Managed Care

If you’re a member of HMO Illinois, Blue Advantage, Blue Precision, Silver Cross Health Connection is a physician-hospital organization (PHO) made up of independent physicians who have been approved by these managed care providers to treat patients within the Silver Cross Health Connection network. Silver Cross Health Connection makes it easy to choose a covered provider or medical group for you. You’ll have access to over 500 independent primary and specialty care physicians* within this network under your plan, as well as the ability to be treated by your independent provider at Silver Cross Hospital. These independent providers even include Modern Pain Consultants.

*All physicians, physicians' assistants, and nurse practitioners are independent contractors and not agents or employees of Silver Cross Hospital.

Choosing a Managed Care Health Plan

It used to be that selecting a health plan was a relatively simple process. Your employer offered to enroll you in the company plan, and once you signed on the dotted line, most of your health care expenses were covered. But times have changed. For many people, choosing health insurance feels like a high-wire act, where even a single misstep might send them into a free fall if illness strikes.

Managed care is still the name of the game for many consumers, forcing them to make sense of the alphabet soup of health care delivery systems, most commonly HMOs (health maintenance organizations) and PPOs (preferred provider organizations).

What is Managed Care?
Managed care is a way to ensure that the patient receives the right care, in the right place at the right time. There are two basic types.

HMO vs. PPO
An HMO offers a kind of one-stop shopping for health care. HMOs provide a comprehensive health care services on a pre-paid basis to its members. An HMO member selects a primary care physician as his or her personal doctor and agrees to use only doctors and hospitals affiliated with the HMO. In return, an HMO minimizes out-of-pocket expenses members have to pay when they see doctors. There are usually no deductibles and very small co-payments.

PPOs do not require members to select a primary care physician. However, the PPO members receive financial incentives to use doctors and hospitals affiliated with the PPO. Generally, there are no deductibles and small co-payments. A PPO may pay 50 to 70% of the cost of services provided by a non-PPO affiliated doctor or hospitals.

Being in a managed care plan is different from traditional health insurance. Traditional health insurance pays doctors from each service provided, known as fee-for-service. There are fewer restrictions on what doctors and hospitals you may choose. However, you will pay more in premiums, deductibles, and other expenses than with a managed care plan. Preventative services are usually not covered.

Choosing Wisely
Even if you're among the majority of Americans who obtain your health insurance through your employer, you'll need to choose from among the plans being offered, and make sense of the scope of the coverage and how much you'll be paying out-of-pocket.

Is your own doctor part of the plan, and does he or she expect to stay on the plan?

Before selecting your coverage, choose your physician, and find out what plans she participates in. If you don't already have a primary care physician, you may want to choose one in our online doctor directory. Here you can find information on a doctor's philosophy of practice, where he/she received their training and office hours.

Do you need to see specialists?

If you have a chronic health problem—like diabetes or allergies—or if you develop a serious condition that should be treated by a cardiologist or gastroenterologist, for example, make sure that you can receive care from such a specialist.

Is medical care available close to home? Check the locations of doctors' offices and hospitals that are part of the plan, and make sure they're as convenient as possible.

Is prescription drug coverage adequate? There can be big differences among plans in their medication benefits. Check on co-payments, the pharmacies you can use, and the maximum amounts that the plan pays per year. On many plans, you will have much smaller co-payments when you choose lower-cost generic drugs.

Does the plan offer preventive and other specialized services? Look for plans that cover vaccinations, preventive screenings (such as mammograms), and "well visits" to the doctor. Also, check for coverage for dental and eye care.

How extensive is mental-health coverage? Services by a psychologist or psychiatrist may be limited in the number of office visits and/or the amount of reimbursement per session. There may also be caps on the number of inpatient hospital days for covered psychiatric disorders and substance abuse.

Are "complementary" or "alternative" services part of the plan? Check whether the plan pays for treatment by chiropractors or acupuncturists, for example.

Does the plan have a "lifetime maximum"? There may be a limit to the total health care benefits available to you over a lifetime—typically, $1 million. This may seem like a lot of money, but if you develop a catastrophic illness or have a major operation (an organ transplant, for example), you could be well on your way to reaching the maximum level. For that reason, the higher the cap, the better.

What do your co-workers think of their plan? If you get your health coverage at work, ask your fellow employees whether they're satisfied with the plans offered by your employer. If you are new to the company or the community, co-workers are also a good referral source for choosing a physician and hospital provider.