| SUMMARY OF YOUR HEALTH CARE RIGHTS: California Regulators Adopt Rules On Timely Access to Non-Emergency Care SACRAMENTO, Calif.—Seven years after the enactment of legislation (A.B. 2179) directing it to do so, the California Department of Managed Health Care (DMHC) announced Jan. 20 it adopted regulations aimed at ensuring plan enrollees have timely access to health care services. According to DMHC Director Cindy Ehnes, the new rules make California the first state to shorten the time a patient has to wait to see a doctor by requiring that managed care plans ensure member appointments with medical providers be scheduled within certain time frames. “California patients are literally sick of having to wait weeks to see a doctor,” Ehnes said in a Jan. 20 statement. DMHC said it receives complaints from managed care plan members having difficulty getting appointments with doctors, noting a 2009 study found that new patients in preferred provider organizations and health maintenance organizations wait an average of 59 days to see a family practice physician in Los Angeles. The adoption of the rules follows multiple rounds of public comment from managed care plans, providers, and consumers through most of last year. The state's Office of Administrative Law (OAL), which oversees regulatory agency rulemaking, rejected a previous version of the regulations issued Jan. 9, 2009, on the grounds that it provided too little time for public comment. In March 2008, OAL also disapproved an earlier set of proposed rules after OAL concluded that by allowing plans to develop their own standards for patient wait times, they failed to comply with California administrative law requiring regulations to set uniform standard governing all plans. Time Frames for Appointment Scheduling The regulations require managed care plans meet the following appointment scheduling time frames: • urgent care appointments for services that do not require prior authorization within 48 hours of the request for appointment; • urgent care appointments for services that require prior authorization within 96 hours of the request for appointment; • nonurgent appointments for primary care within 10 business days of the request for appointment; • nonurgent appointments with specialist physicians within 15 business days of the request for appointment; • nonurgent appointments with a nonphysician mental health care provider within 10 business days of the request for appointment; and • nonurgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition within 15 business days of the request for appointment. However, the regulations permit these time frames to be extended if a provider has determined a longer waiting time will not have a detrimental impact on the health of the patient. The rules also contain an exception for nonurgent services including preventive care and periodic follow-up care. Plans must also provide 24/7 triage or screening services by telephone with wait times not exceeding 30 minutes. Telephone triage or screening services can be provided through plan-operated telephonic triage or medical advice services, the plan's contracted primary care and mental health care provider network, or other means. Must Ensure Sufficient Numbers of Providers Under the regulations, managed care plans are required to adopt written quality assurance standards ensuring they have enough contracted providers to comply with the rules. Plans must draw up compliance monitoring policies and procedures for DMHC review and approval that accurately measure the accessibility and availability of contracted providers and document network capacity. Plans must also survey providers and enrollees annually to assess compliance with timely access to care standards. Managed care plans that use a preferred provider organization network may demonstrate compliance with network provider availability requirements by monitoring at least annually the number of PPO primary care and specialty physicians under contract with the plan in each county of the plan's service area, enrollee grievances and appeals regarding timely access, and the rates of compliance with the timely access to care standards. The rules also require managed care plans to implement “prompt investigation and corrective action” when their compliance monitoring determines their provider network is not sufficient to ensure timely member access to care. ‘Groundbreaking Consumer Protections.’ Health Access California, a consumer advocacy coalition that sponsored A.B. 2179 in 2002, noted that while the concept of timely access to health care was one of the “cornerstones” of the original Knox-Keene Act of 1975 that established and regulated managed care plans in California, it remained largely unrealized and unenforced. “These groundbreaking consumer protections will help ensure that HMO patients get the care they need, when they need it,” Anthony Wright, executive director of Health Access California, said in a Jan. 20 statement. “Care delayed is often care denied, leading to worse health outcomes or unnecessary visits to the emergency room,” Wright said. “These new first-in-the-nation patient rights will provide consumers with clear expectations about how quickly they should get in to see a doctor or specialist.” Plans See Rules as Compromise Patrick Johnston, president of the California Association of Health Plans, said in a Jan. 20 statement that the regulations represent a compromise between health plans and consumer concerns. “Health plans felt it was important care strike a balance between ensuring patients don't face unnecessary delays for care and leaving room for doctors to use their professional judgment in prioritizing patient care,” Johnston stated, noting the rules grant flexibility to prioritize the range of requests for appointments from urgent to preventative care. “We look forward to working with the state on implementation of these new rules to ensure we streamline reporting requirements and do not create unnecessary red tape. At the end of the day, we don't want to get in the way of doctors doing their jobs.” By Frederick L. Pilot The comments and final text of DMHC's Timely Access to Non-Emergency Health Care Services regulations are available at http://wpso.dmhc. ca.gov/regulations/regs/?key=20. • You have the right to receive uninterrupted care from your doctor and HMO and to be referred to other health care providers when necessary. • You have the right to receive a second opinion when you or your doctor request one. • You have the right to receive an authorization from your health plan for referral to a specialist within three days. • You have the right to have your doctor freely discuss your medical treatment options and care with you, without interference or restrictions by your health plan. SUMMARY OF YOUR RIGHTS WHEN GETTING NEW INSURANCE: • If you are joining a group health plan, you have the right to not be denied coverage on the basis of your health status, medical condition or history, genetic information, disability or insurability. • You have the right to receive coverage for preexisting conditions in most cases within 12 months (or, in some instances, six months) of enrolling in a group health care plan. • If you are enrolling in an individual plan, you have the right not to be denied coverage if you have had 18 months of continuous coverage previously and meet certain other requirements. • You have the right to be credited for time enrolled in a previous plan against any preexisting condition waiting period. In 1996, Congress passed a law known as the Health Insurance Portability and Accountability Act or HIPAA (also known as the Kassebaum-Kennedy Act), which went into effect on July 1, 1997. HIPAA was designed to allow employees to move freely from one job to another without the risk of becoming uninsured for their most serious health problems. HIPAA also has protections for individuals who move from a group plan to an individual health plan. In California, there are additional protections for members of group health plans that go beyond the requirements of HIPAA. Continuity of Care is receiving health care services without inappropriate disruption even if your provider or plan changes. WHAT IF I WANT TO SEE A SPECIALIST WHO IS NOT ON MY PANEL? If there is no doctor within your plan’s network that meets the qualified health care professional standard, then the plan must authorize a second opinion from someone with the appropriate qualifications from outside of the plan’s network, taking into account your ability to travel to the provider. WHAT IF NONE OF THE PROVIDERS ON MY INSURANCE PANEL ARE ACCEPTING PATIENTS? You may request to be reimbursed or have a "single case agreement" set up to see a specialist outside the panel if you find that none of the providers on your insurance panel are taking patients or returning phone calls. Please see our free letters for assistance. HOW LONG CAN MY PLAN TAKE TO AUTHORIZE MY REFERRAL TO A SPECIALIST? When you require a referral to a specialist or specialty care center, your health plan must decide whether or not to authorize the referral within three business days of the date when you or your primary care physician made the request and submitted all necessary information and medical records. Once your health plan decides to authorize the referral, the company must make the referral within four business days of when the proposed treatment plan is submitted to the plan medical director. Under California law, your health plan must reimburse any doctor who performs any emergency services that you receive to stabilize you. The only time that a plan is not required to pay for your emergency health care services is when it determines that you did not require emergency services, and you should have known that an emergency did not exist. HELP FOR UNPAID CLAIMS: 1. Don't be fooled or diverted by attempts to make you angry at the party that has not been paid for services they provided. Ask questions, and control your temper -- the person on the phone is not the problem, but may possibly be your avenue to a solution. Some delays really are administrative errors that can be easily corrected. 2. Document who you are speaking to (title), when (date and time), where (location), and what department. Don't forget to get the phone number and extension of the person you are speaking to, and tell them you will call back to follow up in one week. 3. If your claim is not resolved in one week then move up the chain: ask to speak to the supervisor, the Benefits Supervisor, etc. Keep a record of every person you speak to (first and last name -- "Suzie" is not sufficient), and what you were told. 4. Follow up by sending a letter and then a formal written complaint to the Company's Claim Department, Complaint Department, and CEO. They have thirty days to resolve your dispute. If it is not resolved with in thirty days you may file a complaint with the Department of Managed Health Care (see link below). 5. Copy our free form letters to send on the HMOhelpletters tab. 6. If you are having difficulty, ask the claims representative to do a three way call with your doctors office for assistance. WHAT IF THE DOCTOR YOU WANT TO SEE IS NOT ON YOUR PANEL? • If you are denied care, ask for it in writing. You will need a record of the denial if you want to dispute it. Memorialize in written correspondence all conversations if it becomes apparent that you are not receiving cooperation. Leaving a "paper trail" often helps to get results. • Find out the time lines. Most are included on our web site, but you may find additional assistance from the National Committee for Quality Assurance [www.ncqa.org], American Accreditation HealthCare Commission/URAC [www.urac.org] and the Joint Commission on Accreditation of Health Care Organizations [www.jcaho.org]. • Appeal a treatment denial to regulators. • Find allies in the medical profession. When medical experts advocate care, HMOs find it harder to deny treatment. Insist on a second or third opinion-from a qualified professional outside the HMO network, if necessary. If your HMO won't pay for a second opinion, pay out of your own pocket. It could save your life. Private Insurance: The majority of working Americans are covered under employer-provided health insurance plans. One type of plan is a standard indemnity policy: people are free to visit health care providers of their choice and pay out of pocket for their treatment. The insurance plan reimburses members for some portion of the cost. The other common plan is a managed care plan. Medically necessary care is provided in the most cost- effective - or least expensive - method available. Plan members must visit health care providers chosen by the managed care plan. Sometimes a copayment is charged to the patient, but generally all care received from providers within the plan is covered. Recently, managed care companies have begun to provide services in many States for low-income Medicare and Medicaid beneficiaries. Both types of health coverage may offer some coverage for mental health treatment. However, this treatment often is not paid for at the same rate as other health care costs, or there may be limits on visits. A few States have enacted "parity" laws that require insurers to pay for mental health and other health care costs at the same rate. For the Uninsured: If you are not insured, or if your income is limited, you might try other strategies to pay for mental health care. We offer sliding -scale fees based on you and your spouses income - the provider will reduce his or her fees. Other providers, if they are aware of your financial limitations, may be willing to negotiate a payment plan that you can afford or to lower their rates according to what your insurance plan pays. Community-based resources - Many communities have community mental health centers (CMHCs). These centers offer a range of mental health treatment and counseling services, usually at a reduced rate for low-income people. CMHCs generally require that you have a private insurance plan or be a recipient of public assistance. Your church or synagogue can put you in touch with a pastoral counseling program. Certified pastoral counselors, who are ministers in a recognized religious body and have advanced degrees in pastoral counseling, as well as professional counseling experience. Pastoral counseling is often provided as a sliding-scale fee. Self-help groups - Another option is to join a self-help or support group. Such groups give people a chance to learn more, talk about and work on their common problems-such as alcoholism, substance abuse, depression, family issues, and relationships. Self-help groups are generally free and can be found in virtually every community in America. They have proven to be very effective. Public assistance - People with severe mental illness may be eligible for several forms of public assistance, both to meet basic costs of living and to pay for health care. Such programs include Social Security, Medicare, Medicaid, and disability benefits. Medicare is America's major Federal health insurance program for some people who are 65 or older and for some with disabilities who are under 65. It provides basic protection for the cost of health care. Two programs can help people who have low incomes receive benefits. These are the Qualified Medicare Beneficiary (QMB) and the Specified Low-Income Medicare Beneficiary (SLMB) programs. Medicaid and Medical pays for some health care costs for America's poorest and most vulnerable people. More information about Medicaid and who is eligible for it is available at local welfare and medical assistance offices. Although there are certain Federal requirements, each State has its own rules and regulations for Medicaid. Helpful Links: Making A Killing: HMO and the Threat to Your Health http://www.consumerwatchdog.org/healthcare/ http://www.calpatientguide.org http://www.mhac.org/ The following resources have been compiled to assist you in getting the care you need: Department of Managed Health Care California HMO Help Center 980 Ninth Street, Suite 500 Sacramento, CA 95814-2725 Phone: (888) HMO-2219 or (800) 400-0815 or TDD: (877) 688-9891 Fax: (916) 229-0465 http://www.dmhc.ca.gov Consumer Advocacy Groups. Patients can register complaints with the local chapters of the: Mental Health America (call 1-800-969-NMHA for local phone numbers) and the National Alliance for the Mentally Ill (call NAMI's Helpline at 1- 800-950-NAMI for local phone numbers of chapters and affiliates). Foundation for Taxpayer and Consumer Rights. 2000. HMO Patient Self-Defense Kit. California Consumer Health Care Council Department of Corporations 980 9th Street, Suite #500 Sacramento, CA 95814-3860 916-445-7205 Consumer Services Unit 800-400-0815 Related Articles/Resources Making A Killing: The HMO Threat To Your Health Dealing With Kaiser and Other HMO's Foundation for Taxpayer and Consumer Rights http://www.calpatientguide.org Need help with less expensive prescriptions? There are clinical trials and prescription programs that can help. http://www.rxexpresscanada.org/ |
Linder Psychiatric Group, Inc. Child, Adolescent, Adult, and Forensic Psychiatry, Psychology, and Psychotherapy 193 Blue Ravine Road, Suite 170, Folsom, CA. 95630 970 Reserve Drive, Suite 205, Roseville, CA. 95678 Phone (916) 608-0714 Fax: (916) 608-0717 Phone (916) 780 1070 Fax: (916) 780-1199 www.echildpsychiatry.com Email: admin@echildpsychiatry.com |
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