WHAT CARE SHOULD BE COVERED

The answer to the question of what health care services should be cove red by a managed care plan is straight forward; the plan should cover whatever the consumer is willing to pay for. From the plan's perspecti ve, the consumer is the payer, that is, the employer who negotiates th e plan; not the individual patient whose personal preferences and inte rests may be quite different. Since managed care organizations contrac t with payers to arrange for health care services within a defined set of benefits, there is a broader question as well: Within the benefits chosen by the payer, what actually is covered! Criteria for determini ng ''medical necessity,'' which managed care plans frequently use as t he basis for coverage, are discussed.