California's HMO Guide The State of California OFFICE OF THE PATIENT ADVOCATE Getting the Most from Your HMO Arnold Schwarzenegger GOVERNOR State of California Sunne Wright McPeak SECRETARY Business, Transportation & Housing Agency Ed Mendoza ACTING DIRECTOR Office of the Patient Advocate Copyright 2003 by The Regents of the University of California. All rights reserved. Third edition. 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 Regents of the University of California nor the Office of the Patient Advocate 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 Frequent changes in managed health care or in legal protections for consumers may cause the guide to become outdated, obsolete, inaccurate and/or incorrect.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 Regents of The University of California, the Office of the Patient Advocate, 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. The people of California deserve the highest quality care from their HMOs. "California's HMO Guide" helps you and your family get the care you need and expect. Governor Arnold Schwarzenegger, State of California Getting the best health care you can means knowing your rights and responsibilities. I hope this guide will be a useful tool for making important health care decisions. Sunne Wright McPeak, Secretary Business, Transportation & Housing Agency, The University of California, Berkeley To order a free copy of California's HMO Guide in English or Spanish, call: 1-866-466-8900 Office of the Patient Advocate California's HMO Guide is produced by the University of California, Berkeley, in collaboration with the California Office of the Patient Advocate and communities throughout California. What HMO members have to say about California's HMO Guide: "This gives you a license to say, I am in charge of my health and when I ask questions I need answers." "I was amazed at how much information is in here that you can utilize right now." "I don't feel lost anymore. In the past I have felt intimidated, but now have learned to ask questions." [Page 1] Table of Contents Your Rights and Responsibilities--Page 2 Useful Terms--Page 3 Section Heading: Taking Charge of Your Health Care What Is an HMO?--Page 4 Take Charge of Your Health Care--Page 6 Choosing an HMO--Page 8 Paying for Health Care--Page 10 Keeping Your Health Insurance--Page 12 Pre-existing Conditions--Page 14 Your Medi-Cal HMO--Page 16 Your Medicare HMO--Page 18 Section Heading: You and Your Doctor Choosing a Doctor--Page 20 Communicating with Your Doctor--Page 22 Choosing Treatments--Page 24 If You Have a Disability--Page 26 If English Is Not Your Language--Page 28 Section Heading: About Your Benefits Know Your Benefits--Page 30 Routine Care--Page 32 Children's Health Care--Page 34 Specialist Care--Page 36 Prescription Drugs and Equipment--Page 38 Mental Health Care--Page 40 Emergencies and Urgent Care--Page 42 Hospital Care--Page 44 Care at the End of Life--Page 46 Section Heading: If You Have a Problem If You Have a Complaint--Page 48 Need More Help?--Page 50 Request an Independent Review--Page 52 The Office of the Patient Advocate--Page 54 Section Heading: Finding Resources Resources--Page 56 HMO Member Services--Page 60 Index--Page 63 [Page 2] Your Rights and Responsibilities "California's HMO Guide" is a tool to help you use your HMO (health maintenance organization). This guide has answers to many common questions. It does not offer legal advice, but it will tell you about your rights. It will tell you some places you can go to find more help and to learn more about your rights. When you use this guide, remember that each HMO is different. Call your HMO to learn more about its rules and the care it offers. See page 60 for phone numbers for most California HMOs. Your Health Care Rights To be treated with courtesy and respect. To get health care without having to wait too long. To get an appointment when you need one. To get care from qualified medical staff. To see a specialist when you need to. To choose a doctor you trust. To understand your health problem and the risks and benefits of treatments. To get a second opinion about a health problem. To choose or refuse treatment. To know how your health plan works. To appeal a decision your HMO made about your care. To see and get a copy of your health care records. [Page 3] Your Responsibilities--Tips to help you get good care and stay healthy Read and understand your health plan's Evidence of Coverage (EOC): Know what your plan covers, and what it doesn't cover. To get a copy or ask questions about the EOC, call your HMO. Tell your doctor all your health care concerns: Ask questions if you are not clear about your health problem or treatment plan. Know how to contact your HMO: Keep your membership card handy. Your HMO's Member Services phone number is on the card. Keep good records: Keep records of your health care in one place. Include test results and treatment information. Make healthy lifestyle choices: HMOs offer many services to help you stay well, from health education to well-child care. Use these services. Useful Terms benefits package: The services covered by your health insurance COBRA/Cal-COBRA: Laws that help employees keep their group health insurance if their job ends or their hours are cut copayment/copay: A fee that you pay for each doctor visit or prescription covered benefit: A service your HMO will pay for if you need it deductible: The amount you pay before your insurance starts to pay Evidence of Coverage (EOC): Your contract with your HMO. The EOC tells you what your HMO will and will not pay for formulary: A list of the prescription drugs covered by your HMO group coverage: Health insurance you get through a group, like your company or union HMO (health maintenance organization): A kind of health insurance in which you must get your services from the doctors, labs and hospitals that have contracts with the HMO or work for it Medical Group: A group of doctors who have a business together and have a contract with an HMO to provide services to HMO members network: All the doctors, labs and hospitals that have contracts with your HMO or work for it premium: A monthly fee that you, the company you work for and/or the government pays to your HMO primary care provider (PCP): Your main doctor, who provides most of your care and coordinates your other health care services provider: Any person, clinic or group that provides your health care services service area: The area an HMO serves specialist: A doctor with extra training in a special field, like children's health, cancer treatment or health care for seniors [Page 4] Section Heading: TAKING CHARGE OF YOUR HEALTH CARE What Is An HMO? Most people in California belong to a health maintenance organization-an HMO. Like other kinds of health insurance, HMOs have guidelines for getting services. This guide can help you learn about these guidelines and get the services you need. HMOs differ from most other kinds of health insurance in several ways. Each HMO has a network of doctors, labs, hospitals and other providers that work for the HMO or have a contract with it. You get your health care services from the providers in this network. And usually you have a primary care doctor who provides most of your care and manages your treatments. Medical Necessity HMOs, like other health plans, only pay for services that are medically necessary. This means you need the service to treat or prevent a health problem. In an HMO, your doctor usually decides if you need a service. Sometimes your HMO must also approve the service. Caption: Services to Help You Stay Healthy--Many HMOs offer information on parenting, nutrition and other health issues. Questions & Answers Q: Why do I need health insurance? A: Insurance costs a lot, but if you don't have it, one accident or serious illness could leave you in debt. Q: Can I keep my old doctor if I join an HMO? A: Only if your doctor belongs to the HMO's network. Otherwise you must choose a new doctor in the HMO's network. See page 20. Q: Will I be able to see a specialist if I need one? A: Yes, but you will have to follow your HMO's referral guidelines. Usually you must see a specialist in the HMO'snetwork. See page 36. Q: Can I keep my HMO if I move to another city? A: It depends on your HMO'sservice area. This is the specific area your HMO serves. If you are outside that area, only emergency or urgent care is covered. See page 42. HMOs can change areas. They can move into or out of the area where you live. [Page 5] HMOs Limit Which Doctors You Can See: Usually, an HMO pays only for services you get from the doctors, hospitals and other providers in its network. Ask for a list of your HMO's providers. Caption: Tom Likes His HMO."I know where to go and what to expect." But Ed disagrees, "My new plan is an HMO. I had to change doctors, and it's harder to see specialists." Things You Can Do If You Have Health Insurance Through Your Job: Most people get health insurance through their job. Insurance you get through a job is called group coverage. Ask for information about all the plans your employer offers. The plans can change from year to year. The benefits and fees in each plan can also change. Your dependents, such as your spouse, domestic partner or children, may also get insurance through your job. If they are no longer your dependents or your insurance changes, their insurance changes, too; see page 12. There Are Different Kinds of HMOs: Most HMOs have contracts with many doctors and hospitals. One doctor may belong to several HMO networks. In some HMOs, the providers work for the HMO and all their patients belong to that HMO. For information on Medi-Cal HMOs, see page 16. For information on Medicare HMOs, see page 18. For low-cost HMOs for women and children, see page 34. For general information on HMOs, visit www.opa.ca.gov. Help with Your Health Plan: If you have a question or a problem, first call your HMO's Member Services. Find the number on your membership card or on page 60. If you have a problem and you and your HMO can't agree how to solve it, see page 48 or call HMO Help Center. If your health plan is not an HMO, you can get help from Where To Find Help Department of Insurance--Information and help for consumers 1-800-927-4357 www.insurance.ca.gov HMO Help Center--Help for California HMO members 1-888-HMO-2219 www.hmohelp.ca.gov Member Services--To find your HMO's phone number see page 60 Office of the Patient Advocate--Report cards with information on California HMOs 1-866-466-8900 www.opa.ca.gov [Page 6] Take Charge of Your Health Care Taking health care decisions can be hard-whether you are choosing an HMO, finding a doctor or deciding about treatments. If you know what your choices are and know what you need, you will probably get better care. The information in this book can help you make better decisions. You can also talk to your doctor and other health care providers. And you can find more information in the library, on the Internet and at your HMO's health education office. If you are informed and speak up for your needs, you and your family will be able to make the most of the services your HMO offers. Caption: At First We Were Confused. "There was so much to learn about choosing an HMO. But we asked a lot of questions, and we're happy with the HMO and the obstetrician we chose." Take Charge When You Need Information: Make a list of your questions. Keep asking questions until you get the information you need. Take notes. Get the name of the person you are talking to. For extra support, have a friend or relative with you. If you can't get an answer to your question, ask whom to call or ask to speak to a supervisor. Keep copies of important papers. Questions & Answers Q: Am I the only one who thinks HMOs are confusing? A: No. Learning to use the HMO system can be hard. This guide can help you. Q: Does it help to speak up about a problem? A: Yes. Studies have shown that hospital patients who complain and demand better care really do get better care. They also recover faster. Q: How do I know what rights I have? A: You can learn about your rights in this guide. The more you know about your rights, the more likely you are to get what you need. Also visit www.hmohelp.ca.gov or www.calpatientguide.org. [Page 7] Take Charge When You Need Treatment: Before you or your children get medical treatment, you will be asked to sign a consent form. Before you sign, make sure you understand what is being done and why. Ask about risks, benefits and other treatments. Don't decide on treatments when you are stressed, sleepy or taking drugs for pain; see page 24. Caption: It's Your Choice--Lia and her doctor talked about all the things she could do to manage her high blood pressure. Then she chose what would work best for her. Things You Can Do Get to Know Your HMO: Carry your HMO membership card with you at all times. Know what your HMO will pay for; see page 30. Know what to do if you have a problem; see page 48. You Have the Right to See and Copy Your Medical Records: Ask your doctor's office how to see your records. It may take a few days. It's a good idea to ask for a copy of your medical records, in case you change doctors or HMOs. It can take about a week to get your copy. There may be a fee. In most cases, your records are private. No one can see them unless you say they can. If you don't agree with something in your records, call your Member Services. Visit www.calpatientguide.org. Keep All Your Records in One Place: Save your lab reports and vaccination records. Save copies of test results and treatment information. Save copies of medical bills. Save copies of any letters you send to your HMO. Save information your HMO sends you about its services. Protect Your Wishes: You can choose someone to decide about your health care if you cannot. You can also choose what treatments you want or don't want. To do this, fill out a form called an Advance Health Care Directive. Give a copy to your doctor; see page 47. To get a form, call California Healthcare Association. Where To Find Help California Healthcare Association--Free Advance Health Care Directive forms1-800-494-2001 www.calhealth.org California Patient's Guide--A guide to health care rights www.calpatientguide.org HMO Help Center--Help for California HMO members 1-888-HMO-2219 www.hmohelp.ca.gov Member Services--To find your HMO's phone number see page 60 [Page 8] Choosing An HMO Not all HMOs are the same. Before you choose an HMO, find out what other people think about it. Health plans differ in cost, quality and benefits. Your benefits package is all the services that your health plan covers. All plans offer basic benefits, like checkups, routine tests, specialist care, and hospital and emergency care. Other benefits, like prescription drugs and substance abuse treatment, may differ from plan to plan. When you choose a plan, make sure it has the benefits you need. Caption: "We wanted to stay with our doctor so we chose an HMO she worked in." Questions & Answers Q: My job offers only one plan, but I'm not happy with it. What can I do? A: Many jobs offer only one plan. Talk to your employer about changing to a better plan. Or ask if your employer will help pay for insurance you buy on your own. Q: We're planning to have a baby. What should we look for in an HMO? A: Ask about pregnancy and well-baby care and what it will cost to insure your child. Ask other new parents what plans they like. See page 34. Q: Our son has asthma. What questions do we need to ask? A: Ask the plan about specialists for children. Ask if the medicines your son needs are covered. See page 14 for information about protecting your son's coverage. Q: What if my HMO goes bankrupt or leaves my area? A: Your HMO must help you get the care you need if you are in the middle of treatment or are pregnant. However, you will have to start looking for a new plan. You may need to find a new doctor. If you have a problem, see page 50. [Page 9] You Can Compare Plans: Plans differ in many ways, though all plans regulated by the State of California offer the same basic benefits. To compare California HMOs, visit www.opa.ca.gov.To compare Medicare HMOs, call Cal Medicare. To compare Medi-Cal HMOs, call Health Care Options.For more information on choosing a plan, call National Committee for Quality Assurance. Caption: Compare Plans--Mark and Eva used the HMO Report Card to find out what people said about their HMOs. You can view it at www.opa.ca.gov. Things You Can Do9 You Can Change Plans During Open Enrollment: Most employers have Open Enrollment in the fall of each year. This is when you can change plans. Make sure you meet the deadline for Open Enrollment. You can add new dependents to your plan when you marry, have a baby or adopt a child. You may also be able to change plans. Talk to your employer. If you are starting a new job, ask how soon you can get health coverage and when you need to sign up. Before You Choose a Plan, Ask: Are people I know happy with the plan? Can I find a doctor I like? Does the HMO pay for the services I need? See page 30. What do I have to do to get the services I need? How much will I have to pay? See page 10. How much will it cost to cover my dependents? Does the HMO pay for the prescriptions and equipment I need, including brand-name as well as generic drugs? Will I be able to see the specialists I need? Is the hospital nearby? Can I get a doctor who speaks my language? Compare Costs and Benefits: When you compare plans, look at the costs and benefits. The plan that looks the cheapest can cost you more if it doesn't cover the services you need most. Where To Find Help Cal Medicare (California HealthCare Foundation)--Printed information on Medicare HMOs 1-888-430-2423 www.calmedicare.org Health Care Options--Information on Medi-Cal HMOs 1-800-430-4263 National Committee for Quality Assurance--Information on quality health care and HMO standards 1-800-839-6487 www.ncqa.org Office of the Patient Advocate--Report cards with information on California HMOs 1-866-466-8900 www.opa.ca.gov [Page 10] Paying For Health Care The cost of health care in an HMO is usually less than the cost in other health plans. In an HMO, there is a monthly fee called a premium. There are also fees, called copays, for doctor visits and prescription drugs. There may also be limits on how much your HMO will pay for drugs and other services. Try to avoid surprises. Learn about your HMO's fees before you need services. Caption: When you're on a trip know your HMO's rules for getting care outside its service area. Take your membership cards with you. Questions & Answers Q: My boss says an HMO is all he can afford to offer. Do HMOs cost less than other plans? A: Usually HMOs cost less. One reason is that the doctors and other providers in the HMO's network limit what they charge the HMO for their services. Q: My employer pays for my insurance. How can I find out what it costs? A: Ask your employer or HMO. Or look on your paycheck stub. Q: My health care costs keep rising. When will this stop? A: Costs will probably go on rising. Your employer makes new contracts with plans each year, to get the best benefits at the lowest cost. Let your employer know what benefits you want and what you are willing to pay. Q: What if I get a bill from my doctor? A: Providers in your HMO's network are not allowed to bill you for their services. If your letter says, "This is not a bill," you don't have to pay anything. If you get a bill, don't pay it. Call Member Services. [Page 11] Avoid Costly Surprises--You may have to pay the bill if: You get services that are not part of your benefits package; See page 31. You see a specialist without a referral from your doctor. You see a provider who is not in your HMO's network before your HMO approves the visit, unless it's an emergency. You go to an emergency room for non-emergency care; See page 42. You get care outside your HMO's service area, unless it's an emergency. Caption: If Your Child Is Sick--If it's not an emergency, visit your doctor instead of an emergency room. The copayment is a lot less. Things You Can Do Keep Your Costs Down: Learn about your benefits--know what your HMO does and does not pay for; see page 30. Know your copays. The copay for an office visit is usually under $20, but some HMOs charge as much as $400 a day for hospital stays. Know your HMO's rules for getting care outside its service area. If you can, call your HMO before you get care; See page 42. A few plans divide their network into levels, and charge a higher copay for some levels. If your HMO has levels, you can save money by using providers in the level with the lowest copay. If You Have a Problem with a Bill You Get: Call your Member Services to make sure there's no mistake. If you still have a problem, you can file a complaint with your HMO; See page 48. If your HMO won't pay for emergency or urgent care you received, see page 52 or call the HMO Help Center. Keep copies of any bills you pay, in case you have a problem or need them for your tax return. Prescription Drug Costs: Prescription drugs can cost a lot, even if you have prescription drug benefits. When you choose an HMO, compare drug benefits carefully. Even though you have to pay a higher monthly premium, you may save money if the plan covers the drugs you need; see page 38. If You Can't Afford Health Insurance: For low-cost health care for children and pregnant women; see pages 16 and 34. For low-cost or free health care; see page 16. Where To Find Help HMO Help Center--Help for California HMO members 1-888-HMO-2219 www.hmohelp.ca.gov Member Services--To find your HMO's phone number see page 60 [Page 12] Keeping Your Health Insurance If you quit or lose your job or your hours are cut, find out about COBRA. This is a law that helps you keep your employer's health plan for 36 months. If you keep your plan through COBRA, you will have to pay all of the premium. But it may cost less than insurance you buy on your own. And the benefits may be better. Protection for Family Members COBRA can help your spouse, former spouse, widow or child keep health insurance after your job ends, or after your divorce or death. A child who turns 21 and will no longer be your dependent can also get COBRA for 36 months. Caption: COBRA Protects Your Dependents--"Elena is 21 now, but we're keeping her insured through COBRA until she finds a job." Questions & Answers Q: Why should I keep my employer's plan? A: It may cost less than getting insurance on your own. Prescription drug benefits are often better. And if you have an ongoing health problem, you may find it hard to get insurance on your own. Q: I can't afford COBRA. What can I do? A: For information on low-cost health care, see pages 16 and 34. You can also ask your HMO about other benefit packages. You may be able to get a package that costs less because it has fewer benefits. Q: I'm retiring but I'm only 60. Can I get COBRA? A: Yes, and you may be able to get Senior COBRA after you use up COBRA. Senior COBRA can last until you are 65 or get Medicare. To get Senior COBRA, you must be at least 60 and you must have worked at your job for at least 5 years. Call a benefits counselor at HICAP. [Page 13] How to Get COBRA: You have 63 days after your job ends to apply for COBRA and pay your first month's premium. To apply you have to fill out a form that says you want COBRA. If you don't get your application form or you have questions, call your Member Services or talk to your employer. Or call U.S. Department of Labor. If you work for a small company, with 2 to 19 employees, call HMO Help Center. Caption: COBRA Protects You Between Jobs--When Jim was laid off, he used COBRA. "It was hard to come up with the money, but I was glad I did. I broke my leg and really needed the health care." Things You Can Do Questions About COBRA, Cal-COBRA and Senior COBRA?: COBRA is a federal law. It applies to most employers with at least 20 employees. If you have questions about it, call U.S. Department of Labor. Cal-COBRA is California's COBRA for businesses with 2 to 19 employees. For more information, call HMO Help Center. Cal-COBRA also helps people keep coverage when COBRA runs out. For more information, call HMO Help Center. For more information about Senior COBRA, call HICAP. Keeping Your Employer's Health Insurance: Ask your HMO or employer about COBRA if your job is ending or your hours are being cut. Make sure you meet the deadlines for signing up for COBRA, Cal-COBRA or Senior COBRA. Pay your premiums on time or you will lose your coverage. If you move out of your HMO's service area or your former employer stops offering health insurance, you will lose your COBRA or Senior COBRA. If you qualify as disabled during the first 2 months you're on COBRA, some of the COBRA rules are different. Call U.S. Department of Labor. Getting Insurance on Your Own: Compare the cost of using COBRA to buying a health plan on your own. If you know your insurance will end, shop around now. Compare benefit packages and costs. For more information on getting insurance on your own, see the next chapter. Where To Find Help HICAP (Health Insurance Counseling & Advocacy Program)--Information about Senior COBRA 1-800-434-0222 HMO Help Center--Information about Cal-COBRA 1-888-HMO-2219 www.hmohelp.ca.gov Member Services--To find your HMO's phone number see page 60 U.S. Department of Labor--Information about COBRA and HIPAA 1-866-444-3272 www.dol.gov/ebsa [Page 14] Pre-Existing Conditions You may have diabetes, a bad back or other health problem that needs care. If you have a health problem or condition like this, be extra careful when your insurance ends or changes. Your new insurance company may say that you have a pre-existing condition. Your employer's plan cannot refuse to insure you if you have a pre-existing condition. However, it may not cover services for your condition right away. And you may find it hard to buy health insurance on your own. It is easier to get new insurance if you sign up less than 63 days after your old insurance ends. COBRA can help you keep your old insurance until you get a new plan. See page 12. Caption: Andy Has Cerebral Palsy--"When I changed jobs I made sure to keep our insurance through COBRA, so there was no gap in coverage." Questions & Answers Q: What is a gap in coverage? A: It's 63 or more days in a row without health insurance. If a gap is shorter than 63 days, it's easier to get care for preexisting health problems. Q: If I'm pregnant when I join a plan, will I be covered? A: You'll be covered if you join a group plan. But a plan you buy on your own may not cover services for this pregnancy. Q: I have an old injury. Will I have to wait to get care in my new plan? A: Ask your new employer or your new plan. Not all plans have waiting periods. A group plan can't make you wait if you haven't had care for your injury in the last 6 months. Q: Can my employer's plan charge me more if I have HIV? A: No, your employer's plan cannot charge you more. Call California AIDS Hotline. [Page 15] When You Start a New Job: The group plan at your new job may have a waiting period before it will cover a pre-existing health problem. You can shorten or avoid this waiting period if you have had 3 to 12 months of coverage with no gaps. Call U.S. Department of Labor. Visit www.dol.gov/ebsa. Caption: You May Have to Wait for Care--Joe needed knee surgery. "I didn't have insurance for 3 years. Now I have it, but I'll have to wait 6 months before I can get the surgery." Things You Can Do Avoid Gaps in Your Coverage: If your insurance ends, try to sign up for a new plan within 63 days. Look for new insurance as soon as you know you will have to change plans. It can take 30 days or more from the time you apply until the time you are approved. When your insurance ends, get a letter from your HMO that says how long you were insured. This is called a Letter of Creditable Coverage. Keep it in case you need it when you apply for health insurance. If You Have Medi-Cal or Medicare: A Medi-Cal or Medicare HMO will not limit your care for preexisting health problems. See pages 16 and 18. To Get Insurance on Your Own: A law called HIPAA protects your rights to get insurance on your own. It protects coverage for a pre-existing condition. The law limits how much a plan can charge you. Call Department of Insurance or visit http://cms.hhs.gov. Use up your COBRA first and apply for HIPAA individual coverage within 60 days of the date your COBRA ends. You must have coverage without a gap for the last 18 months. If you are denied care because of a pre-existing condition, find out about your rights. See page 27 or visit www.calpatientguide.org. Where To Find Help California AIDS Hotline--Information on HIV/AIDS services 1-800-367-2437 www.sfaf.org California Patient's Guide--A guide to health care rights www.calpatientguide.org Centers for Medicare & Medicaid Services--Information on HIPAA 1-877-267-2323 http://cms.hhs.gov Department of Insurance--Information and help for consumers 1-800-927-4357 www.insurance.ca.gov U.S. Department of Labor--Information about COBRA and HIPAA 1-866-444-3272 www.dol.gov/ebsa [Page 16] Your Medi-Cal HMO Many people with Medi-Cal belong to Medi-Cal HMOs. Like other HMOs, Medi-Cal HMOs have networks of doctors, pharmacies, clinics, labs and hospitals. You use these providers when you need health care services. You will have one doctor or clinic that you go to first for all your health care needs. If you don't choose a doctor or clinic when you join the HMO, the HMO will choose one for you. But you can change your doctor or clinic if you want. Medi-Cal HMOs provide many services to help members stay healthy. They also have interpreter services for all members with limited English. Caption: Medi-Cal for Mothers-- Monica got Medi-Cal as soon as she knew she was pregnant so she could get prenatal care. Questions & Answers Q: How do I get Medi-Cal? A: There are many ways to qualify. Call your county Social Services office for information. Both your income and your medical need are looked at. Q: I am pregnant and need Medi-Cal. How soon can I get it? A: You can get it right away. Apply now. Q: How do I get family planning services? A: You can visit any doctor or clinic in your HMO that has family planning services. You don't need to get a referral from your doctor. Q: Can I stay with my current doctor? He's been treating my diabetes for 2 years. A: You may be able to stay with your doctor. Call Health Care Options. Q: Can I switch my Medi-Cal HMO? A: Yes, if your county has more than one plan. Q: What if my Medi-Cal is cancelled? A: There may be a problem with the way you qualify. Call your social worker or Medi-Cal Managed Care Ombudsman. [Page 17] Your Medi-Cal HMO Medi-Cal Offers These Services for Adults and Children: Doctor services; Preventive care, like exams and shots; Health education; Hospital care; Family planning; STD tests and treatment Pregnancy tests and care; Prescription drugs; Vision and hearing care; Emergency and urgent care; Lab work, like blood tests; X-rays and mammograms; Physical therapy; Chiropractic care; Foot care; Dental care; Medi-Cal for Children Caption: Your children may be able to get Medi-Cal, even if you can't. Things You Can Do To Enroll in Medi-Cal: Pick up an application form at your county Social Services office or at a hospital, clinic or school. If there is more than one plan in your county, you can choose which plan to join. If you do not choose within 30 days, the county will choose a plan for you. If You Have a Complaint: You can file a complaint with your HMO. Call your HMO Member Services; see page 48. If you have a problem switching doctors, call your HMO Member Services. If your HMO says you cannot get the services you feel you need, call Medi-Cal Fair Hearing. If you have a complaint about a provider or the quality of your care, call Medi-Cal Managed Care Ombudsman. If You Have a Serious Health Problem: You may not need to join an HMO. If you do join one, you may be able to see a specialist who is not in your Medi-Cal HMO. Call Health Care Options. If you have HIV, you have the right to see an HIV specialist. Mental Health Care: If you belong to a Medi-Cal HMO and need mental health care, call your County Mental Health Agency or Medi-Cal Mental Health Care Ombudsman. See page 40. Where To Find Help Health Care Options--Join or leave a Medi-Cal HMO 1-800-430-4263 Medi-Cal Fair Hearing--File an appeal if your HMO denies you the services you need 1-800-952-5253 Medi-Cal Managed Care Ombudsman--Help if you have a problem you can't solve with your HMO 1-888-452-8609 Medi-Cal Mental Health Care Ombudsman--Help with Medi-Cal mental health care services 1-800-896-4042 Member Services--To find your HMO's phone number see page 60 [Page 18] Your Medicare HMO Most seniors and some younger people with disabilities get Medicare. Medicare is health insurance sponsored by the government. Many people in Medicare get their care through HMOs. The government pays your Medicare HMO a fixed amount each month. Usually, you still pay a monthly premium for your share of Medicare Part B. In most ways, Medicare HMOs are like other HMOs. You must use the providers in the plan's network, and the plan or your doctor must approve most services before you get them. When you have a problem, you have the right to file a complaint and ask for a review of your HMO's decisions. A Medicare HMO may cost you less or offer more benefits than traditional Medicare. When you are deciding how to get your Medicare, you should look at all your choices. Caption: Learning to Use an HMO--"We joined a Medicare HMO because we didn't want to deal with a lot of paperwork. But it took us a while to find doctors and learn how to get services." Questions & Answers Q: If I join a Medicare HMO, will I have the same benefits I have in traditional Medicare? A: Yes. The HMO must cover the services covered by Medicare Parts A and B. Q: Can I change my HMO? A: Yes, you can change if there is more than one Medicare HMO in your area. Q: My HMO is leaving my area. What can I do? A: You can join another Medicare HMO. Or you can return to traditional Medicare and get a Medigap plan to cover services Medicare doesn't cover. Call HICAP. Q: My wife has had hip surgery and doesn't feel ready to come home. What can I do? A: Ask the hospital social worker about the home care your wife will need. And you can call California Medical Review right away and ask about keeping your wife in the hospital longer. Q: I have retirement health benefits. Will I need Medicare? A: Yes. Ask how the employee plans work with Medicare. [Page 19] Your Medicare HMO Costs May Include: A monthly premium; Copays for doctor's visits, hospital stays, prescription drugs and some other services; Additional costs for some services. Medicare HMOs can change fees and benefits once a year. They must notify you, so that you can change plans if you want to. If You Have a Problem Talk to your doctor and HMO. Call HICAP for more help. You can file a complaint, or "grievance," with your HMO. See page 48. If your HMO says you cannot get a service you think you need, you can ask for a review or "reconsideration." If your problem is urgent, ask for an Expedited Review. A HICAP counselor or a doctor can help you do this. Your HMO must review your case within 3 days. If you think you need to stay longer in the hospital, or have a complaint about your care, call California Medical Review. Things You Can Do Help with Medicare: Do you have questions or need help with your Medicare? For free help, call HICAP, a program that helps people use Medicare and get the care they need. For information, call 1-800-Medicare or Cal Medicare. Changing or Leaving Your Medicare HMO: To change HMOs, fill out an enrollment form at the HMO you want to join. It can take about a month to join. Do not drop your old plan until your new plan says you are covered. Leaving a Medicare HMO is called disenrolling. There are three ways to disenroll. You can send a request in writing to your HMO. You can visit your Social Security office and fill out a form, or you can call 1-800-Medicare. Before you disenroll, decide whether you want to join another HMO or get traditional Medicare. If you return to traditional Medicare, you can buy a Medigap policy to cover some of the services that Medicare doesn't cover. But be sure to meet the deadlines for getting Medigap. Call HICAP. Prescription Drugs: Before you join an HMO or buy prescription drug benefits, see if the drugs you need are covered. Some HMOs do not cover prescription drugs, and some only cover generic drugs; see page 38. To compare drug benefits, call Cal Medicare. If your pharmacy accepts Medi-Cal, it must also offer drug discounts for Medicare members. There is a yearly limit on what many HMOs will pay for drugs. Where To Find Help California Medical Review--Call about problems with the quality of your care 1-800-841-1602 www.cmri-ca.org Cal Medicare (California HealthCare Foundation)--Printed information about Medicare HMOs 1-888-430-2423 www.calmedicare.org HICAP (Health Insurance Counseling & Advocacy Program)--Help for Medicare members 1-800-434-0222 1-800-Medicare--Information and help with Medicare 1-800-633-4227 www.medicare.gov [Page 20] Section Heading: YOU AND YOUR DOCTOR Choosing a Doctor Your primary care doctor gives you your basic care and oversees all your treatments. In many HMOs, you must have a primary care doctor. If you don't choose one, the HMO may choose one for you. But you can change doctors if you don't like the doctor you have. You have the right to your own doctor in your HMO's network. It's a good idea to choose one, even if you don't have to. Your doctor can help you understand your care and get the services you need. Over time, your doctor will get to know you and can watch for changes in your health. Caption: Find a Doctor You Like--"We met Dr. Liu at an urgent care clinic and really liked her, so we asked if she could be our regular doctor." Questions & Answers Q: Every time I have an appointment, I see a different doctor. How can I choose my own doctor? A: Call Member Services and ask for a list of primary care doctors. You may have to call several doctors before you find one who's taking new patients. Q: What if I don't like my doctor? A: You can change doctors. It may take up to a month to get a new doctor. Q: What if my plan ends its contract with my doctor? A: You will have to choose a new doctor. Ask your old doctor for the names of good doctors in the network. Or call Member Services. If you are pregnant, you may be able to keep your doctor until after your baby is born. If you are being treated for a serious health problem, you may also be able to keep your doctor for a while. Call Member Services. [Page 21] Choosing Your Doctor: Ask friends and co-workers which doctors they like. Then call the doctor's office and ask: Is the doctor in the HMO's network? Is the doctor taking new patients? How long does it take to get an appointment? Can I get evening or weekend appointments if I need them? Can the doctor help me with my problems-such as an ongoing condition or disability? How does the doctor make referrals to specialists? What happens in an emergency? Does the doctor use a hospital near me? How will I reach the doctor if I have a problem between visits? Your Doctor Has a Responsibility to You: Your primary care doctor has a duty to make sure you get the care you need. He must tell you all of your treatment choices. If he can't see you, you must be able to see another doctor. If your doctor leaves your plan, you must be told ahead of time so you can get another doctor. Things You Can Do The Right Primary Care Doctor for You: If you don't have a primary care doctor, you can get one. It's good to meet your doctor before you need care. Your primary care doctor can be a family doctor, an internist, a pediatrician or a gynecologist. You can also choose a nurse practitioner who works with a doctor. You may want one doctor for your whole family. Or family members may want their own doctor. Your doctor's office should be easy for you to get to. You can usually ask for a doctor within 15 miles or 30 minutes of your home or work. Ask your HMO for a list of doctors who speak your language. To get a report comparing language and cultural services, call Office of the Patient Advocate. Your Doctor's Medical Group: A Medical Group is a group of doctors who have a business together and have a contract with an HMO to give services to the HMO members. If your doctor can't see you, another doctor in the Medical Group must see you. Most of the specialists you see will also be in your doctor's Medical Group. The Medical Group or your HMO may need to approve your doctor's referrals to specialists. For information on Medical Groups, order a free HMO Report Card. Call Office of the Patient Advocate. If your Medical Group closes or leaves the plan, your HMO must make sure you have care until you find a new doctor. If you have a problem, call Member Services. Where To Find Help Member Services--To find your HMO's phone number see page 60 Office of the Patient Advocate--Report cards with information on Medical Groups 1-866-466-8900 www.opa.ca.gov [Page 22] Communicating with Your Doctor Good health care depends on you and your doctor being able to talk freely. You should be able to discuss all your concerns comfortably. Be as open as you can-the more your doctor knows about you, the better care she can give you. And let your doctor know if you don't understand what she says. Keep asking questions until you are sure you understand. Make the Most of Your Visit: Most doctor visits are short. Plan ahead so you can cover everything. Bring a list of your questions and concerns. Bring a list of all the prescription and over-the-counter drugs you take. Repeat things in your own words to make sure you understand. Take notes. If you need treatment, agree on a plan with your doctor. Ask how to reach your doctor between visits. If you have a lot to talk about, ask for another visit. Bring someone with you for support. Caption: Ask for Explanations--Maria's doctor uses a model to explain birth control. Questions & Answers Q: My doctor is always in a hurry. How can I get him to listen? A: Doctors are often in a hurry. If you don't feel that your doctor listens your concerns, repeat your questions. Ask him to explain his answers. If you still feel that he doesn't listen, you may want to change doctors. Q: How do I know what to tell my doctor? I don't know which symptoms are important. A: Tell your doctor all of your concerns-what hurts, where it hurts, when it hurts. And ask all your questions: Should I be worried? What should I do? Q: What if I don't speak English well? A: Look for a doctor who speaks your language, or ask your doctor or HMO for an interpreter. You have the right to an interpreter when you need one. See page 28. Q: How do I bring up hard topics, like sexual problems or drinking? A: Sometimes the things that are hardest to talk about are the most important. It may be easier if you make a list of your questions and give your doctor a copy. [Page 23] When You Make an Appointment: Ask how long you will have to wait. Ask how to get to the office and where to park. Ask if you need to do anything to prepare for your visit. Request a longer appointment if you need one. Request an interpreter if you need one; see page 28. Ask about access if you need to because of a disability; see page 26. Caption: You Can Bring Someone with You--Brenda helped her brother ask all his questions. "We asked his doctor to explain the lab tests in plain English." Things You Can Do Making Appointments: Ask if there is a number to call to make appointments. You may be put on hold for a long time. Have something to do while you wait. You may find it easier to make an appointment in person, especially if you're already at your doctor's office and need another visit. Ask How to Reach Your Doctor Between Visits: When you call, leave your phone number and the best times for the doctor or nurse to call you back. Ask who will call you backÑyour doctor, a nurse or someone else. Ask if you can fax or e-mail your message. If your doctor's office doesn't return your phone calls, call your Medical Group or HMO Member Services. If the person you speak with asks you for a lot of personal medical information, you can say that you want to tell your doctor the details. Bring a Friend or Relative with You : When you visit your doctor, you can bring someone with you to help you listen, ask questions and take notes. This is very helpful when you have to decide about treatments or start new drugs. Do Your Homework: If you are told you have a health problem, try to learn more about it. Write down questions for your doctor. See page 24 or visit www.healthfinder.gov. Where To Find Help Healthfinder--An introduction to health information on the Internet www.healthfinder.gov Member Services--To find your HMO's phone number see page 60 [Page 24] Choosing Treatments It is not always easy to choose the best treatment. Most treatments have risks as well as benefits. Work with your doctor and learn about your choices so you can make an informed decision. If you have a serious health problem, you may want to get a second opinion about your treatment from another doctor in your HMO. Your doctor should tell you all your treatment choices, even if they are not covered by your plan. If you need to decide about an important treatment, ask how much time you have to decide. It can take some time to understand your choices. Compare Treatments: What are the risks and benefits of each treatment? What risks are you willing to take? Which treatments are most likely to help? Least likely? How much time will each treatment take? What about recovery time? How much will each treatment cost you? How much discomfort or pain are you willing to take? Caption: Work with Your Doctor--"My doctor and I talked about ways to manage my colitis. We agreed on a treatment plan that works for my lifestyle." Questions & Answers Q: Can I get a second opinion? A: You have a right to get a second opinion. But if you want to see a doctor outside your HMO's network, you need a referral from your HMO. This can take about a week. If your problem is urgent, your HMO must reply to your request in 3 days. Or you can pay for the visit yourself. Q: What if my HMO won't pay for the treatment my doctor recommends? A: You can file a complaint with your HMO. See page 48. Q: I read about a new treatment for my cancer. How can I learn more about it? A: Ask your doctor about it. It may not be approved for the public yet. Look for information on the Internet or at a medical library, or call Cancer Information. Q: What if I don't want any treatment? A: You have the right to refuse treatment for yourself. [Page 25] Before You Agree to a Treatment: You usually have to sign a consent form before you or your children receive treatment. The form says you agree to the treatment. Before you sign, make sure you understand what is being done and why. Compare the risks and benefits of all the treatment choices. Don't decide about health care treatments when you are stressed, sleepy or taking drugs for pain. Caption: Ask Questions--Rachel asks her doctor about the risks and benefits of treatments for her daughter's heart problem. Things You Can Do Talk with Your Doctor About Your Treatment: Ask about common side effects. How can they be treated or prevented? What should you do if you have a side effect? How will you know if your treatment is working or if it should be stopped? If you are in a lot of pain, tell your doctor. Ask about pain treatments; see page 47. Learn About Your Medical Condition: Visit your local library or a medical school or hospital library. Ask your doctor about medical centers doing research on your health problem. Look for a local group that helps people with your health problem, like the American Cancer Society. Look on the Internet. Visit www.healthfinder.gov or www.health.nih.gov. To learn about your lab tests, visit www.labtestsonline.org. To learn about medical guidelines for treating your health problem, visit www.guideline.gov. Ask for a Second Opinion: When your problem or the cause is unclear. When you have doubts about surgery. When you have doubts about a treatment for a serious health problem, or when the treatment isn't working. Where To Find Help Cancer Information--Information on cancer treatments 1-800-422-6237 www.cancer.gov Healthfinder--An introduction to health information on the Internet www.healthfinder.gov Lab Tests Online--Information about lab tests www.labtestsonline.org National Guideline Clearinghouse--Care guidelines for many health problems www.guideline.gov National Institutes of Health--Information on many health issues www.health.nih.gov [Page 26] If You Have A Disability Make sure that you get all the services you need, from routine care to care for your disability. Know your rights and look for a doctor who understands your disability and will support you in getting services. If you can't get into a provider's office or use his equipment, ask your HMO to find you another provider. You or your doctor may ask for changes in the way services are offered. For example, you may need someone with more training to draw your blood. Or you may need routine dental work done in a hospital. Your HMO must pay for these services if there are medical reasons why you need them. You Have the Right to: 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. A sign language interpreter if you need one; see page 28. Health information you can use if you are blind or have low vision. Special medical equipment, like an exam table or a scale that works for you if you use a wheelchair. Take your service animal into exam rooms with you. For more information on these rights, visit www.dralegal.org. Caption: Ask for What You Need--Mona's HMO did not have a mammogram machine she could use. So she asked the HMO to pay for her visit to a clinic outside the network. Questions & Answers Q: I was referred to a specialist, but I can't get into his office because I use a wheelchair. What should I do? A: The specialist or your HMO must find you an accessible provider. Your HMO must pay for this provider, even if he is not in the HMO's network. Q: I have a rare condition. There's a new treatment that might help, but my HMO won't pay for it. What can I do? A: Discuss the new treatment with your doctor. You may be able to get a review of your HMO's decision. See page 52. [Page 27] When You Apply for Health Insurance: Your employer's plan cannot refuse to cover you, or charge you more, if you have a disability. If you apply for insurance on your own, a plan can charge you more, but only if it can show that care for your disability costs more. See pages 13-15. Caption: Your Doctor Should Be Your Advocate--Because of her disability, Suzanne needed extra days in the hospital after her baby was born. "My doctor helped me get the care I needed." Things You Can Do When You Make an Appointment: Let the provider know if you will need help getting onto an exam table, extra time for an appointment, a sign language interpreter, an accessible bathroom or other services. Your Medical Records: It's a good idea to keep your own copy of your medical records. If you change providers, it can take a while for your new provider to get your records; see page 7. Medical Equipment: Before you join an HMO, ask if it covers the equipment you need and what the copayment is. HMOs only pay for "Medically necessary" equipment. If you disagree with your HMO about what you need, see page 48. For more information about equipment for people with disabilities, call Protection & Advocacy or AT Network. Protect Your Rights: For a guide on your rights to health insurance and accessible health care in California, call Disability Rights Advocates. For legal assistance, call Protection & Advocacy. Find More Services: For services for children with disabilities, see page 34. For more information on health care programs, talk to your local Independent Living Center or visit www.cfilc.org. In Home Support Services (IHSS) helps people with low incomes and disabilities pay for some home health care. To apply, call your county Social Services department. Where To Find Help AT Network--Information on equipment and assistive technology 1-800-390-2699 www.atnet.org California Foundation for Independent Living Centers--Resources for people with disabilities www.cfilc.org Disability Rights Advocates--A guide to the health care rights of people with disabilities 1-888-926-0274 www.dralegal.org Protection & Advocacy--Legal advocacy for people with disabilities 1-800-776-5746 www.pai-ca.org [Page 28] If English Is Not Your Language You and your family have the right to good communication with your doctor and other providers. Look for doctors who speak your family's language or ask for an interpreter if you need one. You have the right to an interpreter who translates medical information correctly and respects your privacy. You also have this right when you seek care for your child, so that you can talk with your child's doctor. Ask for a Medical Interpreter: Certified medical interpreters are trained to translate health information correctly. They must respect your privacy and keep all information private. The interpreter may be in the same room with you and the doctor, or may be on the telephone or a video screen. You can request an interpreter if you speak another language or use sign language. You can also ask your HMO for written materials in your language. Caption: Now I Ask for an Interpreter. "My daughter used to interpret for me, but I didn't like talking about my problems in front of her. So now I ask for an interpreter." Questions & Answers Q: When should I ask for an interpreter? A: You should ask for an interpreter any time understanding your doctor is important to your health, such as when she explains the results of your tests. Make sure to call before your visit to ask for an interpreter. Q: Do I have to pay for interpreter services? A: This service is usually free- check with your health plan. Call HMO Help Center. Q: How can I find an HMO with services in my language? A: You can get a report on California HMOs and the language and cultural services they offer. Call Office of the Patient Advocate. Q: What if I am Deaf or Hard of Hearing? A: You have the right to a sign language interpreter. Try not to rely on lipreading. Even good lip-readers can have trouble with medical terms. For more information, call Deaf Counseling, Advocacy and Referral Agency. [Page 29] Try Not to Depend on Your Family and Friends to Interpret for You: You may not feel comfortable having a friend or relative hear your private health problems or questions. And they may not translate medical information correctly. You may want a family member or friend with you for support, but try not to rely on them to interpret for you. Caption: If Your Language Is American Sign Language--You have the right to an interpreter so that you and your doctor can understand each other. Things You Can Do Making Appointments: Ask if your HMO has staff who speak your language and can help you make appointments. If you know that you will need an interpreter, tell your doctor as far ahead as you can. You and Your Doctor: Ask your HMO for a list of doctors who speak your language. Your doctor should treat you and your culture with respect, even if she does not speak your language. Make sure that you and your doctor understand each other. If something is not clear, repeat it in your own words. Ask the interpreter to translate your words back to the doctor. You Have the Right to an Interpreter When You Need to: Explain your symptoms or medical history to your doctor. Understand your health problem or treatment choices. Understand instructions about medications, medical equipment or follow-up care. Order California's HMO Guide in Spanish: To order this guide in Spanish, call 1-866-466-8900. Health Care Topics in Many Languages: For information in many languages on Medi-Cal and Healthy Families, visit www.healthconsumer.org. Where To Find Help Deaf Counseling, Advocacy and Referral Agency--Resources for people who are Deaf or Hard of Hearing 1-877-322-7299 1-877-322-7288 (TTY) www.dcara.org Health Consumer--Health care information in several languages www.healthconsumer.org HMO Help Center--Help and information in many languages 1-888-HMO-2219 www.hmohelp.ca.gov Office of the Patient Advocate--Report cards with information on California HMOs 1-866-466-8900 www.opa.ca.gov [Page 30] Section Heading: ABOUT YOUR BENEFITS Know Your Benefits When you buy health insurance, you are buying a set of services called a benefit package. All HMO benefit packages include the same basic services, but details may differ and some HMOs include more services. Your HMO must give you a written description of your benefits. This is often called the Evidence of Coverage. It lists what your plan does and does not pay for. Before you join an HMO, find out if it covers the services you need. For example, if you are planning to have a baby, you will want to know about pregnancy benefits. If you take any medications, you'll want to know about prescription drug benefits. Caption: Many HMOs Have Health Education Programs--You can get free brochures, borrow videos, talk to a health educator-or take a childbirth class. Questions & Answers Q: I have a lot of benefits, but will I be able to use them if I need them? A: Yes, you can use your benefits when they are needed for your health care. If you have a problem getting services you need, see page 48. Q: I read about a new treatment that may help my heart problem. But my plan says it doesn't cover experimental treatments. What can I do? A: You can file a complaint with your HMO and ask for a review of the decision. You may get the treatment if research shows that it could help. See pages 50 and 52. Q: My husband and I have been trying to have a baby for 5 years. Our doctor suggests infertility treatments. Will my plan pay for these? A: Your plan may pay for part of your treatment. Call your Member Services to find out what is covered. [Page 31] Know Your Benefits. All HMOs Include These Basic Services in Their Benefit Packages: Doctor services; Hospital and outpatient services; Lab work like blood tests, STD tests and pregnancy tests; Tests like x-rays and mammograms; Preventive care, like vaccinations and checkups; Emergency and urgent care-even if you are outside your HMO's service area, see page 42; Some physical therapy; Some home health or nursing home care after hospital visits; Some care at home for people who are dying, see page 46; Mental health care for some serious problems, see page 40; Diabetes home care supplies. Caption: Finding Problems Early--Marvin is having his yearly checkup. All HMOs provide basic care like this to find and prevent problems. Things You Can Do Learn About Your Benefits: Your Evidence of Coverage is your contract with your HMO. It explains your benefits and fees. For easier reading, ask for a summary of your benefits. Remember, two people in the same HMO may not have the same benefits. They or their employers may not have bought the same benefit packages. Have a question? Call your HMO's Member Services or your benefits office at work. Visit www.hrh.org or www.healthscope.org. Prescription Drug Benefits: Prescription drugs are part of most benefit packages provided by employers. Your HMO will have a list of the drugs it covers; see page 38. If a plan covers prescription drugs, it must also cover prescription birth control. If a plan covers prescription drugs, it must cover diabetes medications. When You Join a New Plan: You may not be able to use all your benefits right away. There may be a waiting period before you can get care for health problems you have before you join the plan; see page 14. Vision, Hearing and Dental Care: Ask if your plan covers vision and hearing care, or part of the cost of glasses or hearing aids. Most plans do not cover routine dental care unless it requires a hospital stay. You may be able to get these or other benefits for an extra fee. Where To Find Help Health Rights Hotline--Health care rights and resources www.hrh.org HealthScope--Information on California HMOs www.healthscope.org Member Services--To find your HMO's phone number see page 60 [Page 32] Routine Care Routine care is care that helps your doctor prevent health problems or find them before they become serious. Routine care includes services like physical exams, checkups, lab work and gynecological exams. You and your doctor should agree on how often you need a complete exam and routine tests. Your HMO may have a schedule for these visits. If that schedule doesn't work for your health needs, talk with your doctor about changing it. Make the most of your visits. Ask questions about things that have been bothering you. Remember moles that have changed, pains that come and go. These exams are a chance to look at the health of your whole body. Caption: "I learned I have high blood pressure at my annual exam so my doctor said I should start exercising to help keep it under control." Questions & Answers Q: What should I do if I'm sick? A: If you're sick, call your doctor or your HMO's Advice Nurse. You may not need to visit the doctor's office if they can tell you what to do to feel better. But if you think you need an appointment, make sure you get one. Q: Will my plan pay for routine care if I'm traveling? A: No. If you're outside your HMO's service area, only emergency and urgent care will be covered. See page 42. Q: I have sickle-cell disease. I'd like to see a specialist for my regular care. Is that possible? A: If you have a health problem that needs ongoing care from a specialist, you may be able to see the specialist for your routine care. Call Member Services. [Page 33] Ask About Your Tests: Before you have a test, ask why it is being done, how it will be done and if there are any risks. Make sure that you get the results of your tests, and ask your doctor to tell you what they mean. To learn about lab tests, visit www.labtestsonline.org. Caption: Well-Child Visits--Charlene's well-child visit includes immunizations, an ear exam and other routine services for children. Things You Can Do How Often Should You Have an Exam? Ask your doctor or your HMO Member Services how often you should have routine exams and tests. Ask for schedules for children's checkups; see page 34. Make sure your family's shots and vaccinations are up to date. Call National Immunization Hotline. Ask about screening for skin cancer. Talk with your doctor about testing for STDs (sexually transmitted diseases), HIV, and hepatitis B and C. Ask about prostate exams for men. Ask about breast exams, pelvic exams and mammograms for women. If you're an older adult, ask what exams you may need more often, like hearing, vision and colon cancer screenings. Keep Track of Your Care: For forms to help you keep track of your family's care, call the Agency for Healthcare Research and Quality. Know Your Family's Medical History--If a disease or other health problem runs in your family, talk to your doctor. She may want you to have exams more often or take other steps to stay healthy. Where To Find Help Agency for Healthcare Research and Quality Personal Health Guides to routine care 1-800-358-9295 www.ahrq.gov Lab Tests Online--Information about lab tests www.labtestsonline.org Member Services--To find your HMO's phone number see page 60 National Immunization Hotline--Immunization guidelines 1-800-232-2522 www.cdc.gov/nip [Page 34] Children's Health Care If you are a parent, your children's health is one of your biggest concerns. Make sure your children have regular well-baby and well-child checkups. These will help prevent problems and keep your children healthy. You will want to talk with your children's doctor about many issues, such as breastfeeding, nutrition and immunizations. Both you and your children should be comfortable with your doctor. Health Insurance for Babies and Young Children If you want to insure your baby or adopted child through your HMO, you must apply within 30 days of the birth or adoption. Ask your HMO what services for your child are covered in the first 30 days. Ask what newborn tests are covered by your plan, such as newborn hearing tests. Ask for a schedule for well-baby and wellchild visits and immunizations. After age 5, take your child to the doctor at least once a year. For low-cost insurance for children, call Healthy Families or see page 16. Pregnancy and Childbirth When you choose an obstetrician, ask which hospital or birthing center he uses. Ask what birth options are covered by your plan. Visit www.childbirth.org. If you are in labor, any hospital emergency room must accept you. But go to your HMO's hospital if you can. By law, HMOs must cover at least 2 days in the hospital after vaginal delivery and 4 days after a C-section. For low-cost health insurance for middle-income pregnant women, call AIM Program. Caption: Low-Cost Insurance for Your Children: "I'm a single mom. I have insurance through my work, but I insure my baby through Healthy Families." Questions & Answers Q: What does a family practice doctor do? A: She treats children as well as adults and can be the primary care doctor for your whole family. Q: How do I find a family doctor or a pediatrician? A: Ask other parents and your own doctor. For more tips, see page 20 or visit www.kidshealth.org. Q: My doctor is no longer in my HMO's network. I'm 6 months pregnant. What should I do? A: You can usually see the same doctor until after the birth. Check with your plan. Q: My 2-year-old gets bad earaches and wakes up screaming. What should I do? A: Talk to your child's doctor. He can tell you how best to prevent or treat the problem. Q: I am pregnant. How do I get an obstetrician? A: You can see an obstetrician in your HMO network without a referral. But you may want to ask your primary care doctor for names. [Page 35] Health Care for Teens: Teens often don't get the care they need. Help your teen find a doctor he likes or see if your HMO offers a clinic just for teens. Explain to your teen that some services are confidential, such as treatment for substance abuse, physical abuse, STDs and birth control. Call "Talking with Kids". Things You Can Do Urgent Care for Children: Children often need to see a doctor the day they get sick. Ask your children's doctor or nurse how to make same-day, evening and weekend appointments. Healthy Families Insurance: You may be able to get low-cost health, dental and vision insurance for children through some HMOs. It's a great choice if you qualify. Call Healthy Families. More Information for Parents: Ask your HMO about classes on childbirth, breastfeeding, nutrition or exercise. Visit www.wellnessguide.org. Children with Special Needs: If your child has a disability or chronic health problem, see pages 14 or 26. For help getting services, call Family Voices. For help paying for treatment, call California Children's Services at your county Health Department. Where To Find Help AIM Program--Insurance for low- to middle-income pregnant women & infants 1-800-433-2611 www.mrmib.ca.gov Childbirth--Information on childbirth www.childbirth.org Family Voices--Health care advocacy for children with disabilities 1-888-835-5669 www.familyvoices.org Healthy Families--Health insurance for families with low to middle incomes 1-800-880-5305 www.healthyfamilies.ca.gov KidsHealth--Health care for children www.kidshealth.org Talking with Kids--Free booklet on talking with kids about difficult issues 1-800-244-5344 www.talkingwithkids.org [Page 36] Specialist Care A specialist is a doctor who has extra training in one area of medicine. For example, an oncologist is trained to treat cancer, and a gerontologist is trained to treat the problems of aging. You usually need a referral from your primary care doctor to see a specialist. You may also need approval from your HMO. In most cases, you must see specialists who are in your HMO's network. It can be hard to get a referral to a specialist. Even with a referral it can take time to get an appointment. Many specialists have long waiting lists. Ask your doctor or HMO for help when you need to see a specialist. Choosing a Specialist: Ask your doctor to give you the name of a specialist or ask your HMO for a list of specialists. If you need something done that is risky, look for a specialist in your plan who has done the procedure many times. To learn about a specialist's training, call American Board of Medical Specialties. Caption: When I Had a Heart Attack "My doctor gave me a referral to a heart specialist. He worked with my doctor to develop a treatment plan." Questions & Answers Q: Do I need a referral if I am seriously ill? A: Yes. If you are seriously ill but not in immediate danger, you need approval first. Tell your doctor to get an expedited referral. Your HMO must reply to your request within 3 days. Q: If I need ongoing care from a specialist, do I need to get a referral for each visit? A: Not if you have a "standing referral." Ask your doctor or HMO how to get one. It lets you see the specialist when you need to. Q: I have HIV. How can I see a doctor who knows about HIV? A: People with HIV have the right to get a standing referral to a doctor who specializes in treating HIV/AIDS. Q: Do I need a referral to see an obstetrician/ gynecologist? A: No. You may see an obstetrician/gynecologist in your HMO's network without a referral. [Page 37] Your Primary Care Doctor Leads Your Medical Team: Your primary care doctor can handle most of your health care needs. Sometimes she will work with specialists to plan your care and treat a problem. You will return to her for routine care. Caption: Pediatric Specialists--Ask your HMO which pediatric specialists are available. They are specialists with extra training in children's care. Things You Can Do Ask How to Get a Referral to a Specialist: Ask your doctor how to see a specialist in his Medical Group. If you want to see a specialist who is in your HMO's network but not in your doctor's Medical Group, ask your HMO. It usually takes about 5 working days to get a referral. If your problem is urgent, you should be able to get a referral within 3 days or less. To See a Specialist Who's Not in Your HMO: If there's no specialist in your HMO who can give the care you need, or if the waiting list is too long, ask your HMO for a referral to a specialist outside the network. Or you may choose to pay for the visit yourself. If You Can't Get the Referral You Request: If you ask for a referral and you don't get it, your doctor should tell you why. If you disagree, you can file a complaint with your HMO. Call your Member Services or see page 48. Your Doctor May Refer You to a Specialist If: You need a treatment or therapy that requires special training to perform. Your test results are unclear. The treatment you are on now is not helping you. You have a serious health problem and need a doctor who knows more about treating it. To learn about a specialist's training, visit www.abms.org. Where To Find Help American Board of Medical Specialties--Information about specialists' training 1-866-275-2267 www.abms.org Member Services--To find your HMO's phone number see page 60 [Page 38] Prescription Drugs and Equipment Not all plans pay for prescription drugs. If your plan does, your doctor will usually choose medicines from a list of the drugs the plan covers. This list is called a formulary. If you want to use drugs that are not on this list, you must get your HMO's approval or pay for them yourself. Most drugs in the formulary are generic drugs. These drugs cost less than brand-name drugs but have the same basic ingredients. Some HMOs cover brand-name drugs for a higher copay. Your HMO may cover some medical equipment, like walkers and wheelchairs. Only equipment that you medically need will be covered, and you may have to pay part of the cost. Prescription Drug Costs: If your plan covers prescription drugs, you will pay a fee, called a copay, each time you pick up a prescription. Some drugs may have higher copays than other drugs. There may also be a limit on the amount your plan will pay for drugs each year. Caption: Tell your doctor about all your medications--Lily shows her new doctor all the medicines she takes and asks if she should keep taking them. Questions & Answers Q: Why does my plan make me take generic drugs instead of brand-name drugs? A: Generic drugs cost less than brand-name drugs. When a company's patent on a new drug ends, other companies can make the drug. It becomes generic and costs less. Q: My problem was getting better, but my HMO took my medicine off the formulary. Can they do that? A: Yes, your HMO can change its formulary. But if you can show that you need the drug, your HMO may cover it for you. See pages 48-53. Q: I'm leaving my job. What can I do to protect my prescription drug benefits? A: Try to keep your insurance through COBRA. It almost always costs more to get drug benefits on your own. See page 12. Q: I saw an ad on TV for a new drug. But my doctor won't give it to me. Why? A: He may think you don't need it. If your doctor thinks you need it but it's not in your HMO's formulary, see pages 48-53. [Page38] Take Charge of Your Medications: If your doctor suggests a new medication, ask about side effects, risks and benefits. Ask about other treatments or what could happen if you go without treatment. Tell your doctor about any allergies or bad reactions you have had to medications. Tell him all the medicines, vitamins and herbs you take. And tell him if a drug does not seem to be helping. Caption: Medical Equipment--Larry's plan pays for his crutches. He needs them to stay healthy and active. Things You Can Do When You Order a Prescription or Refill: Ask your doctor or pharmacist what the copayment will be. If you need a refill that day, order it early in the morning. If your doctor needs to approve a refill, order it 3 or more days before you need it. When you pick up a prescription, make sure it's correct. Talk to your pharmacist when you get a new medication. Ask your HMO about ordering prescriptions by mail. They almost always cost less. You can order for 3 months at a time. Your HMO's Formulary: Ask to see the list of drugs your HMO covers--its formulary. Ask how often your HMO changes its formulary. To see what's in California HMO formularies, visit http://ca.mcodrugs.com. Birth Control: If a plan covers prescription drugs, it must cover prescription birth control methods, like birth control pills. Keep Drug Costs Down: When your doctor gives you a prescription, ask if your HMO covers it. Ask for generic drugs. If you are on Medicare see page 19. For help paying for HIV/AIDS medications, call AIDS Drug Assistance Program. Ask your doctor about free samples and drug company discounts for people with low incomes. If you need a drug that your insurance won't pay for, compare costs from different pharmacies. But be careful, so you don't get the wrong drug or a dangerous drug by mistake. Medical Supplies and Equipment: Equipment like crutches and wheelchairs is called durable medical equipment. You may need your HMO's approval to get equipment; see page 27. HMOs must cover most home care supplies for diabetes. Where To Find Help AIDS Drug Assistance Program--Help paying for drugs to treat HIV/AIDS 1-888-311-7632 www.ramsellcorp.com California Internet Formulary--HMO drug formularies http://ca.mcodrugs.com [Page 40] Mental Health Care Problems like depression and anxiety may be treated with counseling, medication or hospital care. These services help many people with short-term or long-term problems. Your HMO must cover some serious mental health problems. Children as well as adults have this coverage. Even if your problem does not seem serious, your HMO may provide some benefits. For example, if you feel a lot of anxiety or stress, you may be able to see a counselor. Counseling Services Even if you do not have a serious mental health problem, your plan may still cover some counseling services. However, if your problem is not serious, your copay for counseling may be higher than the copay for a doctor's visit. Caption: Deciding About Medication--"My medicine is helping me deal with depression. I had to try three medications before finding one that worked." Questions & Answers Q: If I get mental health services through my HMO, will my employer or anyone else know? A: Usually no. But in some cases, others may see your medical records. If you apply for new insurance, the company may ask to view your records. If you are involved in a court case, the court may decide to look at your records. Visit www.calpatientguide.org. Q: The medication I take for my depression helps, but I feel there's a lot of prejudice against people with problems like mine. What can I do? A: You have the right to be treated with respect. Self-advocacy groups can help you stand up for your rights and get support. Call National Mental Health Association or California Network of Mental Health Clients. Q: I'm on Medi-Cal. Can I get counseling? A: Yes. If you need mental health services, you can call your County Mental Health Agency. See page 17. [Page 41] Mental Health Care for Serious Problems: HMOs must cover some mental health problems, like severe depression, manic depression, schizophrenia, panic disorders and eating disorders. HMOs must also cover children's serious emotional problems. Your HMO must provide the same benefits for these mental health problems that it does for other health problems. The copays must be the same. If your plan covers prescription drugs, drugs for these mental health problems must also be covered. You have these rights under the state Mental Health Parity Law. Caption: Mental Health Care for Teens--"My daughter was having panic attacks. Our doctor helped her find counseling through our HMO." Things You Can Do If You Want Mental Health Care Services: Ask your HMO what mental health care it pays for. You may be able to get services without a referral from your doctor. Ask your HMO. Some HMOs use independent services, called behavioral health care services, to provide mental health care. Mental Health Care: Care may include visits to a counselor, psychologist or psychiatrist, or group therapy. Most plans cover up to a month of hospital (inpatient) care. Some cover a shorter stay with follow-up care. If you cannot work because you are in the hospital, you may be covered by Disability Insurance or Family Medical Leave; talk to your employer. If you are put in the hospital without your consent, forced to take medication or treated badly, call California Office of Patients' Rights or Protection & Advocacy. Your HMO may offer support groups for people dealing with issues like smoking, drinking, stress or parenting. Medications: Ask your doctor about side effects. If a medication does not seem to be helping, ask about other options see page 38. Where To Find Help California Network of Mental Health Clients--Peer support for mental health clients 1-800-626-7447 www.cnmhc.org California Office of Patients' Rights--Advocacy for patients hospitalized with mental illness 1-916-575-1610 (Not a toll-free number) California Patient's Guide--A guide to health care rights www.calpatientguide.org National Mental Health Association--Information, advocacy and referrals for adults and children 1-800-969-6642 www.nmha.org Protection & Advocacy--Legal advocacy for people with disabilities 1-800-776-5746 www.pai-ca.org [Page 42] Emergencies and Urgent Care In an emergency, you should call 9-1-1 or go to the nearest emergency room. Your HMO must cover emergency care. If you can, go to a hospital in your HMO network. However, any emergency room must treat you until you are well enough to be moved to your HMO's hospital. Your HMO must pay for this treatment. In general, the law says it's an emergency if average people think it's an emergency. If you are not sure if it's an emergency and there's time to call, phone your HMO or doctor. If you need care soon but not right away, you may be able to use your HMO's urgent care services. Urgent care is care you need within 24 to 48 hours. Caption: In an Emergency--Go to a hospital in your HMO if you safely can. Otherwise, go to the nearest emergency room. Shock, severe wounds, a heart attack and labor are all emergencies. Questions & Answers Q: What if it's an emergency and the nearest hospital is not in my HMO's network? A: Your HMO will cover emergency care at any hospital. But you should call your HMO as soon as you can. Your HMO may move you to a hospital in your plan when you are stable enough to be moved. Q: What about ambulance services? A: Your HMO must cover ambulance services in an emergency. Q: What if my HMO refuses to pay for my emergency care? A: You and your HMO may not agree on what problems need emergency care. If this happens, you can file a complaint. See pages 48-53 or call HMO Help Center. [Page 43] What Is an Emergency?: It is an emergency if you think your health is in serious danger and you need care right away. The law says you don't need to have medical training to decide it's an emergency. You can be an average person. You may have a bad injury or sudden illness. You may have an illness that is quickly getting much worse. Severe pain and active labor are also emergencies. On Vacation Caption: "When Tommy broke his arm, we went to the nearest emergency room. Then I called our HMO Member Services to get approval for his follow-up care." Things You Can Do Call the Advice Nurse at Your HMO: Your HMO's Advice Nurses can help you decide what care you need. Poison Action Line: If someone swallows or inhales something poisonous, call Poison Action Line right away. You will be told what to do. Your Rights: If it's an emergency, you can get care at any hospital emergency room, even if it's not part of your HMO. Your HMO must pay for it. If you are in a hospital that is not part of your HMO, your HMO may move you to a network hospital. You must be stable, so that the move won't make you worse. If you are in labor, you can go to any emergency room. But try to go to your own hospital. For more information, visit www.calpatientguide.org. Be Prepared: Learn your plan's guidelines for emergency and urgent care. Ask about the copay for emergency room visits. It may be more than other copays. Ask your doctor what to do if your child needs urgent care. Ask about hospitals and urgent care centers in your HMO. Keep your HMO membership card with you at all times. When You're Traveling: Your HMO should pay for emergency and urgent care when you are out of its service area. You should call your HMO as soon as you can. If your HMO won't pay the bill, see pages 48-53. Where To Find Help California Patient's Guide--A guide to health care rights www.calpatientguide.org HMO Help Center--Help for California HMO members 1-888-HMO-2219 www.hmohelp.ca.gov Member Services--To find your HMO's phone number see page 60 Poison Action Line--Emergency help for victims of poisoning 1-800-876-4766 www.calpoison.org [Page 44] Hospital Care For some care, you need to stay overnight in a hospital. This is called inpatient care. It can include childbirth, surgery and substance abuse treatment. Your doctor usually refers you for hospital care. If there is more than one hospital in your plan, your doctor can help you choose the one that's best for your problem. Ask your doctor who will oversee your care in the hospital and what you can expect during and after your treatment. Caption: Visitors Are Important--If a relative or friend helps watch out for you in the hospital, you'll probably get better care. Questions & Answers Q: I am having a hysterectomy, but I am staying in the hospital only two nights. That doesn't seem long enough. A: Hospital stays are shorter these days. This is partly because hospital care is very costly. But there's another reason-many people recover better at home than in the hospital. If you feel you need a longer hospital stay, ask your doctor if he can arrange it with your HMO. If your HMO says no, see page 48. If you're on Medicare, see page 18. Q: I was in the hospital, and some of the staff were really rude. They ignored my requests for help. What can I do? A: You can complain to your doctor and the hospital. You can also write a letter to your HMO. See page 48. [Page 45] Choosing a Hospital: Find out which hospital in your plan treats your health problem most often. If a hospital has a lot of experience with your condition, you will probably get better care. For more information on hospitals, visit www.healthscope.org and www.jcaho.org. If you and your doctor think that you need to be treated at a hospital outside the HMO's network in order to get the care you need, you can ask your HMO. If your HMO says no, see page 50. Caption: Going Home--Your doctor or nurse or a discharge planner will talk with you and your family about care at home. Things You Can Do Know Your Hospital Benefits: In most cases, you must use the hospitals in your plan's network. Ask your HMO for a list. Unless it's an emergency, you must have a referral from your doctor to get hospital care. If you are in a hospital that's not in your HMO's network, call your HMO as soon as you can. For more information, visit www.calpatientguide.org. Before Your Hospital Stay: Ask how long you are likely to stay in the hospital. Ask people you trust to visit and watch out for your care. Find out who will be in charge of your care in the hospital. Will it be your doctor or someone else? If you are having surgery, make sure to meet with your surgeon and anesthesiologist ahead of time. Ask any questions you have. Visit www.facs.org. Make sure you understand what will happen during your procedure and how long it may take to recover. Fill out an Advance Health Care Directive. This form tells others what kind of care you want if you are not able to speak for yourself; see page 47. After Your Hospital Visit: You may need physical therapy, nursing care or help around the house. Most hospitals have someone called a discharge planner who can help you decide how much help you will need and where to find it. Where To Find Help American College of Surgeons--Information on common operations and choosing a surgeon www.facs.org California Patient's Guide--A guide to health care rights www.calpatientguide.org HealthScope--Information on California hospitals www.healthscope.org JCAHO (Joint Commission on Accreditation of Healthcare Organizations)--Information on standards for hospitals 1-800-994-6610 www.jcaho.org [Page 46] Care at the End of Life Work closely with your doctor and HMO so that the care you or your loved one has in the last months and days of life is the best it can be. Your HMO offers services, such as hospice care and pain management, that can help you at a very hard time. You can make choices ahead of time about your last days and your death. Do you want to be at home or in a hospital? What treatments do you want or not want? If you can no longer decide for yourself, who will decide on your care for you? Fill out an Advance Health Care Directive and talk to your doctor, family and close friends about your wishes. Caption: Hospice Care--Lisa, a hospice volunteer, visits with Frank during his last days. Questions & Answers Q: I filled out an Advance Health Care Directive to say what care I want if I can't speak for myself. How can I make sure it's followed? A: Make sure it is signed and witnessed. Ask your doctor to put it in your medical file. Talk about it with your doctor and your family and closest friends. Make sure they will follow your wishes. Q: My father was in a coma for a week before he died. I had to decide about his care. Is there help for people in my situation? A: Some things are very hard to decide, especially if you are deciding for someone you love. Ask if the hospital has a counselor or doctor you can talk to about ethical and religious questions. [Page 47] Hospice: Hospice care offers help for people who are dying. It provides emotional support, pain management and other services. HMOs must cover hospice care benefits. In hospice, a nurse visits every day or two. She advises the family and helps with medications, bathing and other care. The nurse can also help the family deal with emotional stress and make the final arrangements when the patient dies. For more information, visit www.calregistry.com. Caption: My Son and I Had to Speak Up--"My husband was in terrible pain. We knew he had the right to more pain medication. We really had to speak up-- but it worked, and his last weeks were peaceful." Things You Can Do Protect Your Wishes with an Advance Health Care Directive: This is a form that lets you say what kind of care you want and who will decide on your care if you no longer can. The form must be signed and witnessed. Give copies to your doctor, family and close friends. Talk to them about your wishes. To order a form, call California Healthcare Association. Pain Management: If an HMO plan covers prescription drugs, it must cover pain medications for people who are dying. Make sure your doctor orders enough pain medication. Different Kinds of Care: Hospice care can be at home, in a hospital or in a nursing home. Family or friends may help. Ask your HMO about what nursing home care is covered. For more information on nursing home care, call HICAP or visit www.calregistry.com. Most HMOs cover only a few months of nursing home care. For information on long-term care, call AARP or HICAP. Help for Caregivers: Your HMO's hospice program can help you find extra support and deal with emotional stress. Your HMO may also have a social worker you can talk with. Call Family Caregiver Alliance. Where To Find Help AARP--Information on health care and other issues for seniors 1-800-424-3410 www.aarp.org California Healthcare Association--Free Advance Health Care Directive forms 1-800-494-2001 www.calhealth.org California Registry--Information on hospice care and long-term care 1-800-777-7575 www.calregistry.com Family Caregiver Alliance--Help for family caregivers 1-800-445-8106 www.caregiver.org HICAP (Health Insurance Counseling & Advocacy Program)--Information, counseling and advocacy for Medicare members 1-800-434-0222 [Page 48] Section Heading: IF YOU HAVE A PROBLEM If You Have a Complaint It can be hard to know what to do if you have a problem with your health care. You may feel overwhelmed, especially if you or someone you love is sick. If you're not satisfied with your care, meet with your doctor and talk to your HMO's Member Services. Take notes and bring a friend or relative with you for extra support. If talking to your HMP doesn't solve the problem, you can file a written complaint with your HMO. If you're still not satisfied, see the next two chapters." How to File a Complaint with Your HMO 1. Ask your HMO Member Services to send you a complaint form. 2. Your HMO must take action within 30 days after it receives your complaint. 3. If your problem is urgent, ask for an Expedited Review. Your HMO must take action within 3 days. 4. If your HMO still won't help or doesn't reply within the time limit, see page 50 or call HMO Help Center. Caption: Take Action--My HMO wouldn't approve the tests Pat needed. So I got my doctor to write a letter, and I sent in a written complaint. We got the tests, and now we can make a better decision about Pat's care." Questions & Answers Q: What is a grievance? A: It is a complaint. Your HMO may have a form you can use to file a grievance. Q: My doctor says I can't get a service that I think I need. Do I complain to my HMO or my doctor? A: Ask your doctor why you can't get the service. If her reply does not answer your questions, file a complaint with your HMO. Send a copy to your doctor and your doctor's Medical Group. Q: I've read that many minorities don't get good care. This happened to me. My doctor didn't tell me all the things I could do for my diabetes. What can I do? A: You can file a complaint with your HMO. If that does not help, see page 50. [Page 49] Speak Up for Yourself: Take notes when you have a phone call or meeting. Get the name of the person you talk to. Have someone with you for extra support. If you are told you can't have the care you want, ask for the reason in writing. If the person you talk to isn't helpful, ask to speak to a supervisor. If different people tell you different things about the services you can get, ask to speak to a supervisor. Caption: Be Persistent--It may take many calls to get the services you need. Things You Can Do Call Your HMO Member Services First: If you have a problem, call your HMO's Member Services. You may be able to solve your problem with a phone call. Talk to Someone Who Can Help: There are groups that can help you if you have a problem with your HMO. Call a local legal aid group or see page 54. If you have Medicare, you can get help from HICAP. If you have Medi-Cal, call Medi-Cal Managed Care Ombudsman. Your benefits office at work may be able to help you, too. You Have the Right to: Be treated with courtesy and respect. Get quality health care in a timely manner. Get an appointment when you need one. Get care from qualified medical personnel. Choose a doctor you trust. Understand your health problem and the risks and benefits of your treatment choices. Get a second opinion. Choose or refuse treatment. What About Customer Service Problems?: If you're treated rudely, can't get the appointment you need or have to wait too long, ask to talk to a supervisor or call Member Services. If that doesn't help, file a complaint. Where To Find Help HICAP (Health Insurance Counseling & Advocacy Program)--Information, counseling and advocacy for Medicare members 1-800-434-0222 HMO Help Center--Help for California HMO members 1-888-HMO-2219 www.hmohelp.ca.gov Medi-Cal Managed Care Ombudsman--Help with a problem you can't solve with your Medi-Cal HMO 1-888-452-8609 Member Services--To find your HMO's phone number see page 60 [Page 50] Need More Help? You can prevent many problems by understanding your benefits and working closely with your doctor and your HMO. If you're not satisfied with how your HMO responds to your problem, you can call the HMO Help Center. The HMO Help Center is a toll-free help line for all California HMO members. You can call 24 hours a day, 7 days a week. The staff at the HMO Help Center can help you understand what you can do. They may be able to solve your problem with a few phone calls. If you need to file a complaint, they can help you. How to File a Complaint with the HMO Help Center 1. Unless your problem is urgent, you usually need to file a complaint with your HMO first. See page 48. 2. If your HMO doesn't take action within 30 days or you still need help, you can file a complaint with the HMO Help Center. 3. To file a complaint, call HMO Help Center. To see a complaint form, visit www.hmohelp.ca.gov. Caption: If You're Not Satisfied--"We were worried about Kenny's care. Our HMO didn't answer our letter. We called the HMO Help Center and got the help we needed." Questions & Answers Q: What does the HMO Help Center do? A: The HMO Help Center provides information and help to HMO members. Help is offered in many languages. The HMO Help Center is independent of all HMOs. It is part of the state Department of Managed Health Care. Q: How do I know if I should file a complaint with my HMO or with the HMO Help Center? A: Usually it's best to file a written complaint with your HMO first. But if your problem is urgent, or you aren't sure, call HMO Help Center. Q: The complaint process seems to take so long. I need care now. What should I do? A: Call HMO Help Center now and ask what you can do. You may need an expedited review to have your case handled in 3 days. [Page 51] What Happens After You File a Complaint 1. You will usually get a letter from the HMO Help Center that explains what was decided. You should get the letter in 30 days, or sooner if your problem is urgent. 2. If the complaint is decided in your favor, your HMO must pay for the treatment or other service. 3. If the complaint is not decided in your favor, the letter will tell you why. Caption: Finding Help--When Angela had a problem with her daughter's care, she found a local legal aid group that was able to help. Things You Can Do If You Need Help Right Away: If your problem is causing a serious or urgent threat to your health, such as not getting treatment for a life-threatening disease, call the HMO Help Center. Say that your problem is urgent. Find Other Groups That Can Help: Many of the resources listed in this guide can help you understand your rights and get better care. See page 56 for a full list. You can also call a local legal aid society. If You Have Medicare or Medi-Cal: Your complaint process is not the same. If you have Medicare, see page 19 or call HICAP. If you have Medi-Cal, see page 17 or call Medi-Cal Managed Care Ombudsman. Where To Find Help HICAP (Health Insurance Counseling & Advocacy Program)--Information, counseling and advocacy for Medicare members 1-800-434-0222 Medi-Cal Managed Care Ombudsman--Help with a problem you can't solve with your Medi-Cal HMO 1-888-452-8609 HMO Help Center--Help for California HMO members 1-888-HMO-2219 www.hmohelp.ca.gov [Page 52] Request an Request An Independent Review You and your HMO may not agree about the care you need. Your HMO may say that the treatment you want is not needed for your health or is experimental and that they won't pay for it. Or you may have gotten emergency care that your HMO says it won't pay for. If these things happen, you can ask for an Independent Medical Review, or IMR. California hires doctors to conduct these reviews. The doctors are experts on your health problem, but they are not part of your HMO. And they do not get money from your HMO. Caption: We Asked for an IMR Juan says, "When my plan stopped paying for my medicine, I called the HMO Help Center. They helped us get an IMR." Questions & Answers Q: How does the Independent Medical Review (IMR) decide if my HMO should pay for a treatment I want? A: The IMR looks at your medical needs to see if the treatment is necessary for your care. The kind of treatment you want must be covered by your benefit package. Q: My doctor recommends an experimental treatment, but my HMO won't cover it. How would the IMR make a decision? A: The IMR compares the treatment your HMO offers with the treatment your doctor thinks you should have, to see which is more likely to help you. Your benefit package must cover this general kind of treatment. Q: What happens if I win my appeal? A: Your HMO must pay for the service. Some cases are settled because the HMO agrees to give the medical care before the IMR is finished. We Asked for an IMR Juan says, "When my plan stopped paying for my medicine, I called the HMO Help Center. They helped us get an IMR." [Page 53] You Can Request a Review: If you had emergency or urgent care and your HMO won't pay for it. Or If you asked for a service and your HMO says you don't need it. You must file a written complaint with your HMO first and wait 30 days for a response. If your problem is urgent, you can call HMO Help Center now. Or If you asked for experimental treatment for a serious health problem and your HMO won't pay for it. In general, the kind of service you ask for must be part of your benefits package. For example, if you don't have prescription drug benefits, an experimental drug may not be covered. Caption: I wanted to try a new treatment for prostate cancer "The IMR said that studies didn't show that the treatment would work. So I am doing what my HMO recommended instead." Things You Can Do To Request an Independent Medical Review (IMR): Call HMO Help Center. The staff will help you with the review process. If your problem does not qualify for an IMR, they will tell you what else you can do. In some cases you must file a written complaint with your HMO first. If your problem is urgent, HMO Help Center will help you request a faster review. Your IMR must usually be decided within 30 days--or sooner if your problem is urgent. You do not attend the review. You must ask for a review within 6 months after your HMO denies your request. Read Summaries of the Decisions: Each Independent Medical Review decision is based on the person's problem. Your name and medical records are not made public. You can read summaries of all IMR decisions. Visit www.hmohelp.ca.gov. If You Have Medicare or Medi-Cal: Medicare has its own review process. See page 19 or call HICAP. If your Medi-Cal HMO denies the services you need, call Medi-Cal Fair Hearing or see page 17. If You're Still Not Satisfied: You may be able to take further action. You have the right to sue if you've suffered serious bodily harm. HMO members usually resolve their cases through a process called binding arbitration. This process settles cases out of court. Before you take any action, talk to a lawyer. Visit www.calpatientguide.org. Where To Find Help California Patient's Guide--A guide to health care rights www.calpatientguide.org HICAP (Health Insurance Counseling & Advocacy Program)--Information, counseling and advocacy for Medicare members 1-800-434-0222 HMO Help Center--Help for California HMO members 1-888-HMO-2219 www.hmohelp.ca.gov Medi-Cal Fair Hearing--File an appeal if your HMO denies you the services you need 1-800-952-5253 [Page 54] The Office of the Patient Advocate Trying to choose and use an HMO can be difficult. There are many rules and it's hard to know what your rights are. The Office of the Patient Advocate (OPA) is here to help guide you, so that you can get the care you need for yourself and your family. Choose an HMO That's Right for You: Use the "Quality of Care Report Card" to find out which HMO and Medical Group will best meet the needs of you and your family. Learn about HMO services in different languages. Learn how well HMOs serve people with chronic conditions like diabetes and heart disease. To order the latest report card, call the Oggice of the Patient Advocate. Questions & Answers Q: What is the Office of the Patient Advocate? A: It is a state agency set up to inform HMO members about their rights. Q: I don't understand all the things I get in the mail from my HMO. What should I do? A: Don't worry. You're not alone. If you don't understand something you get, call the Member Services phone number on your HMO membership card. Or ask your personnel office at work to explain your HMO. Caption: Learn About Your HMO Before You Get Sick--Then you'll know how to get help when you really need it. The Quality of Care Report Card Below is a page from the 2003-2004 Report Card tells how well HMOs care for their members. It also tells what members think about their HMOs. HMO Quality Below is a listing of the top 10 Health Maintenance Organizations in California (listed in alphabetical order), with star ratings in four specific health related topics: Care for Staying Healthy, Care for Getting Better, Care for Living with Illness, and Member Rating of Health Plan. In print ratings are shown with stars: Excellent - 3 stars; Good - 2 stars; Fair - 1 star; Poor - no star. Aetna Health of California, Inc. Care for Staying Healthy - 1 star (Fair) Care for Getting Better - 1 star (Fair) Care for Living with Illness - 2 stars (Good) Doctor Communication and Service - 2 stars (Good) Plan Service - 2 stars (Good) Blue Cross HMO CaliforniaCare Care for Staying Healthy - 1 star (Fair) Care for Getting Better - 1 star (Fair) Care for Living with Illness - 2 stars (Good) Doctor Communication and Service - 2 stars (Good) Plan Service - 2 stars (Good) Blue Shield of California Care for Staying Healthy - 1 star (Fair) Care for Getting Better - 2 stars (Good) Care for Living with Illness - 2 stars (Good) Doctor Communication and Service - 2 stars (Good) Plan Service - 2 stars (Good) CIGNA HMO Care for Staying Healthy - 1 star (Fair) Care for Getting Better - 2 stars (Good) Care for Living with Illness - 2 stars (Good) Doctor Communication and Service - 1 star (Fair) Plan Service - 2 stars (Good) Health Net Care for Staying Healthy - 1 star (Fair) Care for Getting Better - 2 stars (Good) Care for Living with Illness - 2 stars (Good) Doctor Communication and Service - 2 stars (Good) Plan Service - 2 stars (Good) Kaiser Permanente Northern California Care for Staying Healthy - 2 stars (Good) Care for Getting Better - 3 stars (Excellent) Care for Living with Illness - 2 stars (Good) Doctor Communication and Service - 2 stars (Good) Plan Service - 3 stars (Excellent) Kaiser Permanente Southern California Care for Staying Healthy - 2 stars (Good) Care for Getting Better - 2 stars (Good) Care for Living with Illness - 2 stars (Good) Doctor Communication and Service - 2 stars (Good) Plan Service - 3 stars (Excellent) PacifiCare of California Care for Staying Healthy - 2 stars (Good) Care for Getting Better - 2 stars (Good) Care for Living with Illness - 2 stars (Good) Doctor Communication and Service - 2 stars (Good) Plan Service - 3 stars (Excellent) Universal Care Care for Staying Healthy - 1 star (Fair) Care for Getting Better - 1 star (Fair) Care for Living with Illness - 2 stars (Good) Doctor Communication and Service - 2 stars (Good) Plan Service - 2 stars (Good) Western Health Advantage Care for Staying Healthy - Not Willing To Report Care for Getting Better - Not Willing To Report Care for Living with Illness - Not Willing To Report Doctor Communication and Service - 2 stars (Good) Plan Service - 2 stars (Good) [End of List] [Page 55] Caption: Find a Doctor Who Speaks Your Language--Li chose an HMO after reading the Quality of Care Report Card. It tells about the services HMOs offer in different languages. Things You Can Do The Office of the Patient Advocate (OPA) Can Help You: Learn about your HMO rights under California law. Learn how to use your HMO. Get the best quality of care. Find help when you have a problem with your HMO. OPA Offers Free Materials On HMOs: California's HMO Guide, in English or Spanish. The Quality of Care Report Card in English, Spanish and Chinese. Brochures on your right to health care, mental health care and other services, in English, Spanish and Chinese. Find Health Events in Your Community: Each month there are many health fairs, conferences and other events to help people learn about their health care rights. View OPA's Calendar of Events at www.opa.ca.gov. Call OPA for help setting up an event in your community. OPA can help you find information, speakers and other resources. OPA Helps People Get Better Health Care: The Office of the Patient Advocate also does research to help people in California get better health care. You can read reports on this research at www.opa.ca.gov. Where To Find Help Member Services--To find your HMO's phone number see page 60 Office of the Patient Advocate (OPA)--Information on California HMOs 1-866-HMO-8900 www.opa.ca.gov [Page 56] Section Heading: FINDING RESOURCES Resources This is a list of all the phone numbers and websites in this guide. Most of these resources have people who can help you find information or solve a problem. If you are having trouble with a recorded message, stay on the line and someone will probably answer. Or try pressing "0". If there's no TTY, call 7-1-1. If you have a speech disability, you can use the Speech-to-Speech Relay. Call 1-800-854-7784. Not all websites are accessible to people with disabilities. If a site is not accessible, e-mail the webmaster. Toll-free phone numbers begin with 1-800, 1-866, 1-877 and 1-888. Other phone numbers are not toll-free. Information below is presented in the following order: Resource, Description, Voice Telephone Number, TTY Number (if available) and Website Sp. means there is usually someone who speaks Spanish AARP--Information on health care and other issues for seniors 1-800-424-3410 (Sp.) 1-877-434-7598 www.aarp.org Agency for Healthcare Research and Quality--Information on choosing quality health care and Personal Health Guides to routine care 1-800-358-9295 (Sp.) 1-888-586-6340 www.ahrq.gov AIDS Drug Assistance Program--Help paying for drugs to treat HIV/AIDS 1-888-311-7632 (Sp.) www.ramsellcorp.com AIM Program--Low cost health insurance for pregnant women with low and middle incomes 1-800-433-2611 (Sp.) www.mrmib.ca.gov American Board of Medical Specialties--Information about specialists' training 1-866-275-2267 www.abms.org American College of Surgeons--Information on common operations and choosing a surgeon 1-312-202-5000 (Sp.) www.facs.org Americans with Disabilities--The rights of people with disabilities 1-800-514-0301 (Sp.) 1-800-514-0383 www.ada.g0v AT Network--Information on equipment and assistive technology 1-800-390-2699 (Sp.) 1-800-900-0706 www.atnet.org California Advocates for Nursing Home Reform--Information and help for people living in a nursing home 1-800-474-1116 (Sp.) www.canhr.org California AIDS Hotline--Information on HIV/AIDS services 1-800-367-2437 (Sp.) 1-888-225-2437 www.sfaf.org California Black Women's Health Project--Information on black women's health; help for women in Los Angeles 1-310-412-1828 www.cabwhp.org California Foundation for Independent Living Centers--Resources for people with disabilities 1-916-325-1690 1-916-325-1695 www.cfilc.org California Health Advocates--Information on Medicare 1-916-231-5110 www.cahealthadvocates.org [Page 57] California Healthcare Association--Free Advance Health Care Directive forms 1-800-494-2001 www.calhealth.org California Health Decisions--Tips for using health care services 1-714-347-7921 www.cahd.org California Internet Formulary--Information on drug formularies http://ca.mcodrugs.com California Medical Review--Medicare HMO quality of care problems 1-800-841-1602 (Sp.) 1-800-881-5980 www.cmri-ca.org California Network of Mental Health Clients--Peer support for mental health clients 1-800-626-7447 www.cnmhc.org California Office of Patients' Rights--Advocacy for patients hospitalized with mental illness 1-916-575-1610 (Sp.) www.pai-ca.org California Patient's Guide A guide to health care rights www.calpatientguide.org California Registry--Information on hospice and long-term care 1-800-777-7575 www.calregistry.com Cal Medicare (California HealthCare Foundation)--Printed information for Medicare members 1-888-430-2423 (Sp.) www.calmedicare.org Cancer Information--Information on cancer treatments 1-800-422-6237 (Sp.) 1-800-332-8615 www.cancer.gov Center for Health Care Rights General information about rights and help for people in Los Angeles County 1-800-824-0780 (Sp.) www.healthcarerights.org Centers for Medicare and Medicaid Services (CMS)--Information on Medicare, Medicaid and HIPAA 1-877-267-2323 1-866-266-1819 http://cms.hhs.gov Childbirth--Information on pregnancy and childbirth www.childbirth.org Deaf Counseling, Advocacy and Referral Agency--Resources for people who are Deaf or Hard of Hearing 1-877-322-7299 1-877-322-7288 www.dcara.org Department of Insurance--Information and help for consumers 1-800-927-4357 (Sp.) 1-800-482-4833 www.insurance.ca.gov Department of Managed Health Care--Information and help for California HMO members 1-888-HMO-2219 (Sp.) 1-877-688-9891 www.hmohelp.ca.gov Disability Rights Advocates--A guide to the health care rights of people with disabilities 1-888-926-0274 1-510-451-8716 www.dralegal.org [Page 58] Families USA--National advocacy for health care consumers www.familiesusa.org Family Caregiver Alliance--Information and help for family caregivers 1-800-445-8106 www.caregiver.org Family Voices--Health care advocacy for children with disabilities 1-888-835-5669 (Sp.) www.familyvoices.org Food and Drug Administration--Information on medicines and equipment 1-888-463-6332 www.fda.gov Health Care Options--Joining or leaving a Medi-Cal HMO 1-800-430-4263 (Sp.) 1-800-430-7077 Health Choices--Information on choosing a health plan www.healthchoices.org Health Consumer--Health care information in several languages www.healthconsumer.org Healthfinder--An introduction to health information on the Web www.healthfinder.gov Health Rights Hotline--Hotline for Sacramento, Placer, Yolo and El Dorado counties 1-888-354-4474 (Sp.) www.hrh.org HealthScope--Information on health plans, Medical Groups and hospitals in Californiawww.healthscope.org Healthy Families--Health insurance for low/middle-income families 1-800-880-5305 (Sp.) 1-800-735-2929 www.healthyfamilies.ca.gov HICAP--Information, counseling and advocacy for Medicare members 1-800-434-0222 (Sp.) HMO Help Center--Information and help for California HMO members 1-888-HMO-2219 (Sp.) 1-877-688-9891 www.hmohelp.ca.gov Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Information on health care standards and filing complaints 1-800-994-6610 www.jcaho.org KidsHealth--Information on children's health www.kidshealth.org Lab Tests Online--Information about lab tests www.labtestsonline.org Medi-Cal Fair Hearing (Department of Social Services)--File an appeal if your Medi-Cal HMO denies you the services you need 1-800-952-5253 (Sp.) [Page 59] Medi-Cal Managed Care Ombudsman--Help with a problem you can't solve with your Medi-Cal HMO 1-888-452-8609 (Sp.) Medi-Cal Mental Health Care Ombudsman--Information and help with Medi-Cal mental health care services 1-800-896-4042 (Sp.) 1-800-896-2512 Medicare (1-800-Medicare)--Information and help with Medicare and nursing home care 1-800-633-4227 (Sp.) 1-877-486-2048 www.medicare.gov Medline Plus--Health information from the National Library of Medicine www.medlineplus.gov National Committee for Quality Assurance (NCQA)--Information on quality health care and HMO standards 1-800-839-6487 www.ncqa.org National Guideline Clearinghouse Care guidelines for many health conditions www.guideline.gov National Immunization Hotline--Immunization guidelines 1-800-232-2522 (Sp.) 1-800-243-7889 www.cdc.gov/nip National Institute on Aging--Information for seniors 1-800-222-2225 (Sp.) 1-800-222-4225 www.nia.nih.gov National Institutes of Health--Information on many health issues www.health.nih.gov National Mental Health Association--Information, advocacy and referrals for adults and children 1-800-969-6642 (Sp.) 1-800-433-5959 www.nmha.org Office of the Patient Advocate--Report cards with information on California HMOs 1-866-466-8900 (Sp.) www.opa.ca.gov Poison Action Line--Emergency help for victims of poisoning 1-800-876-4766 (Sp.) 1-800-972-3323 www.calpoison.org Protection & Advocacy--Legal advocacy for people with disabilities 1-800-776-5746 (Sp.) 1-800-649-0154 www.pai-ca.org Senior Information and Referral--Information about local services for seniors 1-800-510-2020 Talking with Kids--Order a booklet on talking with kids and teens about sex, violence, AIDS and drugs 1-800-244-5344 (Sp.) www.talkingwithkids.org U.S. Dept. of Labor, Benefits Security Administration--Employee Information about COBRA and HIPAA 1-866-444-3272 (Sp.) 1-877-889-5627 www.dol.gov/ebsa [Page 60] HMO Member Services Look for your HMO's Member Services phone number on this list or on your membership card. If you do not speak English, ask if you can speak to someone in your language or use a language line; see page 28. If your HMO does not have a TTY, you can use the Deaf Relay service. Call 7-1-1. If you have a speech disability, you can use the Speech-to-Speech Relay service. Call 1-800-854-7784. Call your member 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; see page 30. Ask about health care outside your HMO's service area. Get a copy of the HMO formulary; see page 38. File a complaint or grievance; see page 48. Get help with access to care for people with disabilities; see page 26. Add or remove family members from coverage. Get a replacement copy of your membership card. Tell your HMO when your address or phone number changes. Get help finding an interpreter; see page 28. Aetna US Healthcare of California 1-800-756-7039 1-800-628-3323 www.aetna.com Alameda Alliance for Health 1-877-932-2738 1-510-747-4501 www.alamedaalliance.com Blue Cross of CaliforniA: General Call 800 number on ID Card TTY: 1-800-735-2922 www.bluecrossca.com. Blue Cross of CaliforniA: Individual Plans 1-800-333-0912 1-800-735-2922 www.bluecrossca.com Blue Cross of CaliforniA: Large Groups 1-800-999-3643 1-800-735-2922 www.bluecrossca.com Blue Cross of CaliforniA: Senior Services 1-800-333-3883 1-800-735-2922 www.bluecrossca.com Blue Cross of CaliforniA: Small Groups 1-800-627-8797 1-800-735-2922 www.bluecrossca.com Blue Shield of California 1-800-200-3242 1-800-241-1823 www.blueshieldca.com CalOptima 1-888-587-8088 www.caloptima.org Care 1st Health Plan 1-800-605-2556 1-800-735-2929 www.care1st.com [Page 61] Central Coast Alliance for Health 1-800-700-3874 1-877-548-0857 www.ccah-alliance.org Chinese Community Health Plan 1-415-834-2118 1-877-681-8888 www.cchphmo.com Cigna HealthCare of California, Inc. 1-800-344-0557 1-800-321-9545 www.cigna.com Community Health Group 1-888-244-4430 1-800-735-2922 www.chgsd.com Contra Costa Health Plan 1-877-661-6230 County of Los Angeles Community Health Plan 1-800-475-5550 1-626-299-7265 http://ladhs.org/chp Health Net Large Groups: 1-800-522-0088 1-800-995-0852 www.healthnet.com Health Net Small Groups: 1-800-361-3366 1-800-995-0852 www.healthnet.com Health Net Select 1-800-676-6976 1-800-995-0852 www.healthnet.com Health Net Seniority Plus: 1-800-275-4737 1-800-929-9955 www.healthnet.com Health Plan of San Joaquin 1-800-932-7526 1-209-942-6306 www.hpsj.com Health Plan of San Mateo 1-800-750-4776 1-650-616-8037 www.hpsm.org Inland Empire Health Plan 1-800-440-4347 1-909-890-0731 www.iehp.org Inter Valley Health Plan 1-800-251-8191 1-800-505-7150 www.ivhp.com Kaiser Permanente 1-800-464-4000 1-800-777-1370 www.kaiserpermanente.org L.A. Care Health Plan 1-888-452-2273 www.lacare.org Molina Healthcare of California 1-888-665-4621 1-562-951-1541 www.molinahealthcare.com NAMM California 1-800-864-7500 www.nammcal.com [Page 62] One Health Plan of California, Inc. 1-800-663-8081 www.onehealthplan.com On Lok Senior Health Services 1-415-292-8888 www.onlok.org PacifiCare of California General: 1-800-624-8822 1-800-442-8833 www.pacificare.com PacifiCare of California Secure Horizons: 1-800-228-2144 www.securehorizons.com San Francisco Health Plan 1-800-288-5555 www.sfhp.org Santa Barbara Regional Health Authority 1-877-814-1861 www.sbrha.org Santa Clara County Valley Health Plan 1-408-885-4760 www.scvmed.org Santa Clara Family Health Plan 1-800-260-2055 1-800-567-7759 www.scfhp.com Scan Health Plan 1-800-559-3500 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 M.dicos Nacionales S.A. (SIMNSA) 1-800-424-4652 www.simnsa.com Turtle Health Plan 1-888-887-8538 www.turtlehealth.org UHP Healthcare 1-800-544-0088 1-888-702-3323 www.uhphealthcare.com Universal Care 1-800-635-6668 www.universalcare.com University of California, San Diego Health Plan 1-800-688-6161 www.health.ucsd.edu Ventura County Health Plan 1-800-600-8247 1-800-735-2929 www.vchca.org/hcp Western Health Advantage 1-888-563-2250 1-888-877-5378 www.westernhealth.com [Page 63] Index Page numbers in parentheses have the most information on the topic. accessibility 26, 27 adopted children 8, 34 Advance Health Care Directive 7, 45, (46-47) Advice Nurse 43 alcohol treatment, see substance abuse ambulance services 42 anesthesiologists 45 appeals, see also complaints; review of HMO decision 48-53 appointments (22, 23), 26, 27, 29, 35 arbitration, binding 53 benefit package 8, 9, 17, (30-31) bills 10, 11 birth control/family planning 16, 17, 35, (39) birth/labor 34, 35, 43, 44 blindness 26 cancer 24, 33 caregivers, family 47 cesarean section 34 checkups/physicals 32, 33, 34 children, see also dependents 11, 17, (34-35), 40, 41, 43 clinical trials 24 COBRA/Cal-COBRA/Senior COBRA (12-15), 38 complaints 17, 19, 37, 44, (48-53) confidentiality/privacy 7, 23, 28, 29, 35, 40, 41 consent forms 7, 25 contraception, see birth control copayments/copays (10), 11, 19, 38, 41, 43 costs (10-11), 12, 19, 24, 38 counseling (40-41), 46 coverage, continuous 14-15 coverage, gaps in 14-15 coverage, group 5, 14 coverage, individual 13, 14, 15 customer service problems 49 deaf services, see also hearing care 26-29 death/dying 14, (46-47) denial of service 15, 17, 19, 38, (48-53) dental care 17, 31, 35 dependents 5, 8, 9, 12 depression 40, 41 diabetes 31, 39 diagnosis 25, 29 disability 14-15, 18-19, (26-27) disenrolling 19 divorce 12 doctors, see also appointments 4, 5, (20-23), 28, 29 drug abuse, see substance abuse eating disorders 41 education programs 17, 30 emergency room visits 34, (42-43), 53 employer sponsored insurance 5, 8, 9, (12-15), 31, 38, 49 equipment, medical 9, 26-27, (38-39) Evidence of Coverage 30, 31 exercise 32, 35 Expedited Review 19, 48 experimental/new treatments 24, 26, 30, 38, 52, 53 family members, coverage 8, 9, 12, 34-35 family planning, see birth control fees, see bills; costs; premiums formulary 38, 39 generic drugs 38 glasses, see also vision care 31 grievances, see also complaints 48 guidelines, medical 25 gynecologists 21, 32, 33, 36 hearing care 17, 31, 33 hepatitis 33 herbs 39 HICAP 19 HIPAA 15 HIV/AIDS 14, 17, 33, 36, 39 HMO Help Center 50-51 home health care 27, 31, 45, 46, 47 hospice care 46-47 hospitals 5, 34, 41, 42, 43, 44-45 immunizations/vaccinations 7, 17, 31, 33, 34 Independent Medical Review (IMR) 52-53 infertility 30 information, finding 6, 24, 25 inpatient care, see also hospitals 41, 44 internists 21 interpreters 16, 21, 22, 23, 27, (28-29) language services, see interpreters legal assistance 48-53 Letter of Creditable Coverage 15 limitations on service 4, 5, 11, 39 lipreading 28 long-term care 47 low-cost health care 16-17, 34, 35, 39 [Page 64] mammograms 17, 26, 31, 33 manic depression 41 Medi-Cal 15, (16-17), 49, 51 Medical Groups 21, 23, 37, 48 medical history 33 Medicare 15, (18-19), 49, 51 medication, see also prescription drugs (38-39), 40, 41, 47 Medigap 18, 19 membership card 7, 10, 43 mental health services 17, (40-41) moving 4, 13 newborns 34 nurse practitioners 21 nursing home care 45, 47 nutrition 34 obstetrician 34 ongoing conditions (14-15), 21, 32, 36 Open Enrollment 9 out-of-network care 11, 24, 26, (37), 42, 43, 45 over-the-counter drugs 22 pain 24, 25, 46, 47 panic disorders 41 patient advocacy 5, 27, 40, 41, (48-53) pediatricians 21, 34, 37 physical therapy 17, 31, 45 plans, changing 8, 9, 14, 15, 16, 17, 18, 19 poisoning 43 pre-existing conditions, see also ongoing conditions 14-15 pregnancy 14, 16, 17, 31, (34), 35 premiums 10, 11, 12, 13, 18, 19 prescription drugs 11, 19, 22, 31, (38-39), 40, 41, 47 preventive care 17, 31, 32 primary care provider, see also doctors (20-21), 36, 37 privacy/confidentiality 7, 23, 28, 29, 35, 40-41 psychiatrists/psychologists 41 records, medical 7, 27, 40, 46, 53 referrals, see specialists refills 39 research 25, 30 retirement 12 review of HMO decision 19, (52-53) rights 2, 6, 15, 26, 27, (48-53) risks and benefits of treatments 7, (24-25), 39 rudeness 44, 49 schizophrenia 41 second opinions 24, 25 seniors 12, 18-19 serious conditions 14-15, 20, 24-25, (36-37), 40-41, 46-47, 48-53 service animals 26 sexual problems 22 shots 7, 17, 31, 33, 34 side effects 25, 39, 41 sign language services 26, 27, 28, 29 skin cancer 33 smoking 41 Social Security 19 specialists 11, 17, 21, 32, (36-37) spouse/partner 5, 8, 9, 12 standards of care 9 standing referrals 36 STDs (sexually transmitted diseases) 17, 31, 33, 35 stress 25, 40, 41, 47 substance abuse 8, 22, 35, 41, 44 supplies, medical 31, 39 support groups 41 surgery 18, 24, 25, (44-45) symptoms 22, 29 teenagers 35 terminal illness 31, (46-47) tests/lab tests 7, 25, 31, (33), 48 translation services, see also interpreters (28-29) travel 10, 11, 32, 43 treatment decisions 6-7, (24-25), 39, 46, 52-53 treatments, new 24, 26, 30, 38, 52, 53 unemployment 12-15 urgent care 24, 31, (42-43), 48-53 vacations/out-of-area care 10, 11, 32, 43 vaccinations/immunizations 7, 17, 31, 33, 34 vision care 17, 31, 33 vitamins 39 waiting lists 36-37 waiting periods, see pre-existing conditions well-child/baby visits 8, 33, 34 wheelchairs 26, 38, 39 x-rays 17, 31 [Page: Back Page] The University of California, Berkeley For more information about this and other publications, contact: Center for Community Wellness School of Public Health University of California, Berkeley 2140 Shattuck Avenue, 10th Floor Berkeley, California 94704-1210 Voice 1-510-643-9543 TTY 1-510-642-9792 wellnet@uclink.berkeley.edu www.ucwellness.org Stephen M. Shortell, PhD, Dean, School of Public Health Linda Neuhauser,DrPH, Co-Principal Investigator S. Leonard Syme, PhD, Co-Principal Investigator Shelley Martin,MPH, CHES, Executive Director, Editor-in-Chief Katherine Simpson,MA, Principal Editor James T. Nguyen, Managing Editor The University of California Wishes to Thank Ed Mendoza, Cori Reifman, Susan Meier, Agustin Maravilla and John Torres of the Office of the Patient Advocate for the commitment and coordination they brought to the development of this guide. Nancy Oster for her contributions to content; Robin L. Goldfaden for her expertise and careful commentary; Elena Conis and Marilyn Mansfield for editing; Mike Doyle of the UC Office of the President for review and support; Deborah Lloyd and Edie Charlot of the UC Human Resources Department for information and assistance; Bill Martin for design consultation; Sylvia Caras, Sharon Clausen and Judi Rogers for review; Clare Watsky for indexing; Lacy Clayton,Mona Desai, Gladys Fleitas, Vino Goonewardena, Cheryl Iny, Karen Koh, Alice Kuo and Vanessa Lee for research. Design: PeterNamDesign, San Francisco. The Office of the Patient Advocate and The University of California, Berkeley Would Like to Offer Special Thanks: to the many consumer assistance groups, patient advocacy organizations and HMOs who contributed to the development of this guide; the many California HMO members who have contributed to the content and format; the many organizations and agencies that have worked with us, including WIC, the Black Women's Health Project, community centers, cultural centers and senior centers throughout California, the California Department of Health Services, and the U.S. Department of Labor, Employee Benefits Security Administration. We would also like to thank the California Department of Managed Health Care and its HMO Help Center, Bobbie Reagan, and Penny Fowler, for assistance with the development of this guide and their commitment to quality health care for Californians. The Patient Advocate A Voice for You www.opa.ca.gov