There are two definitions of the term “gatekeeper,” one used in relation to health insurance and one regarding long-term care plans.
When used in relation to health insurance, gatekeeper describes the person in charge of a patient’s treatment. Anyone who receives health insurance coverage in the form of a managed care plan, specifically a health maintenance organization (HMO) plan, is assigned a gatekeeper or allowed to choose one. In some cases, the insured party is instructed to choose a primary care physician from a list, and that doctor becomes the gatekeeper for the patient.
A gatekeeper’s duty primarily is to manage a patient’s treatment. This means the gatekeeper is in charge of authorizing the patient’s referrals, hospitalizations and lab studies. When a patient falls ill or needs to be referred to a specialist, the patient contacts the gatekeeper who, in turn, refers the patient to doctors and specialists within the plan network. (To learn more about managed care plans, read: How to Choose a Healthcare Plan.)
In regards to long-term care, gatekeepers are not people, but rather the requirements that must be met before an individual can receive any payouts from their long-term care insurance plan.