California's HMO Guide For Seniors Getting The Most From Your HMO The State of California OFFICE OF THE PATIENT ADVOCATE Arnold Schwarzenegger, GOVERNOR State of California Sunne Wright McPeak, SECRETARY Business, Transportation & Housing Agency Ed Mendoza, ACTING DIRECTOR Office of the Patient Advocate A note to users of this text file: Section heading and topic headings are labeled through out this guide. Print page numbers are included. [Page 1] Section Heading: What's In The Guide--Table of Contents Useful Terms--Page2 Section Heading: Know Your Health Care Choices What Is an HMO?--Page 4 Choosing an HMO--Page 6 Joining or Leaving an HMO--Page 8 Paying for Health Care--Page 10 Help Paying for Health Care--Page 12 Retirement Health Benefits--Page 14 Section Heading: Take Charge of Your Health Care Take Charge of Your Health Care--Page 16 Choosing a Doctor--Page 18 Talking with Your Doctor--Page 20 Choosing Treatments--Page 22 Making Your Wishes Known--Page 24 If You Have a Disability--Page 26 If English Is Not Your Language--Page 28 Section Heading: Know Your Benefits Know Your Benefits--Page 30 Routine Care--Page 32 Specialist Care--Page 34 Prescription Drugs--Page 36 Paying for Prescription Drugs--Page 38 Medical Equipment--Page 40 Care for Chronic Conditions--Page 42 Mental Health Care--Page 44 Emergencies and Urgent Care--Page 46 Hospital Care--Page 48 Home Care--Page 50 Nursing Home Care--Page 52 Care at the End of Life--Page 54 Section Heading: If You Have a Problem If You Can't Get the Care You Need--Page 56 If You Have a Customer Service Problem--Page 58 Office of the Patient Advocate--Page 60 Section Heading: Member Services--Page 62 Section Heading: Resources--Page 64 Section Heading: Index--Page 67 [Page 2] Useful Terms appeal: A request you can file with your HMO to review a denial of treatment benefits package: The services covered by your HMO chronic condition: An illness or condition that cannot be cured but can be controlled by medicine and other treatments COBRA/Cal-COBRA/HIPAA: Laws that help employees keep their health insurance if their job ends co-pay/co-payment: A fee that you pay each time you get a service covered benefit: A service your HMO will pay for if you need it Evidence of Coverage: Your contract with your HMO. It tells what your HMO will and will not pay for. formulary: A list of all the prescription drugs that your HMO covers generic drugs: Drugs that cost less because no company owns the patent on them grievance: A written complaint that you can make to your HMO about a customer service problem HMO (health maintenance organization): A kind of health insurance in which you must get your medical services from the doctors, labs, hospitals and other providers that have contracts with the HMO or work for it Medi-Cal: California's program to help people with low incomes pay for health care Medical Group: A group of doctors who have a business together and have a contract with an HMO to provide services to the HMO's members medically necessary services: Services you need in order to stay healthy, cure a disease, heal an injury, or keep an illness or chronic condition from getting worse Medicare: A national health insurance program that covers part of the cost of health care for people 65 and older and for some younger people with disabilities [Page 3] Medicare Advantage Plan/Medicare Plus Choice Plan: A Medicare HMO or other kind of Medicare managed care plan Medicare HMO: An HMO that has a contract with Medicare to provide health care services to people with Medicare Medicare Part A: The part of Medicare that covers hospital care--it is free for people who get Social Security. Medicare Part B: The part of Medicare that covers doctor care and lab tests. If you buy Part B, the premium is taken out of your Social Security check each month. network: All the doctors, labs, hospitals and other providers that have contracts with the HMO or work for it pre-existing condition: An illness, chronic condition or disability that you have before you join an HMO premium: A monthly fee you pay to your HMO. If you have Medi-Cal or retirement health benefits, the government or the company you worked for pays all or part of the premium. primary care provider (PCP): Your main doctor, who gives you most of your care and oversees your other health care services provider: Any person, group, clinic or hospital that gives you your health care services referral: A request for services from a provider who is not your primary care doctor second opinion: Advice from a second doctor about your choice of treatments or the cause or nature of your illness service area: The area you must live in to join an HMO specialist: A doctor with extra training in one field of medicine Summary of Benefits: A short list of your HMO's benefits and fees urgent care: Care that you need soon, but not right away, for a sudden illness or injury [Page 4] Section Heading: KNOW YOUR HEALTH CARE CHOICES Topic Heading: What Is An HMO? An HMO--Health Maintenance Organization--is a kind of health insurance. Each HMO has a network of doctors, labs, hospitals and other providers that work for the HMO or have contracts with it. You get your health care from these providers. Usually you have a primary care doctor who gives you most of your care and manages your treatments. Medicare HMOs have agreements with Medicare. If you join a Medicare HMO, you will get all your Medicare services through your HMO. Medicare pays the HMO to cover your care. Medicare HMOs are sometimes called Medicare Advantage or Medicare Plus Choice plans. Medicare is a national health insurance program. It covers part of the health care costs for people 65 and older and for some younger people with disabilities. It has two parts. Part A covers hospital care and is usually free to people who get Social Security. Part B covers doctor care and lab tests and will cost about $78 a month in 2005. If you sign up for Part B, the government takes the monthly premium out of your Social Security check. Caption: Mrs. Lau is turning 65. "I was so confused by Medicare. Then I called HICAP. Mrs. Walker really helped clear things up for me." The volunteers at HICAP, the Health Insurance Counseling & Advocacy Program, provide free help with Medicare. [Page 5] Questions & Answers Do I need Medicare Part B if I'm in an HMO? Yes. What is Original Medicare? It is the kind of Medicare most people have if they are not in a Medicare HMO. You can see any doctor who accepts Medicare. You are billed directly for your share of the cost of services. Original Medicare is also called Traditional Medicare. Will I have the same benefits in a Medicare HMO that I'd have in Original Medicare? Yes. For more on Medicare benefits, see page 30. I've heard there's a lot of paperwork for Medicare. Is that true if I am in an HMO? No. You usually don't have much paperwork if you are in an HMO. Things You Can Do Free Help with Medicare HMOs: Call your HMO's Member Services. Find the number on your membership card or on page 62. Call HICAP for free information and help. Joining Medicare: Most people who can get Social Security can also get Medicare. You may also get Medicare if your spouse, deceased spouse or former spouse had Social Security. Call Social Security. Social Security will send you a letter 3 months before your 65th birthday. Your Medicare membership card will be attached. It's best to sign up for Part B when you start getting Part A--at age 65 or when you retire. If you wait to enroll in Part B, you pay more. If you are still working at 65, you can wait to join Medicare. When you are ready to retire, call Social Security and tell them you want to start Medicare Parts A and B benefits. For more on retirement benefits, see page 14. Where To Find Help HICAP (HEALTH INSURANCE COUNSELING & ADVOCACY)--help with Medicare 1-800-434-0222 www.calmedicare.org Member Services--To find your HMO's phone number, see page 62. Social Security--Information on Social Security and Medicare 1-800-772-1213 www.ssa.gov [Page 6] Topic Heading: Choosing An HMO Not all Medicare HMOs are the same. Before you choose one, compare the benefits as well as the costs. The plan that looks the cheapest can end up costing you more if it doesn't cover the services you need most. And find out what your friends and other people think about the HMO. Compare benefits. Your benefits package is all the services that your health plan covers. All HMOs must offer the benefits covered by Medicare Parts A and B. This includes checkups, routine tests, specialist care, and hospital and emergency care. Other benefits, like prescription drugs, differ from plan to plan. Compare quality of care. All HMOs are regulated by the state of California. This means they must meet basic standards of care. For help comparing Medicare HMOs in your area, call HICAP Caption: "We wanted to stay with our doctor, so we chose an HMO she worked with." [Page 7] Questions & Answers How can I find out what Medicare HMOs are in my area? Call 1-800-MEDICARE. Or go to the Medicare Personal Plan Finder at www.medicare.gov. I am confused by the different plans. How can I choose one? It is often hard to compare plans. Try comparing a few costly benefits, like prescription drugs and hospital care. Also, call HICAP and talk with a volunteer counselor who can help you choose. I have a chronic condition. What questions should I ask? If you have an ongoing condition, like diabetes or a heart condition, ask if the medicines and specialist visits you need are covered. See page 42 for more questions to ask. Do all areas have HMOs? No. Many areas do not have any Medicare HMO. Things You Can Do Before You Choose a Plan, Ask: Does it serve my area? Are people I know happy with the plan? How much will I have to pay? Does the HMO pay for the drugs I use now? Does it cover brand-name as well as generic drugs? Is the specialist I see part of the HMO? Is the hospital near my home? How much will I have to pay if I'm in the hospital? Can I get a doctor who speaks my language? Does the HMO offer any services, like a shuttle bus, to help me get to appointments? Does the plan have preview meetings, where you can learn more and ask questions before you join. Where to Find Help 1-800-MEDICARE--Information and help with Medicare 1-800-633-4227 www.medicare.gov HICAP (HEALTH INSURANCE COUNSELING & ADVOCACY)--help with Medicare 1-800-434-0222 www.calmedicare.org [Page 8] Topic Heading: Joining Or Leaving An HMO It's easy to join or leave a Medicare HMO--but never leave your old plan until your new plan tells you that your new coverage has started. If you leave your Medicare HMO, you can change to another Medicare HMO, or you can change to Original Medicare. If you choose Original Medicare, you may be able to buy a Medigap policy to pay for some of the services Medicare does not cover. Medicare HMOs must accept new members between November 15 and December 31 of each year. They often accept new members at other times of the year also. You can switch to Original Medicare at any time. Pre-Existing Conditions Medicare HMOs must accept you even if you have a pre-existing condition such as diabetes or heart disease. However, if you are on kidney dialysis, you can't join a Medicare HMO. If you are already in a Medicare HMO, you can stay in it. But if you leave the HMO, you won't be able join another one. For more information, call 1-800-MEDICARE. Caption: Ron had to change plans while he was getting chemotherapy. He talked with his doctor to make sure that no treatments were missed. His old plan worked with his new plan to transfer his care. [Page 9] Questions & Answers My HMO is leaving the Medicare program. Will I lose my Medicare? No. You can join another HMO or return to Original Medicare and get a Medigap policy. What if I move? If your current HMO doesn't have a plan in your new area, you will have to join a new Medicare HMO or return to Original Medicare. If you move outside of the U.S., Medicare will not cover you. I want to join an HMO. Can I keep my Medigap policy a few months while I try out the HMO? Yes. This may be a good idea if you have a pre-existing condition and would not be able to buy a Medigap policy again. Also, if you join a Medicare HMO as soon as you get Medicare and leave within 12 months, you can buy any Medigap policy. Things You Can Do To Change Your Medicare HMO: 1. Fill out an enrollment form for the HMO you want to join. 2. Your new plan will send you a letter telling you when your new coverage starts. It can take about 30 days to join a new plan. 3. Do not leave your old plan until your new coverage starts. Your new plan will notify your old plan of the change. To Return to Original Medicare: Leaving a Medicare HMO is called disenrolling. There are 3 ways to disenroll: Send a request in writing to your HMO. Visit your Social Security office and fill out a "disenrollment" form. Or call 1-800-MEDICARE. Medigap: If you return to Original Medicare, you can buy a Medigap policy to help pay costs that Medicare does not cover. There are 10 kinds of Medigap, called a to j. Each has different costs and benefits. If your Medicare HMO leaves your area, or you move out of your plan's area, you can buy any Medigap policy. • If you leave your HMO for other reasons, you may not be able to get the Medigap policy you want. Call HICAP or 1-800-MEDICARE. Where To Find Help 1-800-MEDICARE--Information and help with Medicare 1-800-633-4227 www.medicare.gov HICAP (HEALTH INSURANCE COUNSELING & ADVOCACY)--help with Medicare 1-800-434-0222 www.calmedicare.org [Page 10] Topic Heading: Paying For Health Care Medicare HMOs often cost less out-of-pocket than other plans, but you still pay some fees. You continue to pay Medicare Part B premiums. You may also pay a monthly premium to your HMO. Medicare HMOs can change fees and benefits once a year. They must tell you, so you can change plans if you want to. You will be charged a co-pay for most services. Ask about co-pays for doctor visits, hospital stays, emergency room visits, ambulance services, outpatient surgery and other services. Also ask about co-pays for generic and brand-name drugs. Medicare HMOs do not pay for all your health care. Make sure you know what your HMO pays for and what you will have to pay for. Some services, such as nursing home care, are limited. You may have to pay high co-pays or deductibles for nursing home and hospital care. Caption: Each time you see a doctor you may be charged a co-pay. Most co-pays are $5 to $25 for each visit. [Page 11] Questions & Answers What is a co-pay? It's a fee you pay for a service, such as $5 to $25 for a doctor visit. Some co-pays can be high. For example you may pay from $50 to $300 for one day in the hospital. What is a yearly or annual maximum? This is the most you will have to pay for health care in each year. Not all HMOs have a yearly maximum. Things You Can Do Know what your HMO does and does not pay for. Call Member Services and ask for the Summary of Benefits. If You Get a Bill: In most cases, providers in your HMO's network should not bill you for their services. If your letter says, "This is not a bill," you don't have to pay anything. Before you pay a bill, you can call Member Services to make sure it is correct. If you think the bill is wrong, see page 56. Keep copies of all bills you pay, in case you have a problem. You Usually Have to Pay If: You get services that are not part of your benefits package. You see a specialist without a referral from your doctor. You see a provider who is not in your HMO's network. You get care outside your HMO's service area, unless it's emergency or urgent care. See page 46. Where To Find Help Member Services--To find your HMO's phone number, see page 62 [Page 12] Topic Heading: Help Paying For Health Care California has programs to help seniors with low incomes pay for health care. To get help, your income must be low or your health expenses very high. You can have a home, one car and some assets, like savings, stocks or bonds. If you don't get Social Security, you can still apply. Medi-Cal Medi-Cal can help pay your Medicare Part B and HMO premiums. It can also pay for many services that Medicare does not cover, such as prescription drugs, dental care and long-term care. You must use providers that take Medi-Cal. To get Medi-Cal, you must have a low income and limited assets. If your income is higher, and your health expenses are very high, you may still be able to get Medi-Cal, but you will have to pay a part of the cost. For more information, call your county Social Security office or HICAP. The Medicare Savings Programs These programs are for people who have low incomes but do not qualify for Medi-Cal. The programs pay the Medicare Part B premium and some other costs. You pay part of the costs also. These programs are also called Medicare "buy-in" programs. For information, call HICAP or 1-800-MEDICARE. Caption: Mrs. Garcia couldn't pay all her medical bills, so she met with a HICAP counselor. "HICAP told me about the Medicare Savings Programs and helped me apply." [Page 13] Questions & Answers How does Medi-Cal work with Medicare? It's complicated. Always show your Medi-Cal card when you get services. For more information, ask your Medi-Cal case manager. My mother is in a nursing home and has run out of money. What can she do? She may be able to get Medi-Cal, to pay for long-term nursing home care. Do I have to be in an HMO if I get Medi-Cal? No. Many people choose Original Medicare with Medi-Cal. For help deciding what is best for you, call HICAP. My mother is an immigrant and cannot get Medicare Part A for free. Can she get help to pay for it? She may qualify for one of the Medicare Savings Programs. Call 1-800-MEDICARE. Things You Can Do Apply for Medi-Cal: Pick up an application form at your county Social Services office or at a hospital or clinic. Apply as soon as you know your medical costs will be more than you can pay. It takes time for Medi-Cal to be approved. You can also ask Medi-Cal to pay your health care costs for the 3 months before the month when you apply. Apply for a Medicare Savings Program: If you are already on Medicare, call your county Social Services office. If you are not yet on Medicare, apply at your Social Security office. Tell them in writing that you are applying for "conditional" Medicare under a Medicare Savings Program. Once you are on Medicare, call or visit your county Social Services office to enroll in a savings program. Where To Find Help 1-800-MEDICARE--Information on the Medicare Savings Programs 1-800-633-4227 www.medicare.gov HICAP (HEALTH INSURANCE COUNSELING & ADVOCACY)--help with Medicare 1-800-434-0222 www.calmedicare.org [Page 14] Topic Heading: Retirement Health Benefits If you have retirement health benefits, follow your employer's or union's rules carefully. You could lose your retirement benefits if you don't. Many retirement health plans require you to enroll in Medicare. Medicare helps your retirement health plan pay for your care. Be prepared for changes. When you go on Medicare, you may have to change to the Medicare version of your HMO. Costs, benefits and the way you get approval for services may change. The area the Medicare HMO serves and the providers in its network may also change. And there are new rules for joining or changing plans. Caption: If you don't retire at 65, you can wait to enroll in Medicare. When you are ready to retire, call Social Security and tell them you want to start Medicare Parts A and B. See page 4. [Page 15] Questions & Answers Do I have to pay for Medicare if I have retirement health benefits? You usually have to pay the Medicare Part B monthly premium, which is taken out of your Social Security check. If you get Social Security benefits, there is no premium for Medicare Part A. Can I change plans when I get Medicare? Yes, you can change during your employer's yearly open enrollment period. Ask your employer if you can change at other times. Why do I need to enroll in Medicare if I already have health coverage as a retiree? Medicare helps you and your employer save money on health care. Can I work and get Medicare? Yes. In some cases your job will require you to get Medicare Parts A and B when you are 65. Talk to your employer or call HICAP Things You Can Do Before You Retire or Turn 65, find out: If you must join Medicare Parts A and B at age 65. If the company stops providing health benefits when you reach 65 and can get Medicare. If your spouse or domestic partner will be covered when they turn 65. If You Retire Before Age 65 with NO Retirement Health Benefits: Ask your HMO or employer about COBRA and Cal-COBRA. These laws help you keep your employer's health plan for up to 3 years. You have to pay the monthly premium, but it may be less than you'd pay on your own. You'll also have better benefits. If COBRA/Cal-COBRA run out before you are 65, a law called HIPAA protects your rights to get health insurance on your own. Make sure you meet the deadlines for signing up for COBRA, Cal-COBRA and HIPAA. Call U.S. Department of Labor. If you have a pre-existing condition, try to keep your health coverage with COBRA, Cal-COBRA and HIPAA. It can be hard to get new coverage. Where To Find Help HICAP (HEALTH INSURANCE COUNSELING & ADVOCACY)--information about COBRA and Cal-COBRA 1-800-434-0222 www.calmedicare.org U.S. Department of Labor--Information about COBRA and HIPAA 1-866-444-3272 www.dol.gov/ebsa [Page 16] Section Heading: TAKE CHARGE OF YOUR HEALTH CARE Making 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 you speak up for what you need, you will probably get better care. Take Charge When You Need Information Make a list of your questions. Keep asking questions until you get the information you need. If you can't get an answer to a question, ask who to call. Or ask to speak to a supervisor. Take notes. Write down the names of the people you talk to. For support, have a friend or relative with you. Take Charge When You Need Treatment If you have a medical problem, ask about all the possible treatments and their risks and benefits. When you get a treatment, you will be asked to sign a consent form. Make sure you understand what is being done and why. Caption: "I wasn't comfortable telling my doctor that I didn't think my treatment was working. So I asked my son to help me talk to my doctor." [Page 17] Questions & Answers How can I make the best decisions about my health care? First, talk to your doctor. You can also talk to other health care providers, and to your family and friends. This guide can also help you. And you can find information in the library, on the Internet and at your HMO's health education office. Does it really help to speak up about a problem? Yes. Studies have shown that hospital patients who complain and demand better care really do get better care. They also recover faster. I want my daughter to understand my health care. Can she call my doctor? Yes. But first you need to tell your doctor that it's OK to talk about your health care with your daughter, or with another relative if you wish. Things You Can Do Get to Know Your HMO: Always carry your HMO membership card with you. If you have a question, call your HMO's Member Services. The number is on your membership card. Know what your HMO will and won't pay for. Ask your HMO for a Summary of Benefits. You Have the Right to See and Copy Your Medical Records: Ask your doctor's office how to see your records. It's a good idea to get a copy of your medical records, in case you change doctors or HMOs. It can take time and there may be a fee. If you don't agree with something in your records, call your HMO's Member Services. Save Copies of All Your: Lab reports, Vaccination records, Test results, Treatment information, Medical bills, Letters you send to your HMO, Information your HMO sends you about its services Where To Find Help Member Services--To find your HMO's phone number, see page 62. [Page 18] Topic Heading: Choosing A Doctor Your primary care doctor gives you your basic care and oversees 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. You can change doctors if you don't like the doctor you have. You have the right to have your own doctor. 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 she will get to know you and can watch for changes in your health. 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 he leaves your plan, you must be told ahead of time so you can choose another doctor. Caption: "I really wanted an African American doctor and my Member Services helped me find one." [Page 19] Questions & Answers Can I keep my old doctor if I join an HMO? Only if your doctor is in the Medicare HMO's network. How can I choose my own doctor? Call Member Services and ask for a list of doctors. You may have to call several doctors before you find one who's taking new patients. What if I don't like my doctor? You can choose a new doctor. It can take up to a month to get a new doctor. What if my doctor leaves my HMO? You will have to choose a new doctor. Ask your old doctor for the names of good doctors in the network. If you are being treated for a serious health problem, you may be able to keep your old doctor for a while. Things You Can Do Choosing Your Doctor: Ask friends 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 specific medical problem? How does the doctor make referrals to specialists? How will I reach the doctor if I have a problem between visits? Does the doctor have referral privileges at the hospital I want to use? Your Doctor's Medical Group: A Medical Group is a group of doctors who have a contract with an HMO. 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. For information on Medical Groups, call Office of the Patient Advocate and order a free HMO Report Card. Where To Find Help Member Services--To find your HMO's phone number, see page 62. Office of the Patient Advocate--Report cards with information on Medical Groups, including language assistance services 1-866-HMO-8900 www.opa.ca.gov [Page 20] Topic Heading: Talking With Your Doctor To get good health care, you must be able to talk freely with your doctor. 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 Doctor Visits Most doctor visits are short. Plan ahead so you can cover everything. Bring a list of your questions and concerns. Bring a list of the prescription and over-the-counter drugs you take. Ask the doctor to explain things in simple terms. 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 the doctor to write it down for you. Ask your doctor how to reach him between visits. If you have a lot to talk about, ask for another visit. Bring someone with you for support. Caption: Brenda helped her brother ask all his questions. "We asked his doctor to explain the lab tests in plain English." [Page 21] Questions & Answers My doctor is always in a hurry. How can I get him to listen? Doctors are often in a hurry. If you don't feel that your doctor is listening, repeat your questions. Ask him to explain his answers. If you still feel that he doesn't listen, you may want to change doctors. How do I know what to tell my doctor? I don't know which symptoms are important. Tell your doctor all of your symptoms and concerns--what hurts, where it hurts, when it hurts. And ask all your questions--should I be worried? What should I do? Things You Can Do When You Make an Appointment: Ask how long you will have to wait. Ask if you need to do anything to prepare for your visit. Ask for a longer appointment if you need one. Ask for an interpreter if you need one. If this is your first visit, ask how to get to the office and where to park. If you do not drive, ask if there is a van or shuttle service. If you have a disability, ask about access. How to Reach Your Doctor Between Visits: Call, fax or e-mail your doctor's office. Leave your name, medical number, phone number, and the best times to call you back. Explain briefly what you are calling about. Ask who will get back to you--your doctor, a nurse or someone else. If your doctor's office doesn't return your calls, call your HMO Member Services. Where To Find Help Member Services--To find your HMO's phone number, see page 62. [Page 22] Topic Heading: Choosing Treatments It's not always easy to decide on treatment. Most treatments have risks as well as benefits. Talk with your doctor to learn about your choices so you can make an informed decision. Compare Treatments Ask your doctor to tell you all your treatment choices, even if your plan does not cover all of them. Ask how much time you have to decide. What are the risks and benefits of each treatment? Which treatments are most likely to help? Least likely? How long will each treatment take? How long will it take to recover? How much will each treatment cost you? How much discomfort or pain will you have? Second Opinions You can ask for a second opinion if: Your problem or the cause is unclear. You are not sure about surgery. You have doubts about a treatment for a serious health problem. The treatment isn't working. If you want to see a doctor outside your HMO, you need a referral from your HMO. If your problem is not urgent, your HMO must reply to your request in 11 days. If your problem is urgent, the HMO must reply in 3 days. Or you can pay for the visit yourself. You may be able to get reimbursed later. Caption: "My doctor and I talked about ways to manage my colitis. We agreed on a treatment plan that works for my lifestyle." [Page 23] Questions & Answers What if my HMO won't pay for the treatment my doctor recommends? You can file an appeal. See page 56. I read about an experimental treatment for my disease. Can I get it? First ask your doctor about it. The treatment must meet Medicare guidelines. Visit www.clinicaltrials.gov. What if I don't want any treatment? You have the right to refuse treatment for yourself. What can I do if I don't understand the consent form I get? Ask the doctor to explain the form. Never sign it if you don't understand what is being done and why. Things You Can Do Ask Your Doctor About Your Treatment: What are 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? What can you do if you're in pain? See page 42. Learn About Your Condition: Visit your local library or a hospital library. Look for a group that helps people with your condition, like the American Lung Association. Visit www.healthfinder.gov or www.nia.nih.gov. To learn about lab tests, visit www.labtestsonline.org. To learn about medical guidelines for treating health problems, visit www.guideline.gov. Where To Find Help Clinical Trials--Information on current research on treatments www.clinicaltrials.gov Healthfinder--Easy-to-use health website www.healthfinder.gov Lab Tests Online--Information on lab tests www.labtestsonline.org National Guideline Clearinghouse--Care guidelines for many health conditions www.guideline.gov National Institute on Aging--Information for seniors 1-800-222-2225 www.nia.nih.gov [Page 24] Topic Heading: Making Your Wishes Known There are things you can do now to give you more control over your care in the future. This can also prevent confusion, worry and disagreements among family members. Make sure your doctor knows your wishes, too, so she can help carry them out. The California Advance Health Care Directive allows you to say what care you do or do not want. For example, you can say whether you want to be put on a respirator and how much pain relief you want. You can also name a person to act as your health care agent. This person can make health care decisions for you if you can no longer speak for yourself. This form is sometimes called a Living Will. For more information, call Family Caregiver Alliance or California Healthcare Association. Caption: An Advance Health Care Directive lets you say what care you want if you can't speak for yourself. Your doctor and your agent must follow your wishes. [Page 25] Questions & Answers I filled out an Advance Health Care Directive. What do I need to do now? Sign and date your directive and have two other people sign it. Or have a notary public witness your signature. Keep the original, signed document and give copies to your doctor and to your health care agent. It's scary to think of letting someone make decisions about my health. How do I choose an agent? Choose someone you know well and trust, like a spouse, partner, close relative or friend. The person should know your values and beliefs and be able to act on them. Choose a backup person also. Does my health care agent have control over my money? No. If you want someone to pay your bills and manage your money, talk to your bank. Or ask a lawyer about a Durable Power of Attorney for Assets Management or about a Revocable Living Trust. Things You Can Do Make Sure Others Know Your Wishes: Talk to your family and close friends about your wishes. Tell them that you have an Advance Health Care Directive. Be sure they know where it is. Give a copy of your Advance Health Care Directive to your doctor and your agent. Discuss your wishes with them. The law says that your doctor and your agent must follow your stated wishes. Your Health Care Agent: In legal terms, your health care agent has Durable Power of Attorney for Health Care. If You Are in a Hospital or a Nursing Home Make sure your doctor and the nursing home have a copy of your Advance Health Care Directive and understand what care you want. Where To Find Help California Healthcare Association--Free Advance Health Care Directive forms 1-800-494-2001 www.calhealth.org Family Caregiver Alliance--Information on advance directives 1-800-445-8106 www.caregiver.org [Page 26] Topic Heading: If You Have A Disability As we age we are more likely to have disabilities. If you already have a disability, your care may become more complex. Look for a doctor who will support you in getting services. 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. Your HMO must pay for these services if there are medical reasons why you need them. If you have had Medicare before age 65 because of a disability, you should know that some rules change when you are 65. For example, you have more choice of Medigap policies and the costs may be less. Call 1-800-MEDICARE You Have the Right To: Access to health care services, such as a ramp to get into your doctor's office if you need it. Extra time for visits if you need it. A sign language interpreter if you need one. 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. Caption: Mona's HMO did not have a mammogram machine she could use. So her HMO had to pay for her visit to a clinic outside the HMO's network. [Page 27] Questions & Answers I have a disability. Will a Medicare HMO accept me? Yes. Medicare HMOs must accept you, unless you are on kidney dialysis. See page 8. And the HMO can't charge people with disabilities more than other people. 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? Discuss the new treatment with your doctor. Ask if it is a treatment covered by Medicare. You can appeal your HMO's decision. See page 56. I don't drive and getting on the bus is hard for me. How can I get to the doctor? Most counties have van service for seniors and people with disabilities. To find it, call Senior Information and Referral. Things You Can Do When You Make an Appointment: Let your provider know ahead of time if you will need help getting onto an exam table, extra time for an appointment, a sign language interpreter, an accessible bathroom or other equipment or services. For More Services: For more information on services for people with disabilities, talk to your local Independent Living Center or visit www.cfilc.org. For help paying for home health care, call your county Social Services department and ask about In-Home Support Services (IHSS). For legal help, call Protection & Advocacy. For information on rights, visit www.dralegal.org. Where To Find Help 1-800-MEDICARE--Information on Medicare 1-800-633-4227 www.medicare.gov CA Foundation for Independent Living Centers--Resources for people with disabilities www.cfilc.org Disability Rights Advocates--Health care rights for people with disabilities www.dralegal.org Protection & Advocacy--Legal help for people with disabilities 1-800-776-5746 www.pai-ca.org Senior Information and Referral--Find local support services 1-800-510-2020 www.aging.state.ca.us [Page 28] Topic Heading: If English Is Not Your Language Look for doctors who speak your language, or ask for an interpreter if you need one. You may want a family member or friend with you for support, but try not to rely on them to translate for you. Ask for consent forms, prescription drug information and other instructions in your language. Certified medical interpreters are trained to translate health information correctly. They must keep all your 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 Have the Right to an Interpreter When You Need To: Tell your symptoms or medical history to your doctor. Understand your health problem or treatment choices. Understand instructions about medicines, medical equipment or follow-up care. Caption: "It is hard for my daughter to translate medical information when she's worried about my health. So I ask for an interpreter to be there, too." [Page 29] Questions & Answers My doctor's office said I should bring someone to interpret for me because I only speak Spanish. Do I have to bring someone? No. Your doctor should provide an interpreter. Call your HMO. If that does not help, see page 58. Do I have to pay for interpreter services? This service is usually free--check with your health plan. How can I find an HMO with services in my language? You can get a report on California HMOs and the language assistance services they offer. Call Office of the Patient Advocate and ask for the HMO Report Card. What if I speak sign language? You have the right to a sign language interpreter. Try not to rely on lipreading. For more information, call Deaf Counseling, Advocacy and Referral Agency. 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's office 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. Information in Many Languages: For information in different languages on HMOs, Medi-Cal and public health benefits, visit www.healthconsumer.org. To order this guide in Spanish, call Office of the Patient Advocate. Where To Find Help Deaf Counseling, Advocacy and Referral Agency--Resources for people who are Deaf 1-877-322-7299 1-877-322-7288 (TTY) www.dcara.org Health Consumer--Health care information in several languages www.healthconsumer.org Office of the Patient Advocate--Information on HMO's language assistance services 1-866-HMO-8900 www.opa.ca.gov [Page 30] Section Heading: KNOW YOUR BENEFITS When you get health insurance, you get a set of services called a benefits package. All Medicare HMOs must offer the same benefits that Original Medicare covers. Some HMOs cover added benefits, such as prescription drugs and eyeglasses. Before you join a Medicare HMO, make sure you understand what it covers. Your Medicare HMO must give you a written list of what your plan does and does not pay for. This is often called the Evidence of Coverage or Summary of Benefits. Medicare HMOs Offer These Basic Services: Doctor services; Hospital and outpatient services; Lab work like blood tests and urine tests; Tests like x-rays and colonoscopies; Preventive care, like vaccinations and checkups; Emergency and urgent care; Some physical therapy; Some home health or nursing home care; Some care at home for people who are dying; Mental health care; Diabetes home care supplies; Drug and alcohol treatment Caption: Marvin is having his yearly checkup. All HMOs cover care like this to find and help prevent problems. [Page 31] Questions & Answers My friend had a stroke and is getting home health care. Why can't I? You can only use your benefits when they are needed for your health care. If you have a problem getting services you need, see page 56. I visit my daughter in Idaho twice a year. Will my HMO pay for me to see a doctor there? Not unless you need emergency or urgent care. See page 46. How can I learn more about the benefits that Medicare covers? Visit www.medicare.gov or call HICAP. 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 Benefits. Have a question? Call Member Services or HICAP. When You Travel: Make sure you know your HMO's rules for getting care away from home. Ask your HMO if it has a branch where you are going, and if you can receive care there. HMOs only pay for urgent and emergency care outside the service area. You usually need your HMO's approval to get urgent care. Always take your membership card and extra medication with you when you travel. Vision, Hearing and Dental Care: Some Medicare HMOs offer more dental, vision and hearing care benefits than Original Medicare. Ask if your plan covers these services, or part of the cost of glasses or hearing aids. If not, you may be able to get these or other benefits for an extra fee. Where To Find Help 1-800-MEDICARE--Information on the Medicare Savings Programs 1-800-633-4227 www.medicare.gov HICAP (HEALTH INSURANCE COUNSELING & ADVOCACY)--help with Medicare 1-800-434-0222 www.calmedicare.org Member Services--To find your HMO's phone number, see page 62. [Page 32] Topic Heading: 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 and lab work. Make the most of your routine care 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. Have a schedule for routine care. Your HMO may have a schedule for routine care and tests. If that schedule doesn't work for your health needs, talk with your doctor about changing it. Caption: "During my annual exam, I learned that I have high blood pressure. My doctor put me on medication. He also said I should start exercising to help keep my blood pressure under control." [Page 33] Questions & Answers What should I do if I'm sick? 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. Will my plan pay for routine care if I'm traveling? No. If you're outside your HMO's service area, only emergency and urgent care are covered. See page 46. I have a rare heart disease and I'd like to see a specialist for my regular care. Is that possible? If you have a health problem that needs ongoing care from a specialist, you may be able to see the specialist for all your care. Things You Can Do How Often Should You Have an Exam? Ask your doctor how often you should have routine exams and tests, such as: Complete physicals; Hearing and vision exams; Flu and pneumonia shots; Colon cancer screenings; Prostate exams if you are a man; Breast exams, pelvic exams and mammograms if you are a woman Keep Track of Your Care: Before you have a test, ask why it is being done, how it will be done and if there are any risks. Make sure you get the results of your tests. Ask your doctor to tell you what they mean. To learn more about tests, visit www.labtestsonline.org. For a recommended list of shots, call National Immunization Hotline. For more information on health care for seniors, call the Agency for Healthcare Research and Quality. If a 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--Free information on health care for seniors 1-800-358-9295 www.ahrq.gov Lab Tests Online--Learn about lab tests www.labtestsonline.org National Immunization Hotline--Immunization guidelines 1-800-232-2522 www.cdc.gov/nip [Page 34] Topic Heading: Specialist Care A specialist is a doctor who has extra training in one area of medicine. For example, a gerontologist is trained to treat the problems of aging and an oncologist is trained to treat cancer. You usually need a referral from your primary care doctor to see a specialist. In most cases, you must see specialists who are in your HMO's network. Your doctor may refer you to a specialist if: You need treatment from a doctor with special training. Your test results are unclear. The treatment you are getting now is not helping you. You need a doctor who knows more about treating your health problem. Caption: "After 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." [Page 35] Questions & Answers Do I need a referral if I am seriously ill? Yes. If you are not in immediate danger, you need a referral first. Ask your doctor for an "expedited referral." Your HMO must reply to your request within 3 days. If I need ongoing care from a specialist, do I need to get a referral for each visit? 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. Will my HMO pay for me to see a specialist who's not in my HMO's network? Only if you can show that there is no specialist in your HMO who can give you the care you need. If your HMO disagrees with you, you can file an appeal. See page 56. Things You Can Do 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 a procedure or operation that is risky, look for a specialist in your plan who has done the procedure many times. • To learn about the training that specialists have, visit www.abms.org. Getting a Referral: Ask your doctor how to see a specialist in his Medical Group. Ask if there are specialists that you can see without a referral. 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, ask for an expedited referral. This takes 3 days or less. If You Have a Problem: Many specialists have long waiting lists. If the waiting list is too long, ask your doctor for a referral to another specialist. If you can't get a referral, your doctor should tell you why. If you disagree, you can file an appeal with your HMO. See page 56. Where To Find Help American Board of Medical Specialties--Information about specialists' training 1-866-275-2267 www.abms.org [Page 36] Topic Heading: Prescription Drugs If your plan covers prescription drugs, 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 more for them. Most drugs in the formulary are generic drugs. These drugs cost less than brand-name drugs, but they have the same basic ingredients. However, not all drugs are available as generics. You can ask for a list of the drugs your HMO covers. Also ask how often your HMO changes its formulary. To see what's in most HMO formularies, visit www.ca.mcodrugs.com. Work with your pharmacist. Your HMO's formulary can change. If your pharmacy tells you that your prescription isn't covered, or that you have to pay more, ask them to call your HMO and check. If the HMO says it won't pay for the prescription, ask the pharmacist to call your doctor. There may be a form of the medicine that your HMO does cover. Caption: Lily shows her new doctor all the medicines she takes and asks if she should keep taking them. [Page 37] Questions & Answers Why do generic drugs cost less than brand-name drugs? Many brand-name drugs are new drugs. Only the company that developed them can make them. But when a company's patent on a new drug ends, other companies can make the drug. It becomes generic and then it costs less. Can my HMO take my medicine off its formulary? Yes, an HMO can change its formulary. But if you show that you need the drug, your HMO may cover it for you. Talk to your doctor. See page 56. I saw an ad for a new drug but my doctor won't give it to me. Why? 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 page 56. Things You Can Do Take Charge of Your Medicines: If your doctor prescribes a new medicine, ask about side effects, risks and benefits. Ask about other treatments. Ask what could happen if you go without the medicine. Tell your doctor all the medicines, vitamins and herbs you take. Ask him if the new drug is safe to take with them. Tell your doctor about all the allergies or bad reactions you have had to drugs. Tell him if a drug does not seem to be helping. Never cut pills in half or take them less often without talking to your doctor first. When You Order a Prescription or Refill: 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 the one you asked for. Talk to your pharmacist when you get a new medicine. If you are going on a trip, ask the pharmacist for a vacation supply or ask if you can refill prescriptions at other pharmacies. Ask your HMO about getting prescriptions by mail. They usually cost less, and you can order for 3 months at a time. Where To Find Help California Internet Formulary--HMO drug formularies www.ca.mcodrugs.com [Page 38] Topic Heading: Paying For Prescription Drugs Prescription drugs are costly, even if you have prescription drug benefits. When you choose an HMO, compare drug benefits carefully. Even if you pay a higher premium, you may save money if the plan covers the drugs you need. A co-pay is a fee that you pay each time you pick up a prescription. Some drugs have higher co-pays than other drugs. When you order a prescription, ask your pharmacist what the co-pay will be. There are limits on coverage. Some HMOs only cover drugs that are generic. Others also cover some brand-name drugs. Most will only pay for $1,000-$2,000 of brand-name drugs a year. If you take drugs that cost a lot, or many drugs, you may use up this coverage in a few months. Caption: Ask your pharmacist for the generic version of your medicine. [Page 39] Questions & Answers How should I choose a Medicare drug discount card? Most California HMOs offer their own discount cards. If your HMO does, that card is the only one you can buy. Otherwise, you can buy any card that is offered in your area. Buy the card that covers the greatest number of the drugs you take. For help choosing a card, call 1-800-MEDICARE. I've heard that Medicare will start covering drugs soon. How can I find out more? In 2006, Medicare will begin to offer prescription drug coverage, called Medicare D. To find out more, call 1-800-MEDICARE. How do I know if I need a Medicare drug discount card? If you pay over $250 a year for drugs or have a low income, a card may help you. But be sure to find one that covers the drugs you use. Things You Can Do Medicare Drug Discount Cards: Most cards cost $30 a year. The card saves you about 15% on the cost of drugs. You can only have one card. Each card must cover a wide range of medicines. If you have a low income, you may qualify for a free card and $600 credit on your card. You can use the $600 to help pay the cost of your drugs. For more information, call 1-800-MEDICARE. If you have Medi-Cal, you can't buy a drug discount card. Medi-Cal covers prescription drugs. Keeping Drug Costs Down: There are other drug assistance programs. Call HICAP or visit www.calmedicare.org. When your doctor gives you a prescription, ask if your HMO covers it and if it's generic. If you can't afford to buy the drugs you need, tell your doctor. Ask your doctor about free samples. If you buy prescription drugs on your own, compare prices from different pharmacies. Where To Find Help 1-800-MEDICARE--Information on drug discount cards 1-800-633-4223 www.medicare.gov HICAP (HEALTH INSURANCE COUNSELING & ADVOCACY)--help with Medicare 1-800-434-0222 www.calmedicare.org [Page 40] Topic Heading: Medical Equipment HMOs cover some durable medical equipment, like oxygen, walkers and wheelchairs. Your doctor has to prescribe the equipment. You usually have to pay part of the cost. Medicare HMOs only pay for equipment that you medically need--like hospital beds, walkers and wheelchairs that you need because of an illness or injury. Medicare also covers oxygen tanks and ventilators. Air conditioners and dehumidifiers are not covered. Changes to your home, such as ramps or railings, are not covered either. Some HMOs cover part of the cost of hearing aids. Usually, your equipment must be reusable. Most supplies that are used and then thrown away, such as bandages, rubber gloves and irrigating kits, are not covered. However, ostomy and diabetes supplies are covered. If you have Medicare and Medi-Cal: If your Medicare HMO does not cover the equipment you need, ask your doctor if Medi-Cal can pay for it. Caption: "After I fell, I needed a walker to help me get around. I talked to my doctor and he asked my HMO to buy it for me." [Page 41] Questions & Answers Medicare paid for my diabetes care supplies. Now that I've joined a Medicare HMO, will they still be covered? Yes. Medicare HMOs have to cover the same medical equipment that Original Medicare covers. This includes supplies for treating diabetes. What if my HMO paid for a walker and now I need a wheelchair? If you can walk with the walker, your HMO probably will not pay for a wheelchair. If you can no longer use a walker, ask your doctor to request a wheelchair. What can I do if my HMO won't pay for medical equipment that my doctor and I think I need? You can file an appeal. See page 56. Things You Can Do For More Information: For more information on what Medicare covers, visit www.medicare.gov/publications. For more information about equipment for people with disabilities, call Protection & Advocacy or AT Network. Your HMO Must Cover: Most home care supplies if you have diabetes. One pair of eyeglasses, or contact lenses if you have cataract surgery. Breast prostheses if you have a mastectomy. Ostomy supplies that your doctor says you need. An artificial limb if you lose an arm or leg. A brace if you injure your arm, leg, back or neck. Where To Find Help 1-800-MEDICARE--Information on coverage of medical equipment 1-800-633-4223 www.medicare.gov/publications AT Network--Tools for seniors and people with disabilities 1-800-390-2699 www.atnet.org Protection & Advocacy--Legal help for people with disabilities 1-800-776-5746 www.pai-ca.org [Page 42] Topic Heading: Care For Chronic Conditions Many of us have chronic conditions, such as arthritis, diabetes or heart disease. There are new treatments that make it easier to live with these conditions. Medicare HMOs pay for many of these treatments. When You Choose an HMO: Ask what services the HMO offers people with your illnesses or conditions. How many doctors have experience with your condition? Are they taking new patients? Does the HMO have a treatment plan for your condition? Does the HMO cover the treatments you are getting now? Does it cover the medicines you're taking? Does it cover any other treatments? What diagnostic tests can you get? What is covered if your condition improves? If it gets worse? Caption: Leon's HMO pays for a glucose meter and test strips so that he can check his blood sugar regularly and keep his diabetes under control. [Page 43] Questions & Answers Do Medicare HMOs cover diabetic supplies? Yes. Medicare covers test strips, glucose meters and lancets. Insulin pumps, insulin and therapeutic shoes may also be covered. There may be limits on how many supplies you can get and how often you will be able to get them. My arthritis gives me pain all the time. What can I do? Talk to your doctor and work together to create a treatment plan. This might include physical therapy, exercise, relaxation classes, and acupuncture or chiropractic treatments. If you still have pain, ask your doctor about a pain management program. For more information, visit www.theacpa.org. Will my HMO cover treatments even if my condition is not likely to improve? Yes, your plan must cover services that you need to keep your condition stable or slow down a decline in your health. Things You Can Do Work with Your Doctors: Ask your doctor to write down your treatment plan. It should include care to keep your condition from getting worse and treatments such as physical therapy to improve your condition. Ask what specialists you need and how often you can see them. Make sure your specialists report back to your primary care doctor. Tell your doctors if your symptoms change. If your primary care doctor does not know a lot about your condition, you may want to switch to a doctor who does. Ask About a Disease Management Program: Ask your HMO if it offers classes for people with your condition. Find Out About Your Condition: For information on chronic conditions, call National Institute on Aging or visit www.nih.gov. Where To Find Help American Chronic Pain Association--Support and information for people with chronic pain 1-916-632-0922 (Not toll-free) www.theacpa.org National Institutes for Health--Health information on many health conditions www.nih.gov National Institute on Aging--Information for seniors 1-800-222-2225 www.nia.nih.gov [Page 44] Topic Heading: Mental Health Care Many people deal with problems like depression and anxiety. Services like counseling, medication or hospital care help people deal with these problems. Medicare HMOs provide some mental health coverage. There may be limits on your coverage. Mental health benefits: Medicare HMOs cover inpatient care, including room, meals, nursing, and related services and supplies. They also cover lab tests and visits with a doctor, clinical psychologist or clinical social worker. If your plan covers prescription drugs, drugs for mental health care are covered. Caption: "My medicine is helping my depression. I had to try 3 medicines before finding one that worked." [Page 45] Questions & Answers Mom was very depressed after dad died. Her doctor prescribed medication, but she says it makes her too sleepy. What can I do? Help her talk to her doctor and explain the problem. The side effect may go away. Or there may be a medicine that works better for her. Will my HMO pay for me to go to any counselor? No. You can only go to counselors who are licensed by the state and who are in the HMO's network. Some HMOs use independent services, called behavioral health care services, to provide mental health care. Things You Can Do If You Want Mental Health Care Services: Ask your HMO what mental health care it pays for and how to get services. Ask if you can get services without a referral from your doctor. Ask what the co-pay is. Mental Health Care: Many doctors prescribe medication for depression. Make sure you understand the side effects and how to take the medication correctly. Care may include visits to a counselor, psychologist or psychiatrist, or group therapy. Your HMO may offer support groups for people dealing with issues like smoking, drinking, stress, grieving, caregiving or cancer. If you are put in the hospital without your consent, forced to take medicine or treated badly, call California Office of Patients' Rights or Protection & Advocacy. For information on mental health, call National Mental Health Association. Where To Find Help California Office of Patients' Rights--Help for patients hospitalized with mental illness 1-916-575-1610 (Not toll-free) National Mental Health Association--Information, advocacy and referrals 1-800-969-6642 www.nmha.org Protection & Advocacy--Legal help for people with disabilities 1-800-776-5746 www.pai-ca.org [Page 46] Topic Heading: Emergencies and Urgent Care In an emergency, you should call 911 or go to the nearest emergency room. If you can, go to a hospital in your HMO network. However, any emergency room must treat you, and your HMO must pay for this treatment. Medicare HMOs must cover emergency care. What is an emergency? In general, the law says it's an emergency if average people think it's an emergency. It is an emergency if you think your health is in serious danger and you need care right away. You may have a bad injury or sudden illness. You may have an illness that is quickly getting much worse. Shock, a severe wound, a heart attack or severe pain are emergencies. If you are not sure it is an emergency and there's time to call, phone your doctor or HMO. Urgent care is care you need soon but not right away, for a sudden illness or injury. You may be able to use your HMO's urgent care clinic or get a same-day appointment to see a doctor. If you are out of your HMO's area, your HMO should pay for urgent care. Try to call your HMO or doctor before you get the care. Caption: In an emergency, go to the emergency room at a hospital in your HMO's network if you safely can. Otherwise, go to the nearest emergency room. [Page 47] Questions & Answers What if it's an emergency and the nearest hospital is not in my HMO's network? Your Medicare HMO must cover emergency care at any hospital. But you should call your HMO as soon as you can. You may be moved to a hospital in your HMO's network when you are stable enough to be moved. What about ambulance services? Your Medicare HMO must cover ambulance services in an emergency. There may be a co-pay for the ambulance service. I got a bill for ambulance services. Do I have to pay it? Check your bill. If it is for a co-pay you should pay it. If it is a bill for the full amount of the services, submit it to your HMO's claims department. Your HMO must pay for ambulance services in an emergency. What if my HMO refuses to pay for my emergency care? You and your HMO may not agree on what problems need emergency care. If this happens, you can file an appeal. See page 56. Things You Can Do Be Prepared: Learn your plan's guidelines for emergency and urgent care. Ask about the co-pay for emergency room visits. They are usually higher than other co-pays. Know the locations of the hospitals and urgent care centers in your HMO. Always keep your HMO membership card with you. Don't use an ambulance if it's not an emergency. For example, if you need a ride home from the hospital, use a taxi or paratransit van. If You're Not Sure It's an Emergency: Call the Advice Nurse at your HMO. An advice nurse is trained to help you decide what care you need. Poison Action Line: If someone swallows or breathes something poisonous, call Poison Action Line right away. You will be told what to do. When You Travel: All California Medicare HMOs pay for emergency and urgent care worldwide. Where To Find Help Poison Action Line--Emergency help for victims of poisoning 1-800-876-4766 www.calpoison.org Police, Fire or Ambulance--Emergency services 911 [Page 48] Topic Heading: Hospital Care For some care, you need to stay in a hospital. This is called inpatient care. You may be having surgery or recovering from a severe illness or injury. In most cases, your doctor must refer you for hospital care. Each Medicare HMO has a different way to pay for hospital care. For example, you may pay an $800 deductible for each hospital stay, no matter how long you stay. Or you may have a co-pay for the first few days. Your Medicare HMO may have a hospital benefit period. A benefit period begins the day you go to a hospital. It ends when you have been out of the hospital for 60 days in a row. If you go in the hospital again after the 60 days, you may have to pay the co-pay or deductible again. Caption: Visitors are important. If a relative or friend helps watch out for you in the hospital, you'll probably get better care. [Page 49] Questions & Answers What if I'm being released but I don't feel well enough to go home? Hospital stays are shorter these days, and most people recover faster at home. But if you feel you're not ready to go home, talk to your doctor. If that doesn't work, ask for a written "Notice of Noncoverage." As soon as you get it, call Lumetra. You cannot be sent home until Lumetra reviews your case. When I was in the hospital, some of the staff were rude and ignored my requests for help. What can I do? Tell your doctor and the hospital. And write a letter to your HMO. See page 58. What if I need help when I come home from the hospital? Before you leave the hospital, ask to speak to a discharge planner. She can help you decide how much help you will need and where to find it. See the next section. Things You Can Do Choosing a Hospital: In most cases, you must use the hospitals in your plan's network. Ask your HMO for a list. Try to go to the hospital in your plan that treats your health problem most often. If you and your doctor think that you need to be treated at a hospital outside the HMO's network, ask your HMO. If your HMO says no, see page 56. To compare hospitals, visit www.healthscope.org. Before Your Hospital Stay: Arrange for people you trust to visit you or stay with you in the hospital. They can watch out for your care and help you make decisions. Ask your doctor who will be in charge of your care in the hospital. Ask how long you will be in the hospital and how long it can take to recover. Ask what help you will need when you go home. If you are having surgery, ask to meet with your surgeon ahead of time. Visit www.facs.org. Arrange for someone to take you home from the hospital. Or use a taxi or paratransit van. An ambulance usually costs a lot more. Where To Find Help American College of Surgeons--Information and brochures on common operations 1-800-621-4111 www.facs.org Lumetra (CALIFORNIA MEDICAL REVIEW)--help with hospital discharge problems 1-800-841-1602 www.lumetra.com HealthScope--Information on California HMOs and hospitals www.healthscope.org [Page 50] Topic Heading: Home Care You may need extra help at home after a hospital stay, or you may need on-going help with health care or personal care. Most seniors get help from a family member. Nurses, physical therapists and professional home care workers also give help. Home care workers can help with bathing, house cleaning, shopping, managing medicines and taking you to appointments. Medicare HMOs cover some home health care. You need a referral from your doctor and you need to use home care agencies that are part of the HMO's network. You must need skilled nursing care, physical therapy, occupational therapy or speech therapy. It must be too hard for you to leave home to get care. There are limits on the number of hours per day and days per week that you can get care. If you have a low income, In-Home Support Services (IHSS) may pay for a home care worker or family member to care for you at home. Call your county Social Services office. Caption: Mrs. Wright just got a wheelchair. A home health care worker is helping her learn safe ways to cook. [Page 51] Questions & Answers My daughter helps me do physical therapy exercises, but she will be gone for 2 weeks. What can I do? You can ask your doctor to ask your HMO to approve home visits from a physical therapist. Can I hire help on my own? Yes, but you might have to pay taxes or medical care for the worker in case of an accident or claim. For information, call Senior Information and Referral or California Registry. I care for my mother, who has Alzheimer's. Are there programs to help? Yes. For help call Family Caregiver Alliance. My home health care agency sent me a Notice of Noncoverage. What can I do? You can appeal this decision. Call Lumetra right away. Things You Can Do Look for a Caregiver You Feel Comfortable With: Ask your HMO for a list of home health care agencies in its network. Say if you prefer a man or woman. Say what language and culture you prefer. Ask about caregiving experience. Ask for references, and then call the references. More Services for Seniors: There are many free or low-cost services for seniors, such as meals, social activities and transportation. Call Senior Information and Referral. Where To Find Help California Registry--Get a referral for a home health care agency 1-800-777-7575 www.calregistry.com Family Caregiver Alliance--Learn about resources for caregivers 1-800-445-8106 www.caregiver.org Lumetra (CALIFORNIA MEDICAL REVIEW)--help with home health care coverage problems 1-800-841-1602 www.lumetra.com Senior Information and Referral--Find local support services 1-800-510-2020 www.aging.state.ca.us [Page 52] Topic Heading: Nursing Home Care Medicare HMOs cover some nursing home care. You must need skilled nursing, doctor or rehabilitation services every day you are in the nursing home. Some HMOs require a 3-day hospital stay before you can go to a nursing home. Your doctor must refer you to a nursing home that is part of the HMO's network. Each Medicare HMO has a different way to pay for nursing home care. Co-pays can be high and the amount of time you can stay is limited. Medicare HMOs do not cover long-term care. This is care people need because they can no longer feed themselves, bathe or care for their daily needs. If you have a low income, you can apply for Medi-Cal, which does pay for long-term care. Caption: Mr. Tang visits his wife every day in the nursing home. [Page 53] Questions & Answers If I need nursing care, do I have to go to a nursing home? No. You may be able to get the care you need at home. See page 50. My mother is in a nursing home. How can I make sure she gets good care? Try to have family or friends visit every day. If there's a problem, call your mother's doctor and HMO. And call California Advocates for Nursing Home Reform. They will refer you to local agencies that investigate long-term care facilities for seniors. Things You Can Do Choosing a Nursing Home: Ask your HMO what nursing homes are in its network. Visit several nursing homes. Consider the location, cleanliness, noise level, food and safety of each place. Long-Term Care: If you need long-term care and your money is running out, find out if you qualify for Medi-Cal. See page 12. Long-term care insurance covers some or all costs of nursing home stays, assisted living and home health care. For help making decisions about long-term care and long-term care insurance, call HICAP. For help choosing long-term care, call California Advocates for Nursing Home Reform or California Registry. Where To Find Help California Advocates for Nursing Home Reform--Find a nursing home and learn standards for care 1-800-474-1116 www.canhr.org California Registry--Get a referral for a long-term care facility 1-800-777-7575 www.calregistry.com HICAP (HEALTH INSURANCE COUNSELING & ADVOCACY) Help with Medicare 1-800-434-0222 www.calmedicare.org [Page 54] Topic Heading: 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's services, such as hospice care and pain management, can help at a very hard time. Having an Advance Health Care Directive also helps you get the care you want at the end of your life. See page 24. HMOs must cover hospice care services for people who are dying. In hospice, a nurse visits every day or two. She advises the family and helps with medications, pain management, bathing and other care. The nurse can also help the family deal with emotional stress and make the final arrangements when the patient dies. You can choose any hospice that takes Medicare--it doesn't have to be in your HMO's network. For more information, call California Registry. Caption: "My husband was in terrible pain. My son and I knew he had the right to have more pain medication. We really had to speak up--but it worked, and my husband's last weeks were peaceful." [Page 55] Questions & Answers 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 will be followed? First, have it signed and witnessed. Then make sure your doctor puts it in your medical file. Tell your wishes to your doctor and your family or close friends. Make sure they understand what you want and will follow your wishes. My father has been in a coma for a week. I have to decide about his care. Where can I find help? Ask if the hospital has a counselor or doctor you can talk to about your ethical or religious questions. Hospice can also help you. Things You Can Do 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 can no longer speak for yourself. For more information, see page 24. Call Family Caregiver Alliance or California Healthcare Association. Do Not Resuscitate (DNR): A DNR allows you to say you do not want your heart or breathing started again if it stops. A DNR is usually for people who are already very ill. If you are in the hospital, and you have a DNR, ask your doctor to put your DNR in the chart. Pain Management: Medicare covers most pain medications for people who are dying. Tell your doctor if you are in pain. 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 California Healthcare Association--Free Advance Health Care Directive forms 1-800-494-2001 www.calhealth.org California Registry--Information on hospice 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 [Page 56] Section Heading: IF YOU HAVE A PROBLEM Topic Heading: If You Can't Get The Care You Need 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. Or your HMO may refuse to pay for emergency care you got. If these things happen, talk to your doctor and your HMO's Member Services. If that doesn't help, you can file an appeal. If your situation is urgent, file an expedited appeal. You can file an appeal if your HMO: Refuses to give you treatment. Delays your treatment too long. Won't pay for emergency or urgent care you got outside your area. Won't pay for medical care that you paid for yourself because you couldn't get the care you needed within your HMO. Ends services you believe you still need. Call Lumetra in certain cases. Call Lumetra if your hospital, home health care agency, nursing home or rehabilitation service is ending sooner than you think you need. The government hires Lumetra to work with Medicare members on these problems. Caption: "The HMO wouldn't pay for enough physical therapy after my stroke. So I filed an appeal. Now I'm getting the care I need." [Page 57] Questions & Answers The appeal seems to take so long. I need care now. What should I do? Ask your doctor to help you file an expedited appeal. Your case must be reviewed in 3 days. My doctor says that I can't get a service I need. What should I do? First make sure it's a service covered by Medicare. Then, ask your doctor why you can't get the service. If you're still not satisfied, file an appeal with your HMO. I read about a new treatment that may help my heart problem. But my plan says it doesn't cover this treatment. What can I do? You can file an appeal with your HMO and ask for a review of the decision. You may be able to get the treatment if you show that it meets Medicare's coverage guidelines. Things You Can Do If You Need Care Now: It's important to have medical support to justify an appeal. If you need care now, you can ask for an expedited appeal. You or your doctor will have to show that it would be seriously harmful for you to have a delay in care. Ask a doctor to help you ask for an expedited appeal. The doctor does not have to be part of your HMO. If you qualify, the HMO has to respond in 3 days. If you don't get an expedited appeal, the process will take longer. Call HICAP for information and help filing the appeal. For more information on appeals, visit www.calmedicare.org. If Your HMO Won't Pay a Bill for Services You Got: After you submit your bill for payment, your HMO has 60 days to review it. If your HMO says it will not cover your bill, you have 60 days to file an appeal. The HMO has 60 days to respond to your appeal. If it still says no, there are more steps you can take. Call HICAP. Where To Find Help HICAP (HEALTH INSURANCE COUNSELING & ADVOCACY)--help with Medicare 1-800-434-0222 www.calmedicare.org Lumetra (CALIFORNIA MEDICAL REVIEW)--call for help with certain kinds of appeals 1-800-841-1602 www.lumetra.com [Page 58] Topic Heading: If You Have a customer Service Problem It can be hard to know what to do if you have a customer service problem. Start by talking to your doctor and your HMO's Member Services. If your problem still isn't solved, you can file a grievance. A grievance is simply a written complaint to your HMO. You can file a grievance if: You are unhappy about the way you are treated, the equipment or the facility you use, how long you have to wait for appointments or other customer service concerns. You have a problem with services in a special benefits package you bought, such as dental care. If you want to file a grievance, call Member Services. Ask them to send you a grievance form. Fill out the form and mail it back. Your HMO must take action within 30 days after it gets your form. If your HMO still won't help or doesn't reply within the time limit, you can call Lumetra. Caption: "Each time I visited my doctor, I had to wait 1 to 2 hours, even though I had an appointment. I complained to the HMO and now my service is better." [Page 59] Questions & Answers What if I get poor customer service? 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 grievance. I'm having trouble getting a doctor or interpreter who speaks my language. What can I do? First call your HMO's Member Services. If that does not help, you can file a grievance. Things You Can do For Help and Information: Call your HMO's Member Services. You may be able to solve your problem with a phone call. For more information visit www.calmedicare.org. Speak Up for Yourself--These tips can help you deal with appeals and grievances: 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 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. If you are told you can't have the care you want, ask for the reason in writing. Remember, you can change your doctor or HMO if you want. Or you can change to Original Medicare. Where To Find Help HICAP (HEALTH INSURANCE COUNSELING & ADVOCACY)--help with Medicare 1-800-434-0222 www.calmedicare.org Lumetra (CALIFORNIA MEDICAL REVIEW)--call to report customer service problems 1-800-841-1602 www.lumetra.com Member Services--To find your HMO's phone number, see page 62. [Page 60] Topic Heading: Office Of The Patient Advocate Trying to choose and use a Medicare HMO can be difficult. There are many rules and it's hard to know what your rights are. The Office of the Patient Advocate is here to help guide you, so that you can get the care you need. Choose an HMO That's Right for You: Use the "Quality of Care Report Card" to learn more about HMOs and Medical Groups. Learn how well HMOs serve people with chronic conditions like diabetes and heart disease. Learn about language assistance services. To order the latest Report Card, call the Office of the Patient Advocate. Caption: Learn about your HMO before you get sick. Then you'll know how to get help when you really need it. [Page 61] Questions & Answers What is the Office of the Patient Advocate? It is a state agency set up to inform HMO members about their rights. I don't understand all the things I get in the mail from my HMO. What should I do? 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. If you have retirement benefits, ask the personnel office at your former job to explain your HMO benefits. How can I find out about the Medical Groups in my HMO's network? The "Quality of Care Report Card" rates medical groups. It tells how patients rate each group for overall care, specialist care and communicating with patients. To order a copy, call the Office of the Patient Advocate. Or visit www.opa.ca.gov. Things You Can Do The Office of the Patient Advocate 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. Order Free Materials on HMOs: Call Office of the Patient Advocate to order: "California's HMO Guide" and "California's HMO Guide for Seniors", in English or Spanish. "The Quality of Care Report Card" in English, Spanish or 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 a calendar of events at www.opa.ca.gov. Where To Find Help Member Services--To find your HMO's phone number, see page 62. Office of the Patient Advocate--Information on California HMOs 1-866-HMO-8900 www.opa.ca.gov [Page 62-63] Section Heading: 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. If your HMO does not have a TTY, you can use the Deaf Relay service. Call 711. 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. Get help with access to care for people with disabilities. Get a copy of the Evidence of Coverage or Summary of Benefits. Ask about health care outside your HMO's service area. Tell your HMO if your address or phone number changes. Get help finding an interpreter. See page 28. Ask questions about billing. Get a copy of the HMO formulary. File an appeal or grievance. Get a new copy of your membership card. Aetna U.S. Healthcare, Golden Medicare Plan 1-800-282-5366 TTY: 1-800-628-3323 www.aetna.com Blue Cross Senior Secure 1-888-230-7338 TTY: 1-877-247-1657 www.bluecrossca.com Blue Shield 65 Plus 1-800-776-4466 TTY: 1-800-794-1099 www.mylifepath.com CareMore California Medicare Advantage 1-888-494-8280 TTY: 1-800-577-5586 www.californiamedicare.com Chinese Community Health Plan Senior, Program A/B Plan 1-415-397-3190 TTY: 1-877-681-8888 www.cchphmo.com Contra Costa Senior Health Plan 1-877-661-6230 www.cchealth.org Health Net Seniority Plus 1-800-275-4737 TTY: 1-800-929-9955 www.healthnet.com Inter Valley Health Plan: Service to Seniors 1-800-251-8191 TTY: 1-800-505-7150 www.ivhp.com Kaiser Permanente Senior Advantage 1-800-464-4000 TTY: 1-800-777-1370 www.kaiserpermanente.org On Lok SeniorHealth 1-888-996-6565 TTY: 1-415-292-8898 www.onlok.org PacifiCare Secure Horizons 1-800-228-2144 TTY: 1-800-685-9355 www.securehorizons.com SCAN Health Plan 1-800-559-3500 www.scanhealthplan.com UHP Healthcare for Seniors 1-800-544-0088 TTY: 1-888-702-3323 www.uhphealthcare.com Universal Care Health Advantage 1-800-635-6668 TTY: 1-866-321-5955 www.universalcare.com Western Health Advantage: WHA Care Plus 1-888-563-2250 TTY: 1-888-877-5378 www.westernhealth.com [Page 64-66] Section Heading: 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 711. If you have a speech disability, you can use 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. If Spanish Spoken is indicated, it means there is usually someone who speaks Spanish. In the table below (Sp) means Spanish Spoken. 1-800-MEDICARE--Information on Medicare benefits and drug discount cards (Sp) 1-800-633-4227 TTY: 1-877-486-2048 www.medicare.gov Agency for Healthcare Research and Quality--Free information on health care for seniors (Sp) 1-800-358-9295 TTY: 1-888-586-6340 www.ahrq.gov American Board of Medical Specialties--Information about specialists' training 1-866-275-2267 www.abms.org American Chronic Pain Association--Support and information for people with chronic pain (Not toll-free) 1-916-632-0922 www.theacpa.org American College of Surgeons--Information on common operations and choosing a surgeon (Sp) 1-800-621-4111 www.facs.org AT Network--Information on equipment for seniors/people with disabilities (Sp) 1-800-390-2699 TTY: 1-800-900-0706 www.atnet.org California Advocates for Nursing Home Reform--Find a nursing home and get help if you have a problem 1-800-474-1116 www.canhr.org California Foundation for Independent Living Centers--Resources for people with disabilities www.cfilc.org California Healthcare Association--Free Advance Health Care Directive forms 1-800-494-2001 www.calhealth.org California Internet Formulary--HMO drug formularies 1-866-785-6285 www.ca.mcodrugs.com California Office of Patients' Rights--Advocacy for patients hospitalized with mental illness (Sp) (Not toll-free) 1-916-575-1610 California Registry--Information on hospice and long-term care 1-800-777-7575 www.calregistry.com Clinical Trials--Information on clinical trials www.clinicaltrials.gov Deaf Counseling, Advocacy and Referral Agency--Resources for people who are Deaf or Hard of Hearing 1-877-322-7299 TTY: 1-877-322-7288 www.dcara.org Disability Rights Advocates--Information on health care rights for people with disabilities www.dralegal.org Family Caregiver Alliance--Information and resources for family caregivers (Sp) 1-800-445-8106 www.caregiver.org Health Consumer--Health care information in different languages www.healthconsumer.org Healthfinder--Easy-to-use health website www.healthfinder.gov Health Rights Hotline--Hotline for Sacramento, Placer, Yolo and El Dorado counties (Sp) 1-888-354-4474 www.hrh.org HealthScope--Information on California HMOs and hospitals www.healthscope.org HICAP (Health Insurance Counseling & Advocacy)--Free information and help with Medicare (Sp) 1-800-434-0222 www.calmedicare.org HMO Help Center--Information about Cal-COBRA (Sp) 1-888-466-2219 TTY: 1-877-688-9891 www.hmohelp.ca.gov Lab Tests Online--A guide to understanding lab test results www.labtestsonline.org Lumetra (California Medical Review)--Help with hospital, nursing home and rehab discharge problems (Sp) 1-800-841-1602 TTY: 1-800-881-5980 www.lumetra.com National Guideline Clearinghouse--Care guidelines for many health conditions www.guideline.gov National Immunization Hotline--Recommended shots for people of all ages (Sp) 1-800-232-2522 TTY: 1-800-243-7889 www.cdc.gov/nip National Institute on Aging--Information for seniors (Sp) 1-800-222-2225 TTY: 1-800-222-4225 www.nia.nih.gov National Institutes for Health--Information on many health conditions www.nih.gov National Mental Health Association--Information, advocacy and referrals (Sp) 1-800-969-6642 TTY: 1-800-433-5959 www.nmha.org Office of the Patient Advocate--Report cards on HMOs and Medical Groups (Sp) 1-866-HMO-8900 TTY: 1-877-688-9891 www.opa.ca.gov Poison Action Line--Emergency help for victims of poisoning (Sp) 1-800-876-4766 TTY: 1-800-972-3323 www.calpoison.org Protection & Advocacy--Legal help for people with disabilities (Sp) 1-800-776-5746 TTY: 1-800-649-0154 www.pai-ca.org Senior Information and Referral--Local services for seniors 1-800-510-2020 www.aging.state.ca.us Social Security--Information on getting Social Security and Medicare (Sp) 1-800-772-1213 TTY: 1-800-325-0778 www.ssa.gov State Insurance Hotline--Find information on long-term care insurance (Sp) 1-800-927-4357 TTY: 1-800-482-4833 www.insurance.ca.gov U.S. Department of Labor (Person and Welfare Benefits)--Information about COBRA (Sp) 1-866-444-3272 TTY: 1-800-326-2996 www.dol.gov/ebsa [Page 67-68] Section Heading: Index Page numbers in parentheses have the most information on the topic. Advance Health Care Directives (24-25), 54, 55 Advice Nurses 47 alcohol treatment 30, 45 ambulance services 47 appeals 35, (56-57), 59, 63 appointments 20-21, 27, 29, 32-33 benefits package 6, 10, 11, (30-31) bills 11, 47, 48, 57, 63 blindness, see also: vision care 26 cancer screening and treatment 33, 34, 45 caregivers, family 24, 25, 50, 51, 55 checkups/physicals 6, 32-33 chronic conditions 7, (42-43), 60 clinical trials 23 COBRA/Cal-COBRA 15 complaints, see also: grievances 17 consent forms 23 co-pays/co-payments 10, 11, 38, 48, 52 counseling 44, 45 customer service problems (58-59) Deaf Relay service 62 deaf services, see also: hearing care 26, 27, 29, 62 death/dying (54-55) deductibles 10, 48 dental care 31, 58 depression 45 diabetes 41, 43, 60 dialysis 8 disabilities 4, 21, (26-27), 63 disease management programs 43 disenrolling 9 doctors (18-21), 22-23, 43 Do Not Resuscitate (DNR) 55 drug abuse 45 drugs, over-the-counter 20, 37 drugs, prescription 20, (36-39), 44, 45 Durable Power of Attorney for Assets Management 25 Durable Power of Attorney for Health Care 25 emergency room visits 31, (46-47), 56 equipment, medical 26, 27, (40-41) Evidence of Coverage 30, 63 eyeglasses and contact lenses, see also: vision care 41 family caregivers 24, 25, 50, 51, 55 formularies 36, 37, 63 grievances, see also: appeals 17, 49, (58-59), 63 hearing care 31, 33 heart disease 42-43 HICAP 4, 5 HIPAA 15 HMOs, see also: Medicare HMOs (4) home health care 27, (50-51), 56 hospice care 54, 55 hospital benefit periods 48 hospitals 44, 47, (48-49), 56 immunizations/vaccinations 33 independent living 27 In-Home Support Services 27, 50 interpreters (28-29), 59, 60, 62 lab tests 23, 33, 34 language services (28-29), 59, 60, 62 Living Wills, see: Advance Health Care Directives 1 long-term care 52, 53 low-cost health care (12-13), 50, 52, 53 Lumetra 49, 51, 56, 58 Medi-Cal (12-13), 40 Medical Groups 19, 35 medical records 17 Medicare, Original or Traditional (4), 5, 8, 9, 13 Medicare Advantage Plan/Medicare Plus Choice Plan 4 Medicare Drug Discount Cards 39 Medicare HMOs (4-15) Medicare Part A 4, 5, 6, 15 Medicare Part B 4, 5, 6, 10, 12, 15 Medicare Personal Plan Finder 7 Medicare Savings Programs 12, 13 Medigap 8, 9, 26 Member Services (62-63) membership card 31, 47, 63 mental health services (44-45) networks 11, 14, 19, 31, 35, 49, 53, 61 nursing care 50 nursing home care (52-53), 56 occupational therapy 50, 56 ostomy supplies 40, 41 patient advocacy 60-61 physical therapy 50, 56 Poisoning 47 pre-existing conditions 8, 15 premiums 10, 15 preventive (routine) care (32-33) primary care providers, see also: doctors 1 4, (18-21), 22-23, 43 prostheses 41 psychiatrists/psychologists 44, 45 Quality of Care Report Card 60, 61 quality of care 6, 60, 61 ramps and railings 40 referrals, see also specialists 22, (34-35), 45, 50, 52 retirement health benefits (14-15) Revocable Living Trust 25 routine care (32-33) second opinions 22 service areas 7, 9, 11, 14, 33, 63 side effects 23, 37, 45 sign language services 26, 27, 29 Social Security 4, 5, 15 specialists 11, 19, 33, (34-35) speech therapy 50 Speech-to-Speech Relay service 62 substance abuse 45 Summary of Benefits 17, 30, 63 support groups 45 surgery 22, 48, 49 tests/lab tests 23, 33, 34 transportation 21, 27, 47, 49 travel 31, 37, 47 treatment decisions 20, (22-23), 37, 42, 43, 49, 56 treatments, experimental 23, 27, 42, 57 urgent care (46-47), 56 vans or shuttle services 27, 47, 49 vision care 31, 33 walkers and wheelchairs 40, 41 yearly maximum payments 11 End of Document