[xx cover] How to Use Your Health Plan: A Guide to Getting the Most from Your HMO or PPO State of California, Office of the Patient Advocate www.opa.ca.gov How to use this file * This guide has 25 main chapters, plus sections at the beginning and end. * Pages are numbered to match the hard copy guide. Each page number is in brackets at the beginning of the page. There is an “xx” before each page number. To search for a particular page, such as page 44, type “xx44”. * To skip from chapter to chapter, search for Heading 1. * To skip through the main sections within a chapter, search for Heading 2. * To skip through the resources or questions and answers within a chapter, search for Heading 3. Photos and graphics on cover * A Latino father and mother are holding their newborn and smiling. * A male doctor is preparing to give a shot to a young white girl about 7 years old, while her mom watches. The girl is pushing up her sleeve for the shot and everyone is smiling. * An African American young woman in 20s has been exercising and is about to drink from a water bottle. * An older Japanese couple are doing Tai Chi in a park. * The California State Seal [xx inside front cover] What Californians say about this guide * “It’s clear, easy to use.” * “I feel empowered as a consumer, having a voice in the health care system.” * “I love those numbers and websites. I think that’s really great.” * “This would be good to have during Open Enrollment.” Get help with your health plan, or order a free copy of this guide in English, Spanish, or Chinese. Call: 1-888-466-2219 TTY: 1-887-688-9891 www.opa.ca.gov Produced by the California Office of the Patient Advocate, in partnership with Health Research for Action at the University of California, Berkeley, and with communities throughout California. © 2008 by the State of California. All rights reserved. No part of this publication can be reproduced, published, adapted, distributed, or transmitted in any form by any means (including electronic, microcopying, photocopying, or otherwise) without prior written permission of the copyright owner. Legal Disclaimer: This guide contains general information only and is not a substitute for the advice of health care professionals, consumer advocates, legal advisors, or qualified health plan representatives. Neither the Office of the Patient Advocate nor The Regents of the University of California represent or warrant that the contents of this guide are complete or without error. Frequent changes in managed health care or in legal protections for consumers may cause the guide to become outdated, obsolete, inaccurate, and/or incorrect. In no event will the Office of the Patient Advocate, The Regents of the University of California, or any individual or entity involved in the production of this publication be liable to any party for any direct, special, or other consequential damages resulting, directly or indirectly, from any use of this guide or of any website or phone number contained in this guide. Please consult with a qualified representative from your health plan for specific information about your health plan. [page xx1] What’s Inside Note to reader: The page number is one tab stop after the chapter title. To search for a page search for xx followed by the page number you want, such as xx10 or xx40. Photo: A 5-year-old African American boy and girl are playing. The boy is listening to the girl’s heart with a stethescope. Welcome Health Plan Basics Kinds of Health Plans 4 Health Care Costs 6 Comparing Plans 8 Getting a Plan Through Your Job 10 Buying a Plan on Your Own 12 Medi-Cal Health Plans 14 Medicare Advantage Plans 16 You & Your Doctor Your Primary Care Doctor 18 Referrals & Pre-Approval 20 Choosing Treatments 22 Language Assistance 24 Disability Assistance 26 Getting the Care You Need Your Benefits 28 Preventive Care 30 Drugs, Supplies & Equipment 32 Medicine Safety 34 Seeing a Specialist 36 If You Have a Chronic Condition 38 Emergency & Urgent Care 40 Hospital Care 42 Mental Health Care 44 Home, Nursing Home & Hospice Care 46 Problems & Complaints Speak Up for Your Rights 48 File a Complaint with Your Plan 50 Call the HMO Help Center 52 Getting More Help Contact Your Health Plan 54 Phone Numbers & Websites 56 Common Terms 61 Index 62 [page xx2] Welcome to the Office of the Patient Advocate Photo: OPA staff, 10 men and women of diverse ethnicities and ages, are standing in front of California Capitol building in Sacramento. * The Office of the Patient Advocate (OPA) is watching out to make sure you get the best quality from your health plan. * Each year we publish a Quality Report Card so you can see how your plan and doctors compare. * We also show you how to get the care you deserve and what to do if you have a problem. * We offer free information for consumers, such as the guide you are reading—also available in Spanish and other languages. Photo: An OPA staff member, a Latino man, has an information booth at a health fair, where he is providing information to a woman. The Office of the Patient Advocate (OPA) 1-916-324-6407 TTY: 1-866-499-0858 www.opa.ca.gov [page xx3] www.opa.ca.gov Screenshots of the OPA website homepage and the section of the site called Quality Report Card Call 1-888-466-2219 to order your free resources. * Quality Report Card in English, Spanish, Chinese, Korean, and Vietnamese * HMO Guide for Seniors in English and Spanish * Fact sheets on HMOs in many languages Pictures of these free resources [page xx4] Kinds of Health Plans Most Californians who have health insurance belong to an HMO or a PPO. HMO stands for health maintenance organization. PPO stands for preferred provider organization. HMOs and PPOs have different rules for getting care. Photo: A smiling white man in his 30s is working in a grocery store. Story: Elliot’s job offers two plans—an HMO and a PPO. “The HMO costs less, but I cannot see the allergist I like. With the PPO I can see the allergist, but I’d have to pay more.” Resources Department of Insurance 1-800-927-4357 www.insurance.ca.gov Information on health insurance. HMO Help Center 1-888-466-2219 www.dmhc.ca.gov Information and help 24 hours a day for health plan members. Office of the Patient Advocate (OPA) www.opa.ca.gov Information on getting quality health care. U.S. Department of Labor 1-866-444-3272 www.dol.gov Information on health care rights. Questions and Answers Why would I choose an HMO instead of a PPO? You might choose an HMO to save on costs and avoid getting a bill or submitting a claim. Why would I choose a PPO instead of an HMO? You might choose a PPO because you want to keep your doctor and he is not in an HMO. Or you might want to see specialists and other providers without having to get referrals and pre-approval first. When I joined an HMO I had to choose a doctor. My doctor is in a medical group. What is that? It is a group of doctors and other providers who have a contract with an HMO or PPO to give care to the plan’s members. In an HMO, your primary care doctor’s medical group provides most of your care. [page xx5] HMO and PPO Basics Network: An HMO has a network. These are the doctors, hospitals, labs, and other providers in the plan. You must usually get your care from these providers. You cannot use out-of-network providers unless your plan gives pre-approval, you have an emergency, or you are traveling and need urgent care. PPOs, like HMOs, have a network of doctors, hospitals, labs, and other providers. These are the preferred providers. You usually pay less to see preferred providers. You can use out-of-network providers, but you pay more. Primary care doctor: In an HMO, you must have a main doctor, called a primary care doctor. In a PPO, you can have a primary care doctor, but you do not have to. Referral: In an HMO, you must get a referral from your main doctor for most services, like specialist care or lab tests. In a PPO, you can get many services without a referral. Pre-approval: in an HMO, the HMO or your doctor’s medical group must pre-approve many services. In a PPO, you can get many services without pre-approval. Service area: In both HMOs and PPOs, you must live or work in the area your plan serves. This is called the service area. Learn More About Health Plans * For general information on health insurance, call the Department of Insurance at 1-800-927-4357. Or visit www.insurance.ca.gov. * To learn about health plans for people with low incomes, see pages 6 and 14. * To learn more about HMOs and PPOs, visit www.opa.ca.gov. * To learn about Medi-Cal plans, see pages 14–15. * To learn about Medicare Advantage plans, see pages 16–17. * POS (point of service) plans are like PPOs but you need to have a primary care doctor. To learn more, visit www.dmhc.ca.gov. * For information on high deductible plans, visit www.dmhc.ca.gov and see page 6. * In self-insured plans, the employer uses its own funds to pay for employees’ health care. To learn more, ask your employer or call the U.S. Department of Labor at 1-866-444-3272. [page xx6] Health Care Costs It is a good idea to learn about your health plan’s fees and rules before you need care. This can help you avoid unexpected costs and make the best use of your plan’s services. Photo: A Latina mom and her child are playing on the grass. Story: Elena joined a health plan at her new job. “I got a summary of benefits and costs for the plan. I found out that there was no charge for my children’s immunizations. The charge for hospital care was complicated. So I called my plan and asked them to explain it to me.” Resources My Health Resource www.myhealthresource.org Help finding health care if you do not have insurance. Office of the Patient Advocate (OPA) www.opa.ca.gov Information on health care costs. Look for “Health Plan Basics” under “How to Use Your Health Plan.” Uninsured Help Line 1-800-234-1317 www.coverageforall.org Get help finding low-cost and no-cost health care. Questions and Answers I had surgery that my HMO covered. Then I got a bill from one of the doctors at the hospital. Do I have to pay it? Call your health plan. The doctor may be billing for the difference between what your health plan pays and what she usually charges. This is called balance billing. If this is the reason for the bill, you should not have to pay it. See pages 48–51. Where can I find out about low-cost or free health care? California has a number of low-cost or no-cost health programs. See the Resources to the left, and pages 14–15. My employer is offering a high deductible plan, with lower premiums. Will it save me money? It depends on your health care needs. Study the costs carefully. A high deductible plan has a yearly deductible of at least $1,050 for one person and $2,100 for a family. To learn more, visit www.dmhc.ca.gov. [page xx7] What’s What: Different Kinds of Costs You can print worksheets on “My HMO Costs” and “My PPO Costs” at www.opa.ca.gov. Premium It is the fee a plan charges each month for your coverage. Usually you and your employer both pay a part. If you have a Medicare Advantage plan, the government pays all or part of the premium. Co-pay or co-insurance It is what you pay each time you see a doctor, get a prescription filled, or get other services. A co-pay is a flat fee, like $20 for a doctor visit. Most HMOs have co-pays. Co-insurance is a percent of the cost, such as 20%. Many PPOs have co-insurance. Yearly deductible It is the amount you must pay each year before your plan pays anything. There may be a separate deductible for prescription drugs. Not all plans have a yearly deductible. Out-of-pocket maximum It is the most you have to pay in a year. Once you reach this amount, you do not pay anything for most services. Out-of-network costs It is the amount you pay if you see a doctor or other provider who is not in the network. * HMOs do not pay any part of out-of-network costs, unless you have pre-approval from the plan, you have an emergency, or you need urgent care when you are traveling. * PPOs pay what is called a “usual rate.” If the provider charges more, you have to pay the difference. Tips: If You Get a Bill Bills, or things that look like bills, are confusing. Call your plan and ask for an explanation before you pay anything. * Usually you do not get bills in an HMO unless you have a yearly deductible, you did not pay your co-pay, or you saw a provider outside the network. * In a PPO, you may get a bill for your yearly deductible or co-insurance. If you see providers outside your network you may get a bill for additional costs. * If your plan says you have to pay the bill and you do not agree, you can ?le a complaint. See pages 50–51. * If you are billed for emergency care, see pages 52–53. * If you get a letter that says, “This is not a bill,” you do not have to pay it. * For more information on costs and fees, visit www.opa.ca.gov. Look for “Health Plan Basics” under “How to Use Your Health Plan.” [page xx8] Comparing Plans If you have to choose a plan, compare the quality, the costs, and the benefits. Make sure a plan covers the benefits you need. See if the doctors you like are in the network. And find out what other people think of each plan. Photo: A young African American woman is using a computer. Story: Marion needs to enroll in a health plan at work. “I looked at the summary of benefits and costs for each plan. I asked some of my co-workers which plan they liked. What’s important to me? I want a doctor close to home, and I want prescription drug coverage.” Resources Contact a Health Plan See page 54. E-Health Insurance www.ehealthinsurance.com Compare the costs and benefits for plans you buy on your own. Of?ce of the Patient Advocate (OPA) www.opa.ca.gov Compare the quality of HMOs. Print these worksheets: * Ask About Benefits * Compare HMO Costs * Compare PPO Costs Questions and Answers We are planning on having a baby soon. What questions should we ask about a health plan? Ask about pregnancy and well-baby care. Find out what the costs are and which hospitals are in the plan’s network. Ask what it will cost to insure your new baby. Does quality of care really vary by plan? Yes. You can compare quality of care at www.opa.ca.gov. You can see how well plans meet national standards of care and how members rate their plans. [page xx9] Tips: Compare Benefits All plans must offer basic benefits, like doctor visits and hospital care. A list of basic benefits is on page 29. * Compare benefits for the services you are likely to need. * Compare prescription drug benefits. * Compare the benefits that vary a lot from plan to plan, such as mental health care for less serious conditions. See pages 44–45. Compare Costs Get a summary of benefits and costs for each plan you are thinking about. Ask your benefits office or call the plan. See page 54. * The co-insurance you pay in a PPO can be much higher than the co-pay in an HMO. See page 7. * If you go outside the network in a PPO, you usually pay a lot more. * Look at the hospital costs. They can be high. * Ask about the deductibles. Compare Providers Call the plan and ask: * If a provider you want is in the network. * If a doctor you want is accepting new patients. * Which hospitals you can use. * How to get night or weekend appointments. * Which medical groups are in the network. * If you have to see providers in your primary care doctor’s medical group. * How to see providers who are not in the network. * What services are offered in your language. See pages 24–25. What’s Important to Me? When you have to choose between plans, it can help to think about your own priorities. Check what is most important to you and your dependents. To help compare plans, print the worksheets “Ask About Benefits,” “Compare HMO Costs,” and “Compare PPO Costs” at www.opa.ca.gov. * A low monthly premium * Low costs to see a doctor, get prescriptions, or get hospital care * Care for my children * Prescription drug benefits * Keeping my current doctor * Using a certain hospital * Being able to see any doctor I want * Quality of care for my condition * Services in my language * Mental health care * Weekend/evening services * Other: [page xx10] Getting a Plan Through Your Job A health plan that you get through your job is called a group plan. A group plan cannot reject you because of a current or past health problem. Also, if your group plan is ending, there are laws that protect your right to keep your health coverage. Photo: A young white man is working in a plant nursery. Story: Matt has a group plan through his job. “I added my wife and son to my plan. I have to pay a higher premium, but it costs less than buying an individual plan for them. And the group plan could not reject my son because of his asthma.” Resources Health Insurance Info www.healthinsuranceinfo.net Information on your rights in group plans in California. HMO Help Center 1-888-466-2219 www.dmhc.ca.gov Help with problems and information on COBRA/Cal-COBRA. U.S. Department of Labor 1-866-444-3272 www.dol.gov/ebsa/faqs Information on COBRA. Questions and Answers I was diagnosed with a heart problem 2 years ago. Can a group plan reject me because of it? No. A group plan cannot reject you because of a preexisting condition. In some cases, the plan may not pay for care for the condition for up to 6 months. But if you have had a group plan for at least 6 months and it ended less than 60 days ago, there can be no delay. I lost my job. What can I do to keep my health coverage? Ask your employer about COBRA. Make sure you get a COBRA form and sign up before the deadline. For more information, see the next page. Or visit www.dmhc.ca.gov. [page xx11] Joining a Group Plan * Usually you can join your employer’s plan when you start a new job. * There may be a short waiting period—3 months or less—before your new plan starts. * You can also join a plan or change plans during your employer’s Open Enrollment. This happens once a year. * Usually, your husband, wife, or domestic partner, and your unmarried minor children can be on your health plan. You may have to pay a higher premium to cover them. * If you marry, have a baby, or adopt a child, you must add them to your plan within 30 days. Otherwise, you have to wait until Open Enrollment. Keeping a Group Plan with COBRA * If your group plan ends, you can usually keep it for up to 36 months through COBRA and Cal-COBRA. COBRA is a federal law. Cal-COBRA is a state law that extends COBRA. * You must pay all of the monthly premiums. * Usually you must sign up for COBRA and pay the first premium within 60 days after your group plan ends. Ask your employer. If you miss the deadlines, you lose your right to get COBRA and Cal-COBRA. * Your dependents can keep your group plan through COBRA and Cal-COBRA if they no longer qualify as dependents or if you die, divorce, or start getting Medicare. * When your COBRA and Cal-COBRA end, you may qualify for an individual plan. See page 13. Picture: An Asian woman, about 40, is talking on the telephone. Story: Mieko’s company laid her off. She kept her plan through COBRA until she found a new job. It was hard because she had to pay all of the monthly premium. But if she had a medical problem and did not have health insurance, she could lose all her savings. Avoid a Gap in Coverage * A gap in coverage is a period when you do not have a health plan. * If you have a gap of more than 60 days after your group plan ends, you lose your right to get COBRA and Cal-COBRA. It is also harder to get an individual plan. * When your group plan ends, you should get a Certificate of Creditable Coverage from the plan. It says how long you were covered. Keep it. You can use it to prove that you had coverage without a gap. [page xx12] Buying a Plan on Your Own A health plan you buy on your own is called an individual plan. It usually costs more and gives you fewer benefits than a plan you get through your job (a group plan). Also, an individual plan can reject you or charge you more if you have a past or current health problem. Photo: A white mom in her 30s is holding her baby girl and talking on a cell phone. Story: Brenda needed to buy an individual health plan when she started working for herself. “I applied to several plans. However, I have a pre-existing condition—migraine headaches. Only one accepted both me and my daughter.” Resources Health Insurance Info www.healthinsuranceinfo.net Information on your rights in individual plans in California. HMO Help Center 1-888-466-2219 www.dmhc.ca.gov Help with problems and information on rights. MRMIP (Major Risk Medical Insurance Program) 1-800-289-6574 www.mrmib.ca.gov Insurance for people who are turned down by individual plans because of a pre-existing condition. The program is managed by Blue Cross. U.S. Department of Labor 1-866-444-3272 www.dol.gov/ebsa/faqs Information on HIPAA. Questions and Answers Is it hard to get individual coverage? Yes, it is often difficult. Insurance companies reject many people because of current or past health problems. Before you leave your old plan, wait until a new plan accepts you and your new coverage starts. I have an individual plan. My insurance says it is canceling my coverage. Can they do that? It may not be legal. Call your plan right away and ask why they are canceling your plan. Then call the HMO Help Center at 1-888-466-2219 and explain the problem. If you have not been able to pay your premium on time, ask the plan to arrange a different payment schedule. Sometimes a plan is willing to be flexible. [page xx13] Applying for Insurance on Your Own * When you apply for an individual plan, you have to fill out health history forms for yourself and for any dependents you want to cover. * You may be rejected or charged more, based on your health history. * Even if the plan agrees to cover you, you may have to wait up to 12 months before it will cover care for a pre-existing condition. * If you are turned down for an individual plan because of your health history, you may be able to get coverage through a program called MRMIP. Call 1-800-289-6574 or visit www.mrmib.ca.gov. This program is administered by Blue Cross. * Do not cancel your other plan until your new coverage starts. If an individual plan agrees to cover you, it will tell you when your new coverage will start. Getting an Individual Plan When Your Group Plan Ends * If your employer stops offering health insurance, you may be able to buy a HIPAA plan or a conversion plan. HIPAA is a federal law. Conversion coverage is a state law. * If you use up your COBRA and Cal-COBRA, you may be able to buy a HIPAA plan or a conversion plan. * You cannot be rejected because of your health history. * You must pay the monthly premium. * Usually you need to sign up and pay the first premium within 60 days after your group plan ends. To learn the exact deadlines, ask your plan or your employer. Post Claims Underwriting Photo: An African American man who is about 45, is talking on the phone and looks frustrated. Story: Tom’s insurance was cancelled after he had back surgery. The plan said he should have told them about the back problem on his application. When a plan does this, it is called “post claims underwriting.” It may be illegal, unless Tom deliberately lied on his application. If this happens to you, call the HMO Help Center at 1-888-466-2219. [page xx14] Medi-Cal Health Plans Medi-Cal is for people with a low income. Many people who have Medi-Cal belong to Medi-Cal health plans, which are a kind of HMO. You get the same benefits as you get in Regular Medi-Cal. You also get help finding the doctors and the language assistance you need. You must use the doctors and other providers who belong to your plan. Photo: African American doctor talking to Latina mother with toddler and little boy in waiting room. Story: Dora has Medi-Cal for herself and her children. “We use the same clinic for most care. The clinic gives us referrals to other providers when we need to see a specialist or get a test. Resources Health Care Options 1-800-430-4263 Call to change your Medi-Cal health plan. Healthy Families 1-800-880-5305 www.healthyfamilies.ca.gov Health insurance for children in families with low and middle incomes. Medi-Cal Managed Care Ombudsman 1-888-452-8609 Help if you have a problem that you cannot solve with your health plan. Medi-Cal Mental Health Care Ombudsman 1-800-896-4042 Help with Medi-Cal mental health care services. Questions and Answers Can I keep my doctor and specialist if I join a Medi-Cal health plan? You can only keep your doctor or your specialist if he is in your plan’s network. Can I get services in my language? Medi-Cal health plans must provide assistance for most languages. They must pay for interpreters or ?nd doctors who speak your language. They must provide forms and other materials in your language. Can I get mental health care? Yes. Your doctor can provide some care. If you have a serious mental health problem, your doctor should refer you to your County Mental Health Agency. If you have trouble getting care, call the Medi-Cal Mental Health Care Ombudsman at 1-800-896-4042. [page xx15] Ways to Qualify for Medi-Cal * You must have a low income and few assets. * Your children may qualify even if you do not. * If you are pregnant, you may be able to qualify for emergency Medi-Cal and get services right away. * To apply for Medi-Cal, go to your county Social Services office. Getting Help with Your Medi-Cal Health Plan * If you have a problem getting the care you need, first ask your doctor to help you. If that does not work, call your health plan. See pages 48-51. * You can also call the Medi-Cal Managed Care Ombudsman at 1-888-452-8609. * Or you can call the HMO Help Center at 1-888-466-2219. See pages 52–53. To Change Your Medi-Cal Health Plan * You can change plans at any time if your county has more than one Medi-Cal plan. * You should use the providers you see now until you receive a membership card for your new plan. * To change plans, call Health Care Options at 1-800-430-4263. If You Have Regular Medi-Cal * If you now have Regular Medi-Cal, you may be able to join a Medi-Cal health plan. You can return to Regular Medi-Cal at any time. * Find out if the Medi-Cal plans in your county offer the services you need. To learn more, call Health Care Options at 1-800-430-4263. Picture: A doctor checks a little girl’s tonsils while her mom watches. All three are Chinese. Story: Mary’s mother takes her to the doctor for regular check-ups. These are called “well-child” visits because Mary’s doctor makes sure she is growing up as healthy as possible. He updates Mary’s shots, checks her height and weight, and gives her a physical exam at no cost. [page xx16] Medicare Advantage Plans Most seniors have Medicare. Some younger people with disabilities also have Medicare. Many people get their Medicare through a Medicare Advantage HMO or PPO. These are private health plans. Medicare pays the plan a fee each month to give you your health care. Photo: An older Japanese woman is talking to woman in her 30s. Story: Mrs. Matsumoto is thinking about joining a Medicare Advantage HMO. “I called HICAP and met with a counselor. She explained how the HMOs work and gave me a list of all the plans in my area.” HICAP is the Health Insurance Counseling & Advocacy Program. It provides free help and advice for all Medicare members. Resources 1-800-MEDICARE 1-800-633-4227 www.medicare.gov Information and help with Medicare. HICAP (Health Insurance Counseling and Advocacy Program) 1-800-434-0222 www.calmedicare.org Help for Medicare members. Lumetra 1-800-841-1602 www.lumetra.com Call if your hospital, home health, nursing home, or rehab care is ending too soon. Questions and Answers If I join a Medicare Advantage plan, will I have the same benefits I would have in Original Medicare? Yes. Many plans also have prescription drug coverage. And you may have extra benefits, such as hearing, dental, or eye exams. I have a low income. Can I get help paying for Medicare? You may qualify for both Medicare and Medi-Cal. Medi-Cal can help pay some of your costs. Also, Medi-Cal covers long-term care. To learn about Medi-Cal and other programs for Medicare members with low incomes, call HICAP at 1-800-434-0222. [page xx17] Medicare Parts A and B * You must have Parts A and B to join a Medicare Advantage plan. * Part A covers hospital care and is usually free for people who are on Social Security. * Part B covers other care, such as doctor care and lab tests. You pay a monthly premium for Part B. It is taken out of your Social Security check. Medicare Part D Prescription Drug Coverage * If you have a Medicare Advantage plan, you must get your Part D drug coverage through your plan. * Before you buy drug coverage, ask about the costs. They can be complex. How to Join, Change, or Leave a Medicare Advantage Plan * Before you make a change, call HICAP at 1-800-434-0222 or visit www.calmedicare.org. * You can join a plan when you first get Medicare. After that, you can join, change, or leave a plan: • Between November 15 and December 31 each year. • Between January 1 and March 31 each year. However, you cannot add or drop Part D drug coverage during this period. • If your plan closes, you move out of its area, or in some other cases. * To return to Original Medicare, call 1-800-MEDICARE. Ask about buying a Medigap policy and a Part D drug plan. A Medigap policy helps pay for costs and services that Original Medicare does not cover. Do not leave your old plan until your new coverage starts. If You Have a Problem with Medicare * First, try to talk it over with your doctor. * If your plan denies, delays, or stops treatment, file an appeal with your plan. Your plan must reply in 7 days, or 3 days if you file an urgent or expedited appeal. * For help, call HICAP at 1-800-434-0222. * If your hospital, home health, nursing home, or rehab care is ending too soon, call Lumetra at 1-800-841-1602. * If your plan does not cover a drug you need, you or your doctor can call your plan and ask them to cover the drug. If your doctor asks for an expedited review, the plan must reply in 24 hours. In other cases, the plan has 72 hours to reply. [page xx18] Your Primary Care Doctor In most health plans, you must have a primary care doctor. This doctor is also called your PCP, or primary care provider. Your primary care doctor oversees your care and refers you to the other services you need. Photo: A young white female doctor is taking the blood pressure of an older white man. Story: When Walter changed HMOs, he needed to choose a new doctor. “I asked my plan for a list of doctors and called several. I looked for one who had experience caring for my heart problem. Then I made a new patient appointment. The doctor listened carefully and explained things in a way I could understand, so I stayed with her.” Resources HMO Help Center 1-888-466-2219 www.dmhc.ca.gov Information on your rights to continuity of care. Medical Board of California 1-800-633-2322 www.medbd.ca.gov Check a doctor’s license and history of complaints. Provider Directory A Provider Directory lists all the doctors and other providers in a plan’s network. Ask your plan for a Provider Directory, or look on your plan’s website. See page 54. Questions and Answers Do I need to choose a doctor? Usually, yes. If you do not choose a doctor, your health plan usually chooses one for you. Can I change my doctor? Yes. Just call your plan. What is a medical group? This is a group of primary care doctors, specialists, and other providers. In some plans, you can only go to providers in your medical group. Who can be a primary care doctor? There are four kinds of primary care doctors: * Family doctors care for people of all ages. * Internists care for adults 18 years and older. * Pediatricians care for children and teens. * Gynecologists care for women. [page xx19] Tips: Choosing a Doctor To get a list of doctors, call your health plan. You can ask for a list of doctors who speak your language. Before you choose a doctor, ask: * Is the doctor taking new patients? * What is the doctor’s medical training? * Does the doctor have experience with my conditions or concerns? * Which hospital does the doctor use? * How long does it usually take to get an appointment? * Can I get evening or weekend appointments? You can print a worksheet “Choose a Doctor” at www.opa.ca.gov. Keeping a Doctor You Have Now Picture: A 20-year-old African American woman is talking to her doctor. Story: If you change plans or your doctor leaves your plan, in some cases you can keep your doctor for a limited time. For example, you are scheduled for surgery or a procedure, you have an acute condition, or you are in the last 3 months of pregnancy. This is called continuity of care. Call your plan for more information. Make the Most of Your Doctor Visits Most visits are short. Make every minute count. You can print a worksheet “Make the Most of Doctor Visits” at www.opa.ca.gov. Things to bring * My health plan membership card and a photo ID * A list of my questions and concerns * A list of my medicines and the doses * Someone to help listen, ask questions, and take notes * Other: During my visit * Review questions and concerns with my doctor. * Ask my doctor to write down my treatments or diagnosis. * Ask about shots, routine tests, and screenings I should have. * Review my medicines. * Get copies of test results. * Other: Follow-up care I need * Paperwork for tests * New prescriptions * Names and phone numbers of referrals * Follow-up appointment * Other: [page xx20] Referrals & Pre-Approval When you need care from a specialist or another provider in your HMO, you must get a referral from your primary care doctor. Often, your health plan or your doctor’s medical group must pre-approve the referral. If you are in a PPO, you do not need pre-approval to see specialists and other providers. Photo: An older white couple is walking for exercise. Story: Susanne had foot pain for years. It got so bad she could not walk more than a block. “My doctor finally got my health plan to approve a referral to a podiatrist. I went to him and he made me arch supports. It has made a huge difference in my life.” Resources Contact Your Health Plan See page 54. Questions and Answers Do I need a referral if I am seriously ill and want to see a specialist? Yes. If you are not in immediate danger, you need a referral and pre-approval. Ask your primary care doctor for an expedited referral. Your health plan must decide in 3 days. Do I always need a referral? No. Women may see a gynecologist in their health plan’s network without a referral. If they are pregnant, they may see an obstetrician without a referral. Ask your doctor or plan about other specialists you can see without a referral or pre-approval. How do I know if I need pre-approval? Ask your doctor or call your plan. In general, most referrals must be pre-approved, but each plan has its own rules. [page xx21] Getting a Referral * Usually you need a referral to see a specialist or other provider, such as a physical therapist. * You also need a referral for most medical tests. * Your primary care doctor writes the referral. * Your doctor gives you the referral or faxes it to the specialist. Getting Pre-Approval * You usually need pre-approval to see a specialist or other provider. * Your medical group or health plan gives pre-approval. * Your doctor should submit the referral for pre-approval. She must say why you medically need the care. * It takes about 5 business days to get pre-approval, or 3 days if your problem is urgent. * You will get a letter saying whether pre-approval was given or denied. * Sometimes your doctor will need to send more information before the plan can decide. If the Referral Is Denied * First, talk to your doctor. He may be able to send more information to show why you need the referral. * You can file a complaint with your plan. See pages 50–51. * If your plan says that you do not need the referral because it is not medically necessary, you may qualify for an Independent Medical Review (IMR). In an IMR, independent doctors review your case, and your plan must do what they decide. See page 53. Standing Referrals Photo: A female doctor is talking to a Latino male client and filling out his medical chart. Both doctor and patient are in their late thirties. Story: Bill needed on-going care from a physical therapist. He asked for a standing referral. A standing referral allows you to see a specialist without getting a referral from your primary care doctor every time. Your medical group or the health plan usually has to approve a standing referral. [page xx22] Choosing Treatments Most treatments have both benefits and risks. To make the best choice, ask questions. Learn about your condition and the treatments. Then work with your doctor to decide on a treatment plan. Photo: An African American woman in her 30s looks thoughtfully at the camera. Story: When doctors found a small aneurysm in Joanne’s brain, she had to decide what to do. Her doctor told her about her treatment choices. She researched the choices and then made a decision. “All the treatments had benefits and risks. But being actively involved helped me feel good about my decision.” Resources Cancer Information 1-800-422-6237 www.cancer.gov Information on cancer treatments. Clinical Trials www.clinicaltrials.gov Information on current clinical trials. Health?nder www.health?nder.gov An introduction to health care information on the Internet. Mayo Clinic www.mayoclinic.com Easy-to-understand information on health topics. Medline Plus 1-888-346-3656 www.medlineplus.gov Find health information online or with telephone assistance. Questions and Answers The specialist I saw recommends chemotherapy for my cancer. Can I get a second opinion? Yes. You have a right to get a second opinion about a diagnosis or treatment plan. Ask your doctor or plan for a referral. What if my health plan says it will not pay for the treatment my doctor recommends? You can file a complaint with your health plan or the state. See pages 50–51. If your health problem is urgent, see pages 52–53. What are clinical trials? They are medical studies to test how well new medicines and other treatments work and how safe they are. If you are in a study, you may get a new treatment that you could not get otherwise. Ask your doctor about clinical trials. Visit www.clinicaltrials.gov. [page xx23] Tips: Before You Agree to Treatment * You usually have to sign a consent form. It says that you agree to the treatment. * Before you sign, be sure you understand what is being done and why. * You can ask for the form in your language or in large print, audio, or Braille. * Take time to decide. Try not to make important decisions when you are stressed or sleepy. * Get a second opinion if you are not sure. Ask your doctor for a referral to another specialist. * You have the right to refuse treatment for yourself. Learn More About Treatments * Visit your local library or the library at a medical school or hospital. * Ask your doctor for brochures or information on your treatment. * Look on the Internet. Good places to start are www.healthfinder.gov, www.mayoclinic.com, and www.medlineplus.gov. Questions to Ask Your Doctor * What are all the possible treatments? * Which treatments are most likely to help? * Which are least likely to help? * How will I know if a treatment is working? * What are the risks and benefits of each treatment? * What are the side effects of each treatment? Can they be treated? * How long will each treatment take? * How long will it take to recover from each treatment? * How much will each treatment cost me? . [page xx24] Language Assistance If your first language is not English, your health plan usually must give you assistance in your language. You have the right to this assistance when you need to explain your health problem to your doctor, or when you need to understand your health problem, treatment choices, and important written information. Photo: A Latina mom in her thirties with her arm around her son, who is about 8. Story: Loretta asked her health plan, her pharmacy, and her family’s doctors to make a note of the language assistance she needs. “So when I go to my pharmacy they always give me the written instructions in Spanish. I speak some English, but when it comes to my family’s health, I feel more comfortable with Spanish.” Resources Health Consumer Alliance www.healthconsumer.org Fact sheets on low-cost health care, in many languages. Click on “Publications.” Of?ce of the Patient Advocate (OPA) www.opa.ca.gov Compare HMO’s language services. Questions and Answers What if my doctor’s office will not provide an interpreter? You should call your health plan and explain the problem. If they do not solve it, you can ?le a complaint. See pages 50–51. Do I have a right to language assistance? If you have Medi-Cal or Medicare, your plan must provide language assistance in most languages that members speak. A new California law requires other plans to provide language assistance by 2009. Can I ask my adult daughter to interpret for me? You can, but you do not have to. Family and friends are not trained to translate medical terms and information. Also, you may not want them to hear your medical problems or questions. [page xx25] Ask What Language Services Your Plan Offers * Call your plan. The number is on your membership card. Ask what language services they provide. Some plans have many services. * Compare the language services that health plans in California offer. Go to www.opa.ca.gov. * Ask your plan for a list of doctors who speak your language, or ask for a medical interpreter at your office visits. * Ask for office staff who speak your language so they can help you make appointments and find other providers. * Ask for important documents in your language. Using a Medical Interpreter * When you make an appointment, say that you will need an interpreter so the of?ce has time to find one. * Ask if you can meet with the interpreter before your visit. * The interpreter may be in the room with you, or may be on a screen or on the telephone. Photo: Three people in a doctor’s exam room. The patient is a young man who is using sign language. His doctor, a white woman, is watching him. The third person is a sign language interpreter. Story: Jason is deaf and uses sign language. He asked his doctor to arrange for a sign language interpreter Ask for Important Documents in Your Language, such as Consent forms and other forms you need to sign A consent form explains a treatment or procedure (like surgery or an X-ray). You must sign it. Whenever you need to sign a form, you should ask for it in your language. Treatment directions This might tell you how to prepare for surgery or how to fast for a blood test. Information about your medicines This tells you important information about taking the medicine safely, such as side effects or danger signs to watch for, and foods or medicines you need to avoid. [page xx26] Disability Assistance If you have a disability, your health plan must remove most physical or communication barriers that make it hard for you to get the care you need. Look for a doctor who understands your disability and will help you get the services you need. Photo: A woman in her forties who uses a wheelchair is getting onto a doctor’s exam table. The exam table can be raised and lowered. The doctor, a woman, is lowering it to just the height that the patient wants. Story: Janine needs an exam table she can use with her wheelchair. “My plan helped me find a doctor who has an exam table that can be raised and lowered so I can get on and off it.” Resources AT Network 1-800-390-2699 1-800-900-0706 (TTY) www.atnet.org Information on equipment and assistive technology for people with disabilities. California Foundation for Independent Living Centers 1-916-325-1690 1-916-325-1695 (TTY) www.cfilc.org Resources for people with disabilities. Disability Rights Advocates www.dralegal.org/publications/know_your_rights.php A guide to the health care rights of people with disabilities. Questions and Answers I was referred to a specialist, but I cannot get into his office. What can I do? Your health plan must find an accessible doctor for you. And they must pay for this specialist even if he is not in the plan’s network. Call your plan and be firm about what you need. What if I am deaf? You have the right to a sign language interpreter. Ask for one when you make an appointment. Try not to rely on lip reading. Even good lip readers can have trouble with medical terms. What if I cannot get the care I need? If your plan refuses to find accessible providers or pay for them, you can file a complaint. See pages 50–51. [page xx27] Know Your Rights If you have a disability, the Americans with Disabilities Act (ADA) protects your right to: * Accessible and usable medical equipment at a provider’s office or facility. For example, you have the right to access scales, exam tables, and diagnostic medical equipment such as mammography and MRI machines. * Have most physical barriers removed that make it hard for you to use your health care services. * Extra time for visits if you need it. * Health information you can use if you are deaf, blind, or have low vision. * Take your service animal into exam rooms with you. When You Get Health Insurance * If you get a plan through your job, the plan cannot refuse to cover you or charge you more. * It can be hard to get insurance on your own if you have or once had a health problem. See pages 12–13. * Before you join a health plan, ask about the rules for getting equipment. Ask if there are limits on what the plan pays. See page 33. Assistance I Need Check everything that you need if you have a disability that affects communication or physical access. Then tell the doctor’s office ahead of time. Also, ask your doctor to keep a copy in your medical ?le. You can print worksheets on “Communication Assistance” and “Physical Access” at www.opa.ca.gov. Communication Assistance * A support person will be with me. However, please speak directly to me. * Please use “everyday” language and pause often. * Please face me when you speak. * Please speak loudly so I can hear what you are saying. * Please try to explain things using pictures, models, or demonstrations. * I need extra time to respond and to ask questions. * I have trouble taking notes, so I need to record what you say. * I need a sign-language interpreter. * I need help with forms and instructions. Physical Access * I need to be able to get to your building and into your office. * I need an accessible bus stop or parking space. And there needs to be an accessible route from the bus stop or parking space to the office. * I need an accessible restroom. * I need an exam table that adjusts up and down. * I need assistance getting on and off the exam table. * I use a service dog, so please alert anyone who may be allergic to or frightened of dogs. * I have life-threatening or health-threatening reactions to these products: ___________. Charts adapted with permission from June Isaacson Kailes, Associate Director CDIHP. [page xx28] Your Bene?ts All HMOs and some PPOs must cover the basic bene?ts that are listed on the next page. But other bene?ts, like prescription drugs, may not be covered. It’s a good idea to ask your plan for a summary of your bene?ts and costs. This summary also tells you the limits on bene?ts. Photo: A happy white couple in their 30s plays on a swing with their 2-year-old son. Story: Robert says, “Our son needed eye surgery, so we asked our plan to send us information on what it covers. They sent a summary of our bene?ts and costs. They also sent a plan handbook, called the Evidence of Coverage, which gave us more details.” Resources Contact Your Health Plan See page 54. Of?ce of the Patient Advocate (OPA) www.opa.ca.gov Ratings on the quality of bene?ts and services in many HMOs. Questions and Answers My health plan covers many bene?ts. Can I really use them? Yes. You can use any bene?t that you medically need for your health care. If you and your doctor or plan disagree about what you need, see pages 48–53. I changed jobs. I still have the same plan but my costs and some bene?ts are different. Why is that? The same insurance company can offer different bene?ts packages with different costs. Your bene?ts package is all the bene?ts your plan covers. For example, one bene?ts package may include prescription drug coverage, but another may not. And your co-pays can be different. [page xx29] Know Your Basic Bene?ts All health plans must cover these bene?ts. But the costs and limits on bene?ts differ from plan to plan. * Doctor services * Hospital care when you stay overnight (inpatient care) * Outpatient services, such as minor surgery * Lab tests, like blood, pregnancy, and STD tests * Diagnostic services, like X-rays and mammograms * Preventive care, like shots and regular check-ups * Mental health care for severe conditions * Emergency and urgent care * Health education programs. * Physical, occupational, and speech therapy * Language assistance. * Diabetes home care supplies * Limited home health or nursing home care after a hospital stay * Hospice care for people who are dying Customer Services Most plans offer: * A member/customer service helpline. * A 24-hour advice nurse helpline. * Education programs. * Services in many languages. Compare the Quality of Bene?ts and Services OPA publishes a yearly report on health plans called the Quality Report Card. To get a copy, call 1-888-466-2219. You can also use this report to: * Compare plan services, like customer service and language assistance. * Compare how members rate their plans. * Compare quality of care for diabetes, asthma, and other conditions. Optional Bene?ts Some plans also cover these bene?ts: * Prescription drugs * Medical equipment, like wheelchairs and oxygen * Eyeglasses * Hearing aids * Dental care * Infertility treatments [page xx30] Preventive Care Preventive care includes exams, check-ups, and tests that help your doctor prevent health problems or find them before they become serious. Ask your plan for a schedule of recommended preventive care. Then discuss it with your doctor. Photo: A little Latina girl with curly hair is picking yellow daisies in a field. Story: Rebecca’s mom works with her child’s doctor to prevent long-term health problems. “Diabetes runs in our family, and a lot of us are overweight. So I talked to Rebecca’s doctor about what I can do to lower her risk. He checks her weight and has helped me choose a good diet for her.” Resources Agency for Healthcare Research and Quality (AHRQ) 1-800-358-9295www.ahrq.gov/consumer/prevention Get pocket guides to good health for adults, children, and seniors. CDC Info 1-800-232-4636 www.cdc.gov/vaccines Guidelines for immunizations. KidsHealth www.kidshealth.org Information on children’s health. My Family Health Portrait www.dhhs.gov/familyhistory Organize and print your family’s health history. Questions and Answers My health plan sends me the results of my lab tests, but how do I find out what they mean? Call your doctor. You can also learn about lab test results at www.labtestsonline.org. I’m just 28. Do I really need regular check-ups and routine tests? Yes. Even younger adults need check-ups and tests. Talk to your doctor about a schedule for your preventive care. [page xx31] Exams and Routine Tests * The exams and tests you need depend on your age, sex, and family medical history, as well as your own health. * If you are at risk for a disease or condition, your doctor will want you to start screening tests younger and have them more often. * Talk to your doctor and agree on a schedule that works for you. Your Medical History Tell your doctor about: * Illnesses, treatments, and operations you have had. * All the drugs, vitamins, herbs, and over-the-counter medicines you take. * Your usual diet and the physical activity you get. * Health problems your relatives have had. Visit www.dhhs.gov/familyhistory for help creating a family medical history. Preventive Care Picture of OPA worksheets. Print these worksheets at www.opa.ca.gov: * Prenatal Care * Care for Children * Care for Men 18–34 * Care for Men 35–50 * Care for Women 18–34 * Care for Women 35–50 * Care for Adults 50+ * My Health History Preventive Care: Common Issues Check the issues you want to discuss with your doctor. * Regular check-ups * Shots and immunizations * Blood pressure * Blood sugar * Cholesterol screening * Cancer screening * Vision care and glaucoma screening * Weight control * Diet * Lack of exercise * Injuries caused by exercise * Osteoporosis * Birth control * Sexual health * Help to stop drinking * Help to stop smoking * Depression * Anxiety, stress, or anger * Problems communicating with or disciplining your children * Problems communicating with your spouse or partner * Violence in the family * Other: [page xx32] Drugs, Supplies & Equipment Prescription drugs, and most supplies and equipment, are optional benefits. This means that some plans do not cover them. However, diabetes supplies, as well as asthma supplies for children, must be covered. Photo: A white dad in his 30s is showing his 9-year-old daughter how to test her blood sugar level. Story: Hanna’s dad is showing her how to test her blood sugar level. “When Hanna was diagnosed with diabetes, I found out that health plans must cover diabetes supplies like test strips and blood glucose monitors. And since our plan covers prescription drugs, it also pays for Hanna’s insulin.” Resources FDA 1-888-463-6332 www.fda.gov/cder/drug Information on drugs. Pharmacy Checker www.pharmacychecker.com Compare drug prices. Questions and Answers Why does my health plan give me generic drugs? Generic drugs cost less than brand-name drugs. When the patent on a new drug expires, other companies can make the drug. It still has the same basic ingredients. My health plan stopped covering the drug I was taking. Can they do that? Yes. The drugs your plan covers can change because of new research and changes in the prices of drugs. If your doctor can explain why you need the drug, your plan may continue to cover it for you. I need a wheelchair. Will my health plan cover it? Ask your plan what is covered. Even if medical equipment is covered, your doctor needs to explain why the wheelchair is necessary for your health. He may refer you to a rehab clinic for an evaluation. Wheelchairs can be expensive and you may have to speak up for your rights. See pages 48–53. [page xx33] Tips: If You Have Prescription Drug Coverage * Your plan usually has a formulary. This is the plan’s list of preferred drugs. * The formulary may have different levels with different charges. Generic drugs usually have a lower co-pay than brand-name drugs. * If you want a drug that is not on the formulary, you must get pre-approval from your plan. Or you can pay for it yourself. * You must fill your prescriptions at a pharmacy that is in your plan’s network. Keep Drug Costs Down * When your doctor gives you a prescription, ask if your health plan covers the drug. * Ask for generic drugs. Usually they cost less than brand-name drugs. * Ask your doctor or pharmacy about discounts for people with low incomes. * Call your plan and ask how to order on-going prescriptions by mail. They usually cost less, and you can order for 3 months at a time. * If you do not have prescription drug coverage, compare costs. Check out discount, mail order, and online pharmacies. Compare costs at www.pharmacychecker.com. Supplies and Equipment Benefits for supplies, like bandages and syringes, or for equipment, like walkers, respirators, and wheelchairs, vary from plan to plan. * Ask your doctor or plan what is covered. * Also ask if there are limits on what the plan will pay. * Ask which providers or stores you can use. * Health plans must cover most home care supplies for diabetes. * Plans must also cover asthma supplies for children. * If your plan will not approve your doctor’s request for equipment or supplies, you can file a complaint. See pages 50–51. Picture of multi-colored pills and tablets Caption: Drug costs vary. If you do not have prescription drug coverage, compare prices from different pharmacies. [page xx34] Medicine Safety Health care treatments often include prescription medicines. Problems with drug interactions and side effects are common. But there are many things you and your doctor can do to help prevent problems. Photo: An Asian woman in her 20s, looking at the camera. Story: Lisa was struggling with severe allergies. One medicine made her mouth too dry, and another made her too sleepy to work. Lisa talked to her doctor, who suggested that she try a third medicine. “I finally found a medicine that I could live with.” Resources Drug Digest www.drugdigest.org Check drug interactions. FDA 1-888-463-6332 www.fda.gov/cder/drug Information on drugs, vitamins, and herbs. Healthfinder www.healthfinder.gov Information on drug safety. Questions and Answers What can I do to avoid problems with drug interactions? Ask your doctor to check for interactions. Also, fill all your prescriptions at one pharmacy. Make sure the pharmacy uses a computer to check interactions. You can also check online at www.drugdigest.org. I feel like I take too many medicines. What can I do? Make a list of all the medicines you take. Then show the list to your doctor. Ask if you could stop taking any medicines. [page xx35] Tips: Talk to Your Doctor * Tell your doctor all the medicines you take, including vitamins and over-the-counter drugs. * Explain any allergies or bad reactions you have had to medicines. * Tell your doctor if a medicine is not helping. * Tell your doctor if you have a problem with side effects. * Ask how to take a new medicine. * Ask about side effects, risks, and benefits. * Ask about drug interactions. When You Pick Up a Prescription * Make sure it is the correct medicine and the correct dose. * Review the directions for taking the medicine with a pharmacist. * Ask if it is safe to use with other medicines you take. * Review the side effects you need to watch for. Take Medicines as Directed * Take the dose listed on the bottle. * Do not skip doses or split pills unless your doctor tells you to. * Take the medicine for as long as the prescription says. * Throw out medicines after their expiration date. This date is printed on the label. * Use a pill organizer to keep track of your medicines. Photo: Hands holding a seven-day pill box full of pills. My Medicines Make a list of your medicines and show it to your doctor. Keep a copy in your wallet. You can print a worksheet “My Medicines” at www.opa.ca.gov. The form also lets you list any medicines you are allergic to. For each medicine, list the name, the dose, and when and how often you should take it. For example: Lisiprinol, 10mg, 1 pill a day Calcium, 200mg, 2 pills a day with meals [page xx36] Seeing a Specialist A specialist is a doctor who has extra training in one area of medicine, such as heart care or cancer treatment. To see a specialist in an HMO, you must need care that your primary care doctor cannot give you. You must also have a referral from your primary care doctor. Your medical group or health plan may have to approve the referral. Photo: A doctor in his 40s examines the ankle of a woman in her 30s. Story: Mona hurt her ankle in an accident and is having trouble using it. “My primary care doctor referred me to an orthopedist—a bone specialist—who evaluated the problem and recommended 6 physical therapy appointments. Before I made the appointments, I asked about the fees and if I would need pre-approval from my plan.” Resources American Board of Medical Specialties 1-866-275-2267 www.abms.org Learn about different specialties and find out if a specialist is board certified. Contact Your Health Plan See page 54. Questions and Answers My doctor referred me to a specialist, but I can’t get an appointment for 6 months. What can I do? You can ask your doctor to help you get the appointment, or refer you to another specialist. If these things do not help, you can file a complaint with your plan. See pages 50–51. What if I cannot get the referral I want? If you ask for a referral and you do not get it, your doctor or plan should tell you why. If you disagree, you can file a complaint with your health plan. See pages 50–51. I have severe allergies. Can I see an allergist regularly? Ask your primary care doctor for a standing referral to an allergy specialist. A standing referral allows you to go to a specialist without getting a new referral each time. See page 21. [page xx37] Tips: How to Get Specialist Care * Ask your primary care doctor for a referral. * In an HMO, the specialist must be in the HMO’s network, and is usually in your doctor’s medical group. * Your medical group or the health plan may have to pre-approve the referral. See pages 20–21. * You can ask for a referral to a specialist outside your HMO’s network if there is no specialist in the network who can give you the care you need, or you have to wait too long for an appointment. You will need pre-approval from the health plan. * In a PPO, you can see specialists outside the network and pay more. Finding a Specialist * Ask your doctor to recommend specialists. * Look in your health plan’s Provider Directory or on its website. * If you need a treatment or procedure that is risky, look for a specialist who has done it many times. * There are over 100 different medical specialties. To learn about them and to find out about a specialist’s training and certification, visit www.abms.org. Make the Most of Your Specialist Care * Before you go to the specialist, ask your primary care doctor what to expect. * Make sure that your primary care doctor gets copies of the specialist’s reports. * Make sure all your providers know all the medicines you take. * Make sure you still go to your primary care doctor for all your routine care. Picture: Two doctors, a man and woman in their 30s, are looking at x-rays. Story: Usually, a specialist will order an X-ray or other test and evaluate it, and then report back to your primary care doctor. [page xx38] If You Have a Chronic Condition A chronic condition is a health problem that can be managed but usually not cured. Diabetes, arthritis, high blood pressure, and heart disease are common chronic conditions. You and your doctor will make a treatment plan to manage your condition. Following this plan is the best way to take care of yourself and keep your condition under control. Photo: An African American grandfather is helping his 3-year-old grandson swing a plastic baseball bat. Story: Fred has heart disease and high blood pressure. “My doctor and I agreed on a treatment plan. I take 2 medicines and try to eat a low-salt diet. I also walk for 30 minutes on most days. It’s hard to do everything, but my blood pressure has come down. That makes me want to keep trying.” Resources American Chronic Pain Association www.theacpa.org American Diabetes Association www.diabetes.org American Heart Association www.americanheart.org American Lung Association www.lungusa.org Arthritis Foundation www.arthritis.org California AIDS Hotline www.aidshotline.org Office of the Patient Advocate (OPA) www.opa.ca.gov Compare HMO’s quality of care for chronic conditions. For phone numbers, see pages 56–60. Questions and Answers My condition will never get better. Will my health plan still cover treatment? Yes. Your plan must cover services that you need to keep your condition stable or prevent it from getting worse. I have diabetes. My doctor wants me to lose weight and exercise every day. How can I make such a big change? Change is easier with support. Look for support from family and friends. Also, ask your plan about health education programs. And look in your phone book for local chapters of the organizations listed to the left. Many have support groups or other tools to help you. [page xx39] Tips: Learn About Care for Your Condition * Ask what services and education programs your health plan offers for people with your condition. * The Quality Report Card tells you how well California HMOs meet national standards of care for many chronic conditions. Visit www.opa.ca.gov. * The Quality Report Card also tells you why meeting these standards is important. You can use this information to talk to your doctor about your care. * See page 22 for more information on choosing treatments. Picture: A Latina mom carries her 8-year-old daughter piggyback. Story: Gloria used the Quality Report Card at www.opa.ca.gov to compare asthma care for children. “The best HMOs make sure that children who have asthma get the right medicine. I found the best HMO for my daughter’s needs.” Work with Your Doctor * Discuss your treatment plan with your doctor. It should include care to keep your condition from getting worse and treatments to improve it. It should also be a program you can stick with. * Ask your doctor who will be on your medical team and when you will see each member of the team. * Tell your doctor if your symptoms change, your treatment plan does not seem to be working, or you have trouble following it. Learning New Habits Your doctor may ask you to make changes in diet, exercise, and other habits. Change can be hard—so try starting with small steps. You can print a worksheet “Learning New Habits” at www.opa.ca.gov. Example 2 New Habit: Take medicine regularly. Barriers to Change: I forget to take pills. Small Steps that I Can Try: Set alarm to remind me to take pills. Put pills next to breakfast cereal. Example 2 New Habit: Eat less fat. Barriers to Change: I usually eat lunch out. Small Steps that I Can Try: Order lower fat foods, such as chicken without the skin or salads with dressings on the side. [page xx40] Emergency & Urgent Care In an emergency, call 9-1-1 or go to the nearest emergency room. Most health plans cover emergency and urgent care anywhere in the world. Photo: A white man in his thirties playing football. Story: Alan fell and hurt his arm. “It was Saturday. I called my doctor’s office and got the answering machine. I didn’t want to wait until the doctor called me back. My arm hurt a lot and I was pretty sure it was broken, so I went to the ER. They took X-rays and set my arm. I saw my doctor a few days later to make sure everything was OK.” Resources 9-1-1 Call 9-1-1 in an emergency. Say your name and where you are. Do not hang up until the operator tells you to. Contact Your Health Plan See page 54. Poison Action Line 1-800-222-1222 www.calpoison.org Emergency help for victims of poisoning. Questions and Answers What is emergency care? Emergency care is care you need right away because you reasonably believe your health is in serious danger. Emergencies include a bad injury, severe pain, a sudden illness or one that is quickly getting worse, and active labor. What is urgent care? Urgent care is care you need soon, usually within 24 hours. An earache or sprain might need urgent care. They need attention soon, but they do not put your health in serious danger. What if I have an emergency and go to a hospital that is not in my plan’s network? Your plan should cover emergency care anywhere. You should call your health plan within 24 hours or as soon as you can. You may be moved to a hospital in your plan’s network when it is safe to do so. [page xx41] Tips: What to Do in an Emergency * Call 9-1-1 if you have an emergency and you cannot safely get to an emergency room by car. * You can go to the nearest hospital emergency room. It does not have to be part of your health plan. * Try to take your membership card with you. * If you are not sure it is an emergency and there is time, call your doctor or health plan. What to Do if You Need Urgent Care * If your health plan has an urgent care clinic, call the clinic or go directly there. * If you are not sure what to do, call your primary care doctor or your health plan and ask what to do. If You Are Away from Home * Emergency and urgent care are usually covered anywhere in the world. * If you have an emergency, call 9-1-1 or go to the nearest emergency room. * If you need urgent care, call your doctor or health plan. If you cannot call, go to the nearest clinic or urgent care center. * Take your membership card with you. * If you need follow-up care, call your doctor. Your health plan will not pay if you get follow-up care without pre-approval. Ambulance Services Health plans only pay for an ambulance when it is an emergency or when your doctor says you need an ambulance and the plan pre-approves it. Know What to Do Ahead of Time * Learn you plan’s rules for getting emergency or urgent care. * Find out what to do if you need urgent care on the weekend. * Ask your doctor or plan. * Look in your plan handbook or Evidence of Coverage (EOC). My Emergency Contact List Make a list of your important numbers. You can print a worksheet “My Emergency Contact List” at www.opa.ca.gov. List the following numbers. Emergencies 9-1-1 Urgent care clinic My plan’s member services My membership number My primary care doctor My work phone My cell phone [page xx42] Hospital Care Overnight care in a hospital is called inpatient care. You may go to the hospital for surgery, a serious illness, childbirth, or other services. Unless it is an emergency, your doctor must refer you for hospital care. Photo: An older African American couple looking at the camera. Story: Darrell was hospitalized after a mild stroke. “Before I left the hospital, my wife and I asked for someone who could talk to us about follow-up care. We met with a nurse who told me how to take my medicines and what follow-up treatment I would need.” Resources American College of Surgeons 1-800-621-4111 www.facs.org Information on common operations and choosing a surgeon. CalHospital Compare www.calhospitalcompare.org Compare California hospitals. Joint Commission 1-800-994-6610 www.jcaho.org File a complaint by phone or learn about patient safety online. Lumetra 1-800-841-1602 www.lumetra.com Call if your Medicare hospital care is ending too soon. Questions and Answers I am staying in the hospital for only 2 nights after my surgery. Will I really be ready to go home that soon? Tell your doctor your concerns. If necessary, he can ask for a longer stay. In general, hospital stays are shorter these days. This is because hospital care is very costly, and many people recover better at home. If you have Medicare, call Lumetra at 1-800-841-1602. When I was in the hospital, some of the staff ignored me when I asked for help. What can I do? You can complain to your doctor and to the hospital. You can also write a letter to your health plan and file a formal complaint with the Joint Commission at 1-800-994-6610. [page xx43] Tips: Know What Your Costs Will Be * The co-pay or co-insurance for a hospital stay can be high. * If you have a co-pay, call your health plan and ask what the co-pay will be. Or look in your plan’s Evidence of Coverage. * If you pay a percent of the cost (co-insurance), call the hospital billing department. Ask what the charges are likely to be and what you will have to pay. How to Compare Hospitals Screenshot of the website for Calhospitalcompare.org. * Visit www.calhospitalcompare.org to help you find the hospitals that have the most experience treating your medical problem. * If you and your doctor think you cannot get the care you need at a hospital in your plan’s network, ask your plan to approve care at another hospital. Before You Go to the Hospital Fill out an Advance Health Care Directive and choose someone to be your spokesperson and advocate while you are in the hospital. You can print a worksheet “Prepare for a Hospital Stay” at www.opa.ca.gov. Ask your doctor about your care in the hospital. * What will happen during my treatment? * How long will I stay in the hospital? * How will my pain be managed? * Do I need to stop any medicines? Ask about follow-up care. * How long will it take to recover? * Where will I recover? * What help will I need at home? * What follow-up care will I need? Make a list of things to take with you. * Medicines * Toothbrush and other necessities * Alcohol-based hand cleaner * Other: [page xx44] Mental Health Care All health plans must cover care for severe mental health conditions for both adults and children. Plans usually offer limited care for less serious problems. If you think you might benefit from mental health services, talk to your doctor. Or call your plan and ask how to get care. Photo: Professional white man in his 20s is seated at his desk and looking thoughtful. Story: Jake was severely depressed. He tried a medicine that his doctor prescribed, but he did not feel better. “I asked for a referral to a psychiatrist, who evaluated me. He prescribed a different medicine and referred me to a social worker for counseling. After several months I had a follow-up visit with the psychiatrist to see how things were going.” Resources Mental Health Association 1-916-557-1167 (California) 1-800-969-6642 (National)www.mhac.org Information and advocacy for people with mental health problems. NAMI 1-800-950-6264 www.namicalifornia.org Information, advocacy, and support for families with seriously mentally ill relatives. Programs for people who use mental health services. Questions and Answers What mental health care can I get from my primary care doctor? Your doctor can prescribe some medicines, like drugs to treat anxiety and depression. She can also refer you for more help if you need it. Do Medi-Cal and Medicare cover mental health care? Medi-Cal covers care for severe mental health problems. Medicare covers limited care for these problems. Ask your plan what it covers. My plan is not approving enough care. What can I do? If your health plan does not approve the treatment your doctor recommends, they must tell you why in writing. You can file a complaint if you disagree. See pages 50–51. [page xx45] Tips: Choosing a Mental Health Specialist A mental health specialist may be a social worker, family therapist, psychologist, or psychiatrist. * To find a provider, look in the Provider Directory or on the plan’s website. * Ask your doctor and friends for recommendations. * Ask your plan to find you a mental health specialist who is qualified and experienced to treat your condition. * Look for a provider you feel you can trust. * You can change mental health providers if you are not satisfied with the one you have. * If you do not think you are getting the right care, you can file a complaint. See pages 50–51. Severe Mental Health Problems If you have one of the conditions below, you have a right to the care that is needed for your condition. Your benefits and fees are similar to the benefits and fees for other medical conditions. * Major depressive disorder * Panic disorder * Bipolar disorder * Schizophrenia * Schizoaffective disorder * Obsessive-compulsive disorder * Anorexia nervosa and bulimia nervosa * Autism * Pervasive developmental disorder in children * Certain serious emotional disturbances in children Learn More About Your Mental Health Benefits Call your plan or your plan’s behavioral health care provider. The number is on your membership card. Ask: * What kinds of mental health specialists can I see? * Do I need a referral from my primary care doctor? * What counseling or psychotherapy services are covered if a problem is not on the list of severe conditions? Is there a limit on care? What is the cost? * Is treatment for alcohol or drug abuse covered? * Are there support groups and classes, such as classes to help me stop smoking, deal with grief, or manage stress? [page xx46] Home, Nursing Home & Hospice Care Health plans cover some home health care or care in a nursing home, usually after a hospital stay. You must have a referral from your doctor and pre-approval from the plan. The number of days of care is limited, and your cost is usually higher than for other services. Photo: An older white woman in a wheelchair is stirring something on her stove, while a young white occupational therapist looks on. Story: After her accident, Muriel will need to use a wheelchair for at least 4 months. “My plan approved several visits from an occupational therapist to teach me how to care for myself while I am in a wheelchair.” Resources California Hospital Association 1-800-494-2001 www.calhealth.org/public/pubs/frmspstrs.html Download or request a free Advance Health Care Directive. California Registry 1-800-777-7575 www.calregistry.com Information on nursing homes. Family Caregiver Alliance 1-800-445-8106 www.caregiver.org Information for family caregivers. Office of the Patient Advocate (OPA) www.opa.ca.gov Quality ratings on long-term and hospice care. Questions and Answers I have used up my home care benefits and I cannot afford to pay for the additional care I need. Is there any way to get help? If you have a low income, a county program called In-Home Support Services (IHSS) may pay for you to have a home care worker or a family member care for you. Call your county Social Services Office. Do health plans cover long-term home or nursing home care? No. Health plans do not cover long-term care. To get help paying for this care, you need to buy long-term care insurance. If you have a low income, Medi-Cal may pay all or part of the cost of long-term care. [page xx47] Home Health Care Home health care includes services such as physical and occupational therapy, help with medicines or wounds, and dialysis care. It may include some help with personal care, such as bathing. * You must have a referral from your doctor and pre-approval from your health plan. * You must be unable to leave your home to get care. Or your plan and doctor must agree that home is the best place for you to get care. * Ask your health plan or doctor which home health care agencies you can use. Nursing Home Care You may be in a nursing home when you need more skilled nursing care than you can get at home. * Health plans cover limited nursing home care. * Ask your health plan for a list of nursing homes in the network. * Visit www.calregistry.com or call 1-800-777-7575 for help choosing a nursing home. They vary in the quality of their care, as well as in food, cleanliness, noise level, and safety. Hospice Care Hospice care is care to keep a person with a terminal illness comfortable in the last months of life. Hospice also helps relieve some of the stress for family members. * Health plans must cover hospice care. * Services include a nurse to manage pain medicines and an aide to help with personal care. * Ask your plan for a list of hospice agencies you can use. Protect Your Wishes Picture: A middle-aged white woman is filling out an Advance Health Care Directive. * An Advance Health Care Directive lets you say what kind of care you do or do not want and who will decide on your care if you can no longer speak for yourself. * You can download a form free at www.calhealth.org/public/pubs/frmspstrs.html. Or call 1-800-494-2001. * Fill out the form and have your signature witnessed. * Give copies to your doctor, family, and close friends. Tell them about your wishes so they can make sure you get the care you want. [page xx48] Speak Up for Your Rights As a health plan member in California, you have many rights. There are things you can do if you are having trouble getting a service you need. And there are people who can help you. Photo: A white dad in his 30s is holding his 2-year-old son. Story: After Gary’s son had surgery, Gary got a bill from a doctor at the hospital. “I called my health plan. It turns out that the doctor was billing for the difference between what the plan paid and what he usually bills. We did not have to pay it. I had to be persistent, but I made sure the plan dealt with it.” Resources Contact Your Health Plan See page 54. HICAP (Health Insurance Counseling and Advocacy Program) 1-800-434-0222 www.calmedicare.org Help for Medicare members. HMO Help Center 1-888-466-2219 www.dmhc.ca.gov Learn more about your rights. Medi-Cal Managed Care Ombudsman 1-888-452-8609 Call if you have a problem with your Medi-Cal health plan. Office of the Patient Advocate (OPA) www.opa.ca.gov Click on “Get Local Help.” Your Employer Your benefits/human resources office may help you if you have a problem with your plan. Questions and Answers My doctor says I need surgery for my back, but I do not understand how it will help. What can I do? You have a right—and a responsibility—to understand your treatment. Ask the doctor to explain what the surgery will do. Make sure you understand all the risks and benefits. Can I see my medical records? Yes. You have a right to get a copy of your medical records. You may be charged a fee for the copying. My doctor asked my plan to approve a referral 3 weeks ago. I still have not heard back. How long should I wait? Usually your plan should approve or deny a referral within 5 business days, or 3 days if your problem is urgent. Since you have waited so long, you should call your plan and tell them you want to file a complaint. See the next chapter. [page xx49] Tips: Talk to Your Doctor Explain your problem. Ask: * What do you recommend? * Can you help me? * What should I do next? Talk to Your Plan Every plan in California has a member/customer service phone number. Look on your membership card or on page 54. 1. Explain your problem briefly. 2. Ask for someone who can help you. 3. Then, explain your problem in more detail. 4. Make sure the person understands. 5. Ask for the person’s name and direct phone number. 6. Ask what will happen next and how long it will take. 7. Ask for a reply in writing. Tips to Help You Speak Up * Act promptly. * Be persistent. * Ask to speak to a supervisor. * Take notes on your calls. Write down the date and time of each call, the name of the person you spoke with, and a summary of what you each said. * Keep all your notes and letters in one place. * Have someone with you for support during phone calls or meetings. * If you are denied care, ask for the reason in writing. * Learn more about your rights. Visit www.dmhc.ca.gov. See page 52. You Have the Right to: * Be treated with courtesy and respect. * Get quality health care. * Get care from qualified medical personnel. * Choose a doctor you trust. * Get an appointment when you need one. * Understand your health problem and the risks and benefits of your treatment choices. * Get a second opinion about a diagnosis or treatment. * Choose or refuse treatment. * Get a copy of your medical records. Get Local Help There are many organizations that help consumers with health care problems. Some of these groups are listed on pages 56–60. Visit www.opa.ca.gov and click on “Get Local Help” to find a group in your community. [page xx50] File a Complaint with Your Plan If talking with your doctor or your plan does not help, you have the right to file a complaint. A complaint is also called a grievance or appeal. Your plan must give you a written decision. If you disagree with the decision, you can file a complaint with the state. See the next chapter to learn more. Photo: An older doctor listens to the breathing of an eight-year-old Latina girl, while her mom watches smiling. Story: Kendra requested a referral for her daughter to an asthma specialist for children. “Our plan would not approve the referral so I filed a complaint with the plan. And I got her doctor to write a letter explaining why the referral was needed.” Resources Contact Your Health Plan See page 54. HMO Help Center 1-888-466-2219 www.dmhc.ca.gov Help if you have a problem with your health plan. Questions and Answers I called my plan and complained but nothing happened. What can I do? When you call, make sure to say that you want to file a complaint. Then, if the plan does not respond within 30 days, or within 3 days if your problem is urgent, you can call the HMO Help Center. See the next chapter. What is a grievance or an appeal? A grievance or an appeal is another name for a complaint. Each health plan uses different words. My plan says the service I need is not covered. How do they decide this? They look at your Evidence of Coverage (EOC), which is your contract with the plan. It explains your benefits. Ask your plan to send you a copy of the EOC and tell you which page says that the service is not covered. [page xx51] How to File a Complaint with Your Plan * You can file a complaint by letter or e-mail, over the phone, or on your plan’s website. * State clearly that you want to file a complaint. Then explain the problem. * Your plan must give you a decision within 30 days, or within 3 days if your health problem is urgent. * You must file your complaint within 6 months after the incident or action that is the cause of your problem. Common Problems You can file a complaint if you have any problem related to your care or a service. Here are some examples: * You are denied a service, treatment, or medicine. * You are denied a referral. * You get a bill from a provider who is in your plan’s network, other than a bill for your co-pay or co-insurance. * Your plan will not pay you back for a covered service that you paid for and received. * Your plan will not pay for your emergency room care. * You cannot get an appointment as soon as you need it. * You think you received poor care or service. Information You Need When You File a Complaint You can print a worksheet “My Complaint” at www.opa.ca.gov. Have this information handy: 1. Your health plan membership number: 2. A short description of your problem: 3. Why you need this benefit or service: 4. The date the problem happened or started: 5. If you feel the problem is urgent, why: Example: Eleanor’s Complaint 1. My membership number: 1234567 2. My problem is that I need more physical therapy after my accident. I had 5 sessions and my plan said I cannot have more. 3. I need this service because my hip was hurt badly. I am getting better, but I cannot walk more than a block. 4. My doctor asked for more physical therapy on June 13 and I got a denial on June 21. 5. My life is not in danger, but I feel this is urgent because I am in pain and cannot do things. [page xx52] Call the HMO Help Center If you disagree with your plan’s decision about your complaint, you can file a complaint or get an Independent Medical Review with the HMO Help Center. If your problem is urgent, you can call the HMO Help Center without filing a complaint with your plan first. Photo: An older Filipino man looks at the camera. Story: Ken had a procedure to correct a rapid heartbeat. “Afterward, my heartbeat was still too fast, but the doctor just said to come back in a few months. I saw another doctor, who said the procedure should be done again. “My plan denied my request, so I called the HMO Help Center and got an Independent Medical Review. The doctors who reviewed my case agreed with me, so my plan had to pay to do the procedure again.” Resources HMO Help Center 1-888-466-2219 www.dmhc.ca.gov * Call 24 hours a day. Help in many languages. Get forms and instructions for complaints and Independent Medical Reviews. * The HMO Help Center is part of the Department of Managed Health Care, a state agency that regulates health plans and protects the rights of members. * Questions and Answers I have cancer and want an experimental treatment. My plan denied it. What can I do? Most plans say that they do not cover experimental treatments. However, you can ask the state for an Independent Medical Review of this denial. Your condition must be serious. [page xx53] Independent Medical Review (IMR) An IMR is a review of your case by one or more doctors who are not part of your health plan. You do not pay anything. If the IMR is decided in your favor, your plan must give you the service or treatment you asked for. You may qualify for an IMR if your health plan: * Denies, changes, or delays a service or treatment because the plan says it is not medically necessary. * Denies an experimental treatment for a serious condition. If this happens, apply for an IMR right away. You do not have to file a complaint with your plan first. * Will not pay for emergency or urgent care that you already received. How to File a Complaint or Apply for an IMR * Fill out a complaint form or an IMR application form. Call the HMO Help Center at 1-888-466-2219 to get a form, or print one at www.dmhc.ca.gov. * If you do not qualify for an IMR, the HMO Help Center will review your case as a complaint against your health plan. Call the HMO Help Center If: * Your problem is urgent. * You filed a complaint with your plan and you disagree with your plan’s decision. * Your plan does not make a decision within 30 days, or within 3 days if your problem is urgent. * Your plan denies an experimental or investigational treatment for a serious condition. * Your plan cancels your coverage. * You have questions or need IMR or complaint forms. If You Cannot Solve Your Problem with Your Plan * If you belong to an HMO or a Blue Cross and Blue Shield PPO, call the HMO Help Center at 1-888-466-2219 or visit their website at www.dmhc.ca.gov. * If you belong to another PPO, call the Department of Insurance at 1-800-927-4357 or visit their website at www.insurance.ca.gov. * If you belong to a Medi-Cal Managed Care plan, call the Medi-Cal Managed Care Ombudsman at 1-888-452-8609, or call the HMO Help Center at 1-888-466-2219. * If you belong to a Medicare Advantage plan, call HICAP for help and advice at 1-800-434-0222. [page xx54] Contact Your Health Plan Look for your health plan’s Member/Customer Services phone number on this list or on your membership card. * If you do not speak English, ask for someone who speaks your language. See pages 24–25. * If there is no TTY, call the California Relay at 7-1-1. You can also call 7-1-1 if you have a speech disability. Call your Member/Customer Services for general assistance and answers to your questions. * Ask questions about billing. * Get a copy of your Evidence of Coverage or summary of benefits. These documents explain your plan’s benefits, costs, and rules. * Ask about health care outside your plan’s service area. * File a complaint. See pages 50–51. * Add or remove family members from your plan. * Get a replacement copy of your membership card. * Tell your plan when your address or phone number changes. * Get help with access to care for people with disabilities. See pages 26–27. * Get help finding an interpreter. See pages 24–25. Directions to Reader The following list lists the health plan, then the plan’s phone number, TTY and website. To skip from plan to plan, search for Heading 3. Aetna US Healthcare of California 1-800-756-7039 TTY 1-800-628-3323 www.aetna.com Alameda Alliance for Health 1-877-932-2738 TTY 1-510-747-4501 www.alamedaalliance.org Anthem Blue Cross Plans (formerly Blue Cross of California): Anthem Blue Cross Individual Plans 1-800-333-0912 TTY 1-800-735-2922 www.bluecrossca.com Anthem Blue Cross Large Groups 1-800-999-3643 TTY 1-800-735-2922 www.bluecrossca.com Anthem Blue Cross Senior Services 1-800-333-3883 TTY 1-800-735-2922 www.bluecrossca.com Anthem Blue Cross Small Groups 1-800-627-8797 TTY 1-800-735-2922 www.bluecrossca.com Blue Shield of California 1-800-431-2809 TTY 1-800-241-1823 www.mylifepath.com CalOptima 1-888-587-8088 www.caloptima.org Care 1st Health Plan 1-800-605-2556 TTY 1-800-735-2929 www.care1st.com CenCal Health 1-877-814-1861 TTY 1-805-685-4131 www.cencalhealth.org Central Coast Alliance for Health 1-800-700-3874 TTY 1-877-548-0857 www.ccah-alliance.org Chinese Community Health Plan 1-888-775-7888 TTY 1-877-681-8888 www.cchphmo.com Cigna HealthCare of California, Inc. 1-800-344-0557 TTY 1-800-321-9545 www.cigna.com Citizens Choice Health Plan 1-866-634-2247 TTY 1-866-516-9366 www.citizenschoicehealth.com Community Health Group of San Diego 1-800-224-7766 TTY 1-800-735-2922 www.chgsd.com Contra Costa Health Plan 1-877-661-6230 www.cchealth.org/health_plan County of Los Angeles Community Health Plan 1-800-475-5550 TTY 1-800-353-7988 http://ladhs.org/chp EZ Choice Health Plan 1-866-999-3945 TTY 1-800-735-2929 www.easychoicehealthplan.com GEMCare Health Plan 1-877-697-2464 TTY 1-888-833-9312 www.gemcarehealthplan.com Great-West Health Care 1-800-663-8081 www.mygreatwest.com Health Net Large Groups 1-800-522-0088 TTY 1-800-995-0852 www.healthnet.com Health Net Small Groups 1-800-361-3366 TTY 1-800-995-0852 www.healthnet.com Health Net Select 1-800-676-6976 TTY 1-800-995-0852 www.healthnet.com Health Net Seniority Plus 1-800-275-4737 TTY 1-800-929-9955 www.healthnet.com Health Plan of San Joaquin 1-800-932-7526 TTY 1-209-942-6306 www.hpsj.com Health Plan of San Mateo 1-800-750-4776 www.hpsm.org HMO California 1-800-635-6668 TTY 1-866-321-5955 www.hmocalif.com Inland Empire Health Plan 1-800-440-4347 TTY 1-800-718-4347 www.iehp.org Inter Valley Health Plan 1-800-251-8191 TTY 1-800-505-7150 www.ivhp.com Kaiser Permanente 1-800-464-4000 TTY 1-800-777-1370 www.kp.org L.A. Care Health Plan 1-888-452-2273 \www.lacare.org M.D. Care 1-888-285-9676 TTY 1-800-735-2929 www.mdcareadvantage.com MedCore 1-800-320-5688 TTY 1-800-258-6810 www.medcorehp.com Molina Healthcare of California 1-888-665-4621 TTY 1-800-479-3310 www.molinahealthcare.com North American Medical Management (NAMM) California 1-800-864-7500 www.nammcal.com On Lok Senior Health Services 8-996-6565 1-415-292-8898 www.onlok.org PacifiCare of California 1-800-624-8822 TTY 1-800-442-8833 www.pacificare.com Secure Horizons 1-800-228-2144 www.securehorizons.com San Francisco Health Plan 1-800-288-5555 www.sfhp.org San Miguel Health Plan 1-888-946-4040 TTY 1-888-978-7070 www.sanmiguelhealthplan.com Santa Clara County Valley Health Plan 1-888-421-8444 vhp.sccgov.org Santa Clara Family Health Plan 1-800-260-2055 TTY 1-800-567-7759 www.scfhp.com Scan Health Plan 1-800-559-3500 TTY 1-800-735-2929 www.scanhealthplan.com Scripps Clinic Health Plan Services, Inc. 1-888-680-2273 www.scrippsclinic.com Sharp Health Plan 1-800-359-2002 \www.sharp.com Sistemas Médicos Nacionales S.A. (SIMNSA) 1-800-424-4652 www.simnsa.com Ventura County Health Care Plan 1-800-600-8247 TTY 1-800-735-2929 www.vchca.org/hcp Western Health Advantage 1-888-563-2250 TTY 1-888-877-5378 www.westernhealth.com [page xx56] Phone Numbers & Websites This is a list of the phone numbers and websites in this guide. * Toll-free phone numbers begin with 1-800, 1-866, 1-877, or 1-888. * If there is no TTY, call the California Relay at 7-1-1. You can also call 7-1-1 if you have a speech disability. For more information on the Relay, visit www.ddtp.org/california_relay_service. * Not all websites are accessible to people with disabilities. If a site is not accessible, e-mail the webmaster. There may be a link at the bottom of the webpage. * An “ES” after a phone number or website means there is usually someone who speaks Spanish or the website has information in Spanish. Directions to Reader In this list the resource name is followed by the description, the phone number, the TTY if there is one, and the website. To skip from resource to resource, search for Heading 3. 1-800-Medicare Information and help for people with Medicare. 1-800-633-4227 ES www.medicare.gov ES 9-1-1 Call in an emergency. 9-1-1 ES Agency for Healthcare Research & Quality (AHRQ) Information on quality health care. 1-800-358-9295 ES www.ahrq.gov/consumer/prevention ES AIM Low-cost health insurance for pregnant women with low and middle incomes. 1-800-433-2611 ES www.aim.ca.gov ES American Board of Medical Specialties Learn about different specialties and find out if a specialist is board certified. 1-866-275-2267 www.abms.org American Cancer Society Learn about many kinds of cancer; find local support. 1-800-227-2345 ES www.cancer.org ES American Chronic Pain Association Information and resources for people with chronic pain. 1-800-533-3231 \www.theacpa.org ES American College of Surgeons Information on common operations and choosing a surgeon. 1-800-621-4111 ES www.facs.org American Diabetes Association Information about diabetes, diet, exercise, weight loss, and prevention. 1-800-342-2383 ES www.diabetes.org ES American Heart Association Information on heart disease and stroke. 1-800-242-8721 ES www.americanheart.org ES American Lung Association Information on lung diseases; help making treatment decisions. 1-800-548-8252 ES www.lungusa.org ES Arthritis Foundation Information on arthritis and related conditions; help finding local resources. 1-877-226-4267 ES www.arthritis.org ES AT Network Information on equipment and assistive technology. 1-800-390-2699 ES 1-800-900-0706 ES (TTY) www.atnet.org ES CalHospital Compare Resources to help you compare hospitals. www.calhospitalcompare.org ES California AIDS Hotline Information on HIV/AIDS services. 1-800-367-2437 ES www.aidshotline.org ES California Foundation for Independent Living Centers Resources for people with disabilities. 1-916-325-1690 ES 1-916-325-1695 ES (TTY) www.cfilc.org California Hospital Association Download or request a free Advance Health Care Directive form in English or Spanish. 1-800-494-2001 www.calhealth.org California Patient’s Guide A guide to health care rights. www.calpatientguide.org California Registry Information on nursing home, long-term, and hospice care. 1-800-777-7575 www.calregistry.com Cancer Information Information on cancer treatments. 1-800-422-6237 ES www.cancer.gov ES CDC Info Immunization guidelines. 1-800-232-4636 ES www.cdc.gov/vaccines ES Center Watch Information on clinical trials. www.centerwatch.com Clinical Trials Information on clinical trials. www.clinicaltrials.gov Deaf Counseling, Advocacy and Referral Agency Resources for people who are deaf or hard of hearing. 1-877-322-7299 1-877-332-7288 (TTY) www.dcara.org Department of Insurance Information on health insurance. Help with problems. 1-800-927-4357 ES www.insurance.ca.gov ES Department of Managed Health Care (HMO Help Center) Information and help 24 hours a day for health plan members. 1-888-466-2219 ES www.dmhc.ca.gov ES Disability Rights Advocates A guide to the health care rights of people with disabilities. www.dralegal.org/publications/know_your_rights.php ES DrugDigest Check for drug interactions. www.drugdigest.org E-Health Insurance Compare costs and benefits for health plans you buy on your own. www.ehealthinsurance.com Family Caregiver Alliance Information and help for family caregivers. 1-800-445-8106 ES www.caregiver.org ES FDA Information on prescription drugs, vitamins, and herbs. 1-888-463-6332 ES www.fda.gov/cder/drug ES Health Care Options Call to change your Medi-Cal health plan. 1-800-430-4263 ES Health Consumer Alliance Fact sheets in many languages on low-cost health care. Click on publications. www.healthconsumer.org ES Health Insurance Info Download guide to consumer rights under federal and state laws. www.healthinsuranceinfo.net Health Rights Hotline Information on consumer rights. The hotline serves only El Dorado, Placerville, Sacramento, and Yolo Counties. 1-888-354-4474 ES www.hrh.org Healthfinder A portal to health care and drug safety information on the Internet. www.healthfinder.gov ES Healthy Families Low-cost health insurance for children who do not qualify for Medi-Cal. 1-800-880-5305 ES www.healthyfamilies.ca.gov ES HICAP (Health Insurance Counseling and Advocacy Program) Help for Medicare members. 1-800-434-0222 ES www.calmedicare.org HMO Help Center Information and help 24 hours a day for health plan members. 1-888-466-2219 ES www.dmhc.ca.gov ES Joint Commission Call to file a complaint about a hospital or learn about hospital patient safety online. 1-800-994-6610 www.jcaho.org KidsHealth Information on children’s health. www.kidshealth.org ES Lab Tests Online Information about lab tests. www.labtestsonline.org ES Lumetra Help if your Medicare hospital, nursing home, home health, or rehab care is ending too soon. 1-800-841-1602 ES www.lumetra.com Mayo Clinic Consumer information on many health topics. www.mayoclinic.com Medi-Cal Managed Care Ombudsman Help if you have a problem with your Medi-Cal plan. 1-888-452-8609 ES Medi-Cal Mental Health Care Ombudsman Help with Medi-Cal mental health care services. 1-800-896-4042 ES Medical Board of California Licenses and takes complaints about doctors. Check doctors online. 1-800-633-2322 www.medbd.ca.gov Medline Plus Find health information online. Or call for telephone assistance. 1-888-346-3656 www.medlineplus.gov ES Mental Health Association Information and advocacy for people with mental health problems. 1-800-969-6642 ES www.mhac.org MRMIP (Major Risk Medical Insurance Program) Insurance program, managed by Blue Cross, for people who are turned down by individual plans because of a pre-existing condition. 1-800-289-6574 ES www.mrmib.ca.gov My Family Health Portrait Create a family health history report. www.dhhs.gov/familyhistory ES My Health Resource Help finding health care if you do not have health insurance. www.myhealthresource.org NAMI Information and support for families with seriously mentally ill relatives. Programs for consumers. 1-800-950-6264 ES www.namicalifornia.org ES National Committee for Quality Assurance (NCQA) Information on quality health care and HMO standards. 1-888-275-7585 www.ncqa.org National Guideline Clearinghouse Care guidelines for many health conditions. www.guideline.gov National Institute on Aging Information for seniors. 1-800-222-2225 ES 1-800-222-4225 ES (TTY) www.nia.nih.gov National Institutes of Health Information on many health issues. www.health.nih.gov ES Office of the Patient Advocate (OPA) Information on getting quality health care in California. 1-916-324-6407 ES 1-866-499-0858 (TTY) www.opa.ca.gov ES Osteoporosis Information and research on osteoporosis. 1-800-624-2663 ES www.osteo.org ES Pharmacy Checker Compare drug prices. www.pharmacychecker.com ES Poison Action Line Emergency help for victims of poisoning. 1-800-222-1222 ES www.calpoison.org ES Protection & Advocacy Legal advocacy for people with disabilities. 1-800-776-5746 ES 1-800-649-0154 (TTY) www.pai-ca.org Uninsured Help Line Help finding no-cost and low-cost health care. 1-800-234-1317 ES www.coverageforall.org U.S. Department of Labor Information on COBRA, HIPAA, and federal health care rights. 1-866-444-3272 ES www.dol.gov/ebsa/faqs [page xx61] Common Terms Directions to Reader: To skip from term to term, search for Heading 3. benefit/covered benefit/benefits package A service your health plan will pay for if you need it. A benefits package is all the services that a plan covers. COBRA/Cal-COBRA Laws that help people keep their group health plan. COBRA is the federal Consolidated Omnibus Budget Reconciliation Act. Cal-COBRA is a California law. co-insurance A fee based on a percent of the cost of a service. You must pay this fee each time you see a doctor, get a prescription, or get other services. PPOs often charge a co-insurance instead of a co-pay. co-pay/co-payment A flat fee you pay each time you see a doctor, fill a prescription, or get other services. HMOs usually charge a co-pay instead of a co-insurance. Evidence of Coverage (EOC) A document that explains what your health plan does and does not cover and the rules you must follow for getting care. formulary Your health plan’s list of preferred prescription drugs. generic drug A drug that is made without patent protection. When a company’s patent on a new drug runs out, other companies can make the drug and set lower prices for it. group plan A health plan that you get through your job. HIPAA A federal law that protects your right to get an individual plan when your group plan ends. HIPAA is the Health Insurance Portability and Accountability Act. HIPAA also sets national standards for the privacy of personal health information. HMO (Health Maintenance Organization) A kind of health plan in which you must get all your health care services from the doctors and other providers in the plan’s network. IMR (Independent Medical Review) A review of your case by doctors who are not part of your health plan. An IMR can overturn your plan’s denial of a treatment you need. See pages 52–53. individual plan A health plan that you buy on your own, as an individual instead of through your job. medical group A group of doctors and other providers who have a business together. network All the doctors, medical groups, labs, hospitals, and other providers who work for the HMO or PPO or have a contract with it. PPO (Preferred Provider Organization) A kind of health plan. In a PPO you can go outside the plan’s network and pay a higher cost. premium The monthly fee your health plan charges. primary care provider (PCP) Your main doctor who gives you most of your care and refers you for other services when you need them. Also called a primary care physician or PCP. service area The counties or zip codes that a health plan serves. yearly deductible The amount you may have to pay each year before your health plan starts to pay. yearly out-of-pocket maximum The total you have to pay each year for most of your services. [page xx62] Index Directions to Reader * There is an asterisk before the page numbers with the most information about a topic. * The page numbers start one tab after the terms. * To skip from term to term, search for Heading 3. accessibility 26–27 ADA (Americans with Disabilities Act) 27 Advance Health Care Directive 47 ambulance services 41 asthma/asthma coverage 32, 33, 39, 50 benefits/benefits package/services 8, 9, 12, 14, 16, *28–29, 32–33, 50, 61 bill/balance billing 6, 48, 51, 54 cancer treatment 22, 36, 52 care away from home 41 Certificate of Creditable Coverage 11 check-ups 30–31 chronic conditions 38–39 clinical trials 22 COBRA/Cal-COBRA 10, 11, 13, 61 co-insurance 7, 43, 61 complaint/appeal/grievance 17, 21, 22, 24, 26, 33, 36, 42, 44, 45, *48–53 consent form 23, 25 continuity of care 19 conversion plan 13 co-pay/co-payment 7, 33, 43, 61 costs 4, *6–7, 8, 9, 10, 12, 28, 32, 33, 43, 45, 46 deductible (yearly) 7, 9, 61 depression/anxiety 44, 45 denial of services 21, 22, *48–53 diabetes/diabetes coverage 29, 30, 32, 33, 38 disability assistance/disability services *26–27, 54 doctor visits/services 9, 19, 29 drugs, benefits 7, 9, 16, 17, 28, 29, *32–33 drugs, safety/interactions *34–35, 37 emergency care 7, 29, *40–41, 51, 53 Evidence of Coverage 28, 41, 43, 50, 54, 61 expedited appeal/review 17 expedited referral 20 experimental treatment 52–53 formulary 33, 61 gap in coverage 11 generic drugs 7, 32, 33, 61 group plan/group coverage *10–11, 12, 61 HICAP (Health Insurance Counseling and Advocacy Program) 16, 17 high deductible plan 5, 6 HIPAA 12, 13, 61 HMO (Health Maintenance Organization) *4–5, 9, 14, 16, 20, 28–29, 37, 39, 61 HMO Help Center 12, 13, 15, 50, *52–53 home health care 17, 29, *46–47 hospice care 17, 29, *46–47 hospital/inpatient care 6, 9, 17, 29, *42–43 hospital costs 9, 43 immunizations/vaccinations/shots 6, 19, 31 IMR (Independent Medical Review) 21, *52–53, 61 individual plan/individual coverage 11, *12–13, 61 interpreters 14, *24–25, 54 language assistance/language services 9, 14, *24–25, 29 long-term care 47 low-cost health care 5, 6, *14–15, 16, 46 medical equipment/medical supplies 27, 29, *32–33 medical group 4, 9, *18, 21, 36, 37, 61 medical history/health history 13, 31 Medi-Cal/Medi-Cal Managed Care 5, *14–15, 24, 44, 53 Medicare/Medicare Advantage 5, 7, *16–17, 24, 42, 44, 46, 53 member services/customer services 29, 48–49, *54–55 mental health care 9, 14, 29, *44–45 network 5, 7, 9, 33, 37, 40, 43, 61 nursing home care 17, 29, *46–47 Office of the Patient Advocate (OPA) 2–3 Open Enrollment 11 out-of-network providers/costs 5, 7, 40 out-of-pocket maximum 7, 61 post claims underwriting 13 PPO (Preferred Provider Organization) *4–5, 7, 9, 16, 20, 28, 37, 61 pre-approval 4, 5, 7, *20–21, 33, 36, 37, 41, 46, 47 pre-existing conditions 10, 12, 13, 27 premiums 7, 12, 13, 17, 61 prescription drugs/prescription drug benefits 9, 16, 17, 28, 29, *32–33 preventive care 29, *30–31 primary care doctor/primary care provider/PCP 4, 5, 18–19, 36, 37, 41, 44, 45, 61 Provider Directory 18, 37, 45 quality of care/standards of care 8, 9, 29, 39 referrals 4, 5, 7, 19, *20–21, 36, 37, 42, 44, 45, 46, 47, 48–51 Report Card (Quality Report Card) 3, 8, 9, 25, 28, 29, 39, 46 rights 24, 27, *48–49, 50 routine exams/tests 30–31 rules for getting care 4, 6, 41 second opinion 22, 23, 49 service area 5, 54, 61 side effects of medicines 34–35 sign language services 24–25, 26 specialist/specialist care 20–21, 26, *36–37 standing referrals 21, 36 summary of benefits 6, 8, 28, 54 tests/lab tests/screenings 19, 21, 29, *30, 31, 37 travel, care away from home 41 treatment decisions/treatment plan 14, 22–23, 38–39, 49 urgent care 7, 29, *40–41, 53 urgent health problems, and complaints 21, 22, 48, *50–53 waiting period 11 well-baby/well-child care 8, 15 [xx inside back cover] The Office of the Patient Advocate www.opa.ca.gov contactopa@opa.ca.gov Phone: 1-916-324-6407 TTY: 1-866-499-0858 980 9th Street, Suite 500 Sacramento, CA 95814 Health Research for Action, University of California, Berkeley This guide was developed for the Office of the Patient Advocate by Health Research for Action. For more information about this and other publications, contact: www.uchealthaction.org healthaction@berkeley.edu Phone: 1-510-643-9543 TTY: 1-510-642-9792 2140 Shattuck Avenue, 10th Floor Berkeley, California 94704-1210 The Office of the Patient Advocate Wishes to Thank Health plan members, consumer assistance groups, patient advocacy organizations, health plans, and the HMO Help Center for their contributions to the development of this guide. Design: Rick Wong Design, Emeryville Cover photo credits: © Productions Ltd/Blend Images/Getty Images, © DreamPictures/Jensen Walker/Getty Images, © Blue Jean Images/Getty Images, and © photolibrary. All rights reserved. [xx back cover] The HMO Help Center 1-888-466-2219 Call 24 hours-a-day Help in many languages