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Denver, CO    Health insurance is one of the most important investments for people. Consumers often do not fully evaluate their personal health care needs when signing up for a health plan. Consequently, many patients, especially seniors, expect the same service and coverage under a managed care plan as they received when their insurance paid the charges for any service provided.

Medically necessary treatment is one of the most important terms used in the payment of health care services. Indemnity plans define medically necessary, but insurance companies pay for the vast majority of claims that are submitted. Managed care plans review the need for medical necessity much more closely, often using a more conservative definition.

Medically necessary treatment usually means that the procedure is indicated based upon some pre-determined research and standard of practice in the medical industry. Some plans are more progressive and determine medically necessary treatment using more recent research data and protocols. Other companies tend to utilize a more traditional, proven technology or treatment modality. For example, an individual with disruptive behavior might be treated with Haldol, an older drug on a generic formulary, whereas, the same patient in another setting might be treated with Prozac, a newer drug that may not be on the formulary of a health plan. These two prescription drugs may both be effective, but one has fewer side effects.

Medicare's definition of medically necessary treatment or services is ... "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a mal-formed body member". In the Colorado area there are eight companies that currently offer Medicare HMOs to older adults. All companies are required to utilize Medicare's definition in determining whether a specific procedure is medically necessary.

In reality, Medicare beneficiaries are faced with cost and effectiveness as the determinants of medically necessary treatment. However, Medicare's definition is not based on cost, nor does it describe the effectiveness of a specific treatment protocol. Although a procedure is a covered benefit, the health plan may not determine that it is medically necessary, therefore, they may not pay for the service.

Since Medicare's definition is very vague, much variation exists among health plans on the interpretation of the need for medical care. Care varies between plans for the same type of patient and sometimes even varies between plans for the same patient. To show the variation between health plans, a procedure is denied by one health plan. The older adult, exercising his option to change plans in 30 days, disenrolls from that health plan and re-enrolls in another plan and the service that is recommended by the physician is covered by the new plan.

To learn more about choosing a health plan for yourself, send a self-addressed envelope with $3.00 postage for your personal copy of "Knowledge: The Key to Getting the Health Care You Need in a Managed Care World" developed by the Colorado Patients' Rights and Responsibilities in Managed Care Consortium to Colorado Gerontological Society, 3006 East Colfax, Denver CO 80206. If you would like to schedule a seminar on choosing a health plan or assistance selecting a health plan, call 303-333-3482 for more information.