Charges Covered Under a Capitation Agreement or Managed Care Plan

If you are enrolled in a capitation agreement or managed care plan, it is essential to understand the charges that are covered and not covered. Capitation agreements are agreements between a healthcare provider and a payer, where the provider receives a fixed amount of money per patient enrolled in the plan, regardless of the number of services provided. Managed care plans, on the other hand, are healthcare plans that contract with healthcare providers to provide services to their members.

Here is a list of the charges that are typically covered under a capitation agreement or managed care plan:

1. Preventive care: Most capitation agreements and managed care plans cover preventive care, which includes routine checkups, vaccinations, and health screenings. These services are critical in maintaining optimal health, and providers encourage their patients to receive preventive care regularly.

2. Doctor visits: Most capitation agreements and managed care plans cover doctor visits, both in-person and virtually. Patients may have to pay a copay for each visit, which is typically a small amount.

3. Emergency care: Managed care plans and capitation agreements typically cover emergency care services, including ambulance services and emergency room visits. It is always important to call your healthcare provider or 911 in the event of an emergency.

4. Diagnostic tests: Most managed care plans and capitation agreements cover diagnostic tests, including blood tests, radiology tests, and imaging tests.

5. Surgical procedures: Managed care plans and capitation agreements generally cover surgical procedures, including inpatient and outpatient surgeries. Patients may be required to pay a copay or a deductible for these procedures.

6. Mental health services: Most capitation agreements and managed care plans cover mental health services, including therapy and counseling. Mental health services are essential for ensuring overall health and wellness.

Here is a list of the charges that are typically not covered under a capitation agreement or managed care plan:

1. Cosmetic procedures: Capitation agreements and managed care plans typically do not cover cosmetic procedures, such as Botox or plastic surgery.

2. Experimental treatments: Managed care plans and capitation agreements generally do not cover experimental treatments, which are treatments that have not been adequately tested or approved by regulatory agencies.

3. Services rendered by out-of-network providers: Capitation agreements and managed care plans typically do not cover services rendered by out-of-network providers. It is important to check with your healthcare provider to ensure that all services are provided within the network.

4. Services not deemed medically necessary: Managed care plans and capitation agreements typically do not cover services that are not deemed medically necessary. It is essential to work with your healthcare provider to determine which services are necessary to maintain your health.

In summary, managed care plans and capitation agreements play a vital role in ensuring access to affordable healthcare. Understanding the charges covered under these agreements is essential to ensure that you receive the necessary care while minimizing out-of-pocket costs. It is always essential to work with your healthcare provider to determine which services are necessary to maintain your health and wellness.