Health Maintenance Organizations (HMOs)
Benefit Recipients must select a Primary Care Physician (PCP) from a network of participating providers. The PCP directs health care services and must make referrals for specialists and hospitalizations. When care and services are coordinated through the PCP, the Benefit Recipient pays only a co-payment. No annual plan deductibles apply. The minimum level of HMO coverage provided by all plans is described in HMO Benefits. 

Open Access Plan (OAP)

The OAP provides three benefit levels broken into tier groups. Tier I and Tier II require the use of network providers and offer benefits with pre-determined co-payments. Tier III (out-of-network) offers Benefit Recipient flexibility in selecting health care providers with higher out-of-pocket costs. Tier II and Tier III require a deductible. It is important to remember the level of benefits is determined by the selection of care providers. Benefit Recipients enrolled in the OAP can mix and match providers. Specific benefit levels provided under each tier are described in OAP Benefits

Important Reminders About Managed Care Plans

Provider Network Changes: Managed care plan provider networks are subject to change. Always call the respective plan to verify participation of particular provides - even if the information is printed in the plan's directory.

Primary Care Physician (PCP) Leaving a Network: If a plan participant's PCP leaves the managed care plan's network, the Benefit Recipient has three options: 1) choose another PCP within that plan; 2) change managed care plans; or 3) enroll in the College Choice Health Plan. The opportunity to change plans applies only to PCPs leaving the network and does not apply to specialists or women's healthcare providers who are not designated as PCPs.

Out-of-County Managed Care Plans: Benefit Recipients interested in enrolling in a managed care plan that is not available in their county of residence should contact the plan directly to determine if an exception can be made that would allow the Benefit Recipient to participate in the managed care plan.

Dependents: Eligible depends who live apart from your residence for any part of a plan year may be subject to limited service coverage. It is critical that Benefit Recipients who have an out-of-area dependent contact the managed care plan to understand the plan's guidelines on this type of coverage.

June/July Hospitalizations: Benefit Recipients who change health plans during the annual Benefit Choice Period and are then hospitalized, or have Dependent Beneficiaries that are hospitalized before July 1, should contact both the current and future health plan administrators and PCPs as soon as possible.

Psychiatric/Substance Abuse Treatment: Managed care plans determine the maximum number of inpatient and outpatient visits for psychiatric and alcohol/substance abuse treatment. Plans are required to cover a minimum of 
10 inpatient v\days and 20 outpatient visits. These visits are in addition to detoxification benefits that include diagnosis and treatment of medical complications.

Transplant Services: Both organ and tissue transplant services are eligible for coverage under all participating managed care plans. Each plan establishes its own certification criteria, coverage and provider network. Plan participants should contact the respective managed care plan for specific information at the first indication that a transplant may be needed.

Play Year Limitations: Managed care plans may impose benefit limitations on a calendar year schedule. In certain situations, the CIP plan year may not coincide with the managed care plan's year.

Transition of Services: When electing a new health plan during the Benefit Choice Period, plan participants involved in an ongoing course of treatment or who have entered the third trimester of pregnancy, should contact the new plan to coordinate the transition of services and providers for care.

LINKS to:

Dental Plan

Vision Plan

Prescription Drug Benefit

Plan Administrators - Who To Call For Information, etc.

HMO Benefits

Hospital Services

Professional and Other Services

Hospital Services

Physician and Other Professional Services

Other Services

CIP Managed Care Plans For FY 2007