan administrator to determine the exact coverage for any services. Beyond the minimum level of coverage, MCPs are required to provide, there are differences in covered services and to what extent coverage is provided.
  • Use of pharmacies is restricted to those affiliated with each MCP. Mandatory generic and/or formulary restrictions may apply. Contact each MCP for specific information regarding coverage for prescription drugs.
  • All out-of-network services under the OAP are subject to the maximum allowable charge as determined by the plan administrator. This can significantly affect your out-of-pocket costs.

Additional Resources:

FY 2018 Benefit Choice Options booklet (As of July 1, 2017)
CMS HMO Overview
CMS OAP Overview


Maintained by University Human Resources | Contact Information | Last Update: 21-September-2017 | ID: 58