UpDate - Vol. 13, No. 29, Page FB-2
April 28, 1994
Flexible Benefits '94-'95
Important to follow managed health care guidelines

     In a time of rapidly rising medical costs, the practice of managed
health care has risen to the forefront.
     Many health insurance companies and employers have implemented managed
care plans and practices to monitor the quality and control the cost of
medical services. Examples of managed care include health maintenance
organizations (HMOs), preferred provider organizations (PPOs), hospital
pre-admission certification, case management, prospective surgical review
and second surgical opinion programs.
     The University of Delaware offers three managed care plans: Principal
Health Care, Total Health Plus and HMO of Delaware.
     In each of these plans, you choose a primary care physician who
directs your medical care. If you need the services of a specialist-other
than for services rendered by approved ob-gyn or eyecare providers-you must
be referred by your primary care doctor. Additionally, you must use only
authorized pharmacies, laboratory, and x-ray/imaging providers in order for
the plan to cover the service.
     The three traditional insurance plans offered through Blue Cross/Blue
Shield also have managed care components. If you are a subscriber, you are
encouraged to use "network" providers (e.g., MEDLAB, Papastravos
Associates) for laboratory and x-ray/ imaging services. When using network
providers, eligible laboratory and x-ray/imaging expenses are covered at
100 percent; whereas if you choose a non-network provider, expenses are
covered at 50 percent and 65 percent, respectively.
     Another aspect of managed care within the Basic, Basic Plus and
Comprehensive plans is the Medical Services Review Program administered
through Intracorp. This program consists of the following items:

        * Preadmission Certification and Continued Stay Review,
        * High Risk Maternity Program,
        * Prospective Procedure Review,
        * Outpatient Mental Health/Substance Abuse Review,
        * Case Management and
        * Chiropractic Review Program.

     It is very important for participants to read and adhere to the
specific Intracorp guidelines for each program. In most cases, you must
call the state of Delaware Healthline (1-800-422-0266) to have specific
medical services pre-approved.
     The detailed guidelines are printed in your BC/BS plan booklet.
Penalties for overlooking these guidelines are severe and can result in no
coverage or substantially reduced coverage for medical services.
     If you have questions about the specific guidelines and requirements
of your UD health insurance plan, please call the Benefits Office at
831-2913.