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Managed Care
Reviewed by Medicinsk Expert•Last updated: 2026-10-22•Health System

Managed Care

Managed care plans are health insurance options that utilize a network of contracted providers to offer medical care at reduced costs.

Overview

Managed care plans are a type of health insurance. They have contracts with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan's network. How much of your care the plan will pay for depends on the network's rules.

Plans that restrict your choices usually cost you less. If you want a flexible plan, it will probably cost more. There are three types of managed care plans:

  • Health Maintenance Organizations (HMO) usually only pay for care within the network. You choose a primary care doctor who coordinates most of your care.
  • Preferred Provider Organizations (PPO) usually pay more if you get care within the network. They still pay part of the cost if you go outside the network.
  • Point of Service (POS) plans let you choose between an HMO or a PPO each time you need care.

Frequently Asked Questions

Not necessarily. Each managed care plan has its own contracted network of providers. When switching plans, you must check if your current doctors, hospitals, and specialists are included in the new plan's network. If they are not, you will either need to find new providers within the new network or pay out-of-pocket for care outside the network, which can be significantly more expensive and may not be covered at all under strict HMO rules.
In most HMO plans, you must obtain a referral from your primary care physician to see a specialist. If your PCP is unavailable, contact their office to request an urgent referral or ask if they have a covering provider who can sign the referral. Without this referral, the specialist visit may not be covered, and you could be billed the full out-of-network rate. For PPO plans, you can usually see a specialist directly without a referral, though staying within the network will keep your costs lower.
Do not rely solely on the provider's office to confirm their status, as network participation can change. Check your insurance provider's official website or mobile app, where you can search by provider name, specialty, or location. You can also call the member services number on the back of your insurance card to verify current network status and ask about any specific restrictions, such as whether the provider requires prior authorization for certain procedures.
copay is a fixed amount you pay for a specific service, such as a doctor's visit or prescription, usually at the time of service. A deductible is the total amount you must pay out-of-pocket for covered services before your insurance plan starts to share the costs. In many HMO plans, you may pay a copay for primary care visits even before meeting your deductible, whereas PPO plans often require you to meet the deductible before the plan pays its share of specialist or hospital costs.
Source: MedlinePlus, National Library of Medicine

MedlinePlus brings together authoritative health information from the National Library of Medicine (NLM), the National Institutes of Health (NIH), and other government agencies and health-related organizations.

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