Choosing and Using a Health Plan (continued)

Using Care

7. How Can I Get the Most from My Plan?

You will get the best care if you:

Stay Informed

Take Charge

Keep Track

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8. How Do I Obtain Care?

Learning what you can expect from your health plan and how it works are key steps to getting the care you need. Ask these questions:

Find out how your plan provides care outside the service area and what you must do to get care. This is especially important if you travel often, are away from home for long periods, or have family members away at school.

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9. What if I Have to Go to the Hospital?

The time to find out what rules your plan has on hospital care is before you need it.

Planned Hospitalizations

Unless it is a medical emergency, your health plan or primary care doctor will probably have to give advance approval (preadmission certification) for you to go to the hospital. Otherwise, the cost of your hospital care may not be covered. Ask these questions:

Ask how your plan handles getting a second doctor's opinion on whether surgery or another treatment is needed. Are second opinions encouraged or required? Who pays?

Emergency or Urgent Care

If you have a true medical emergency, you should go to the nearest hospital as fast as possible. It is important for you to know what kind of medical problems are defined as emergencies and how to arrange for ambulance service, if needed. Most plans must be told within a certain time after emergency admission to a hospital. If the hospital is not part of the plan network, you may be transferred to a network hospital when your condition is stable. Ask these questions:

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10. What if I Am Not Satisified with My Care?

Getting the best care and services means understanding how your health plan works, what your rights are, and how to complain if you need to.You have the right to get copies of test results as well as medical information about yourself. If you are in a managed care plan, you can ask to change your primary care doctor if you are unhappy with the relationship. You may also be able to switch plans during open enrollment.

Most plans have an appeals process that both you and your doctor may use if you disagree with the plan's decisions. If your plan refuses to provide or pay for services, you can complain or file a grievance about any decision you feel is unfair—or you can appeal it.

You can contact the member services division of your plan for more information or to complain. Use your plan's complaint process fully before taking other action.

Be sure to keep written records of:

If the plan does not satisfy you, you may decide to bring the matter to the attention of your employee benefits manager, your State insurance commissioner, your State department of health, or the legal system. If you are a Medicare or Medicaid beneficiary, you have additional ways through those programs to file a grievance about the care received from a plan or provider. For information, contact your State's medical Peer Review Organization or State Medicaid Program.

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Sources of Additional Information

Many organizations have information that can help you understand your health care choices. Some helpful materials and contacts are listed.

General Information

"Checkup on Health Insurance Choices"
"Questions To Ask Your Doctor Before You Have Surgery"
AHCPR Publications Clearinghouse
P.O. Box 8547
Silver Spring, MD 20907
800-358-9295
E-mail: AHRQPubs@ahrq.hhs.gov

"The Consumers Guide to Health Insurance"
Health Insurance Association of America
555 13th St. N.W., 600 East
Washington, DC 20004-1109
(202) 824-1600

"Guide to Health Insurance for People with Medicare"
"Your Medicare Handbook"
"Managed Care Plans"
Health Care Financing Administration
7500 Security Blvd.
Baltimore, MD 21244-1850
800-638-6833

"Putting Patients First"
National Health Council
1730 M St., NW, Suite 500
Washington, DC 20036-4505
(202) 785-3910

"Managed Care: An AARP Guide"
American Association of Retired Persons
611 E St., N.W.
Washington, DC 20049
(202) 434-2277

"Choosing Quality: Finding the Health Plan That's Right for You"
National Committee for Quality Assurance
2000 L St., N.W., Suite 500
Washington, DC 20036
800-839-6487

"Consumers' Guide to Health Plans"
Consumers' Checkbook
Center for the Study of Services
733 15th St., N.W., Suite 820
Washington, DC 20005
(202) 347-7283

Accreditation and Quality

Accreditation Association for Ambulatory Health Care
9933 Lawler Ave.
Skokie, IL 60077-3708
(847) 676-9610

Accredits outpatient health care settings such as ambulatory surgery centers, radiation oncology centers, and student health centers. Call for a list of accredited organizations.

Community Health Accreditation Program
350 Hudson St.
New York, NY 10014
800-669-1656, ext. 242

Accredits community, home health, and hospice programs; public health departments; and nursing centers. Call for a list of accredited organizations.

Consumer Coalition for Quality Health Care
1275 K Street, N.W.
Suite 602
Washington, DC 20005
(202) 789-3606

A national, nonprofit organization of consumer groups advocating for consumer protections and quality assurance programs and policies. Call with general questions about quality issues or for consumer materials on managed care and activities at the State level.

Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Blvd.
Oakbrook Terrace, IL 60181
(630) 792-5000

Evaluates and accredits nearly 20,000 health care organizations and programs including almost 12,000 hospitals and home care organizations, and more than 7,000 other health care organizations that provide long term care, behavioral health care, laboratory and ambulatory care services. The Joint Commission also accredits health plans, integrated delivery networks, and other managed care entities. Visit Quality Check on the Joint Commission's Web site (http://www.jcaho.org) for information on individual accredited organizations or for general information about assessing the quality of health care organizations.

National Committee for Quality Assurance
2000 L St. N.W., Suite 500
Washington, DC 20036
800-839-6487
Web Site: http://www.ncqa.org

Accredits HMOs and other managed care organizations. Call for the NCQA Accreditation Status List, Accreditation Summary Report, publications list, or for general information about quality.

Utilization Review Accreditation Commission
1130 Connecticut Ave. N.W., Suite 450
Washington, DC 20036
(202) 296-0120

Accredits PPOs and other managed care networks. Call for a list of accredited organizations.

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This consumer's guide was developed by the Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Rockville, MD, in cooperation with the Health Insurance Association of America, Washington, DC.

AHCPR Publication No. 97-0011
Current as of March 1997