Journal Issue: Children and Divorce Volume 4 Number 1 Spring/Summer 1994
Treatment of Providers
The measures vary widely in their treatment of providers. The McDermott/Wellstone bill continues nonrestricted use of individual office-based, clinic-based, and institutional providers who would be paid on a fee-for-service basis. The bill also permits formation of comprehensive health service organizations to provide care through participating providers.
The other measures all depend importantly on private managed care plans such as HMO-type provider networks. Children and families would have to pay out of pocket for services received from nonplan providers unless services were emergency in nature or out-of-plan care is authorized by the family's plan.
In addition, the President's bill takes specific steps to ensure families continued access to certain types of services despite their enrollment in network plans. First, all plans must offer a point-of-service option for a higher premium. This option enables families to see any provider with higher cost sharing. Second, the plan allows children with serious illnesses and conditions access to very specialized services at academic health centers and other "centers of excellence." Third, the President's plan requires that, for a five-year period following implementation of health reform, all health plans contract with certain "essential community providers" (such as community and migrant health centers) who are located in medically underserved communities and are particularly accessible to low-income and medically underserved families.