 | ||||
 |
Your Rights As a Hospital Patient Questions to Prepare for Surgery If You Think You're Leaving the Hospital Too Soon Getting to Know Your MCO (managed care organization) Preventing Prescription Errors
|
|
GETTING TO KNOW YOUR MCO Finding the Right HMO for You | If Something Goes Wrong | Internet Medicine
In 1996, NYPIRG worked with a coalition of health advocates and professionals to successfully to get the Managed Care Patients’ Bill of Rights passed in the New York State Legislature. The Patients’ Bill of Rights brings extensive protection to consumers enrolled in both managed care and traditional insurance plans. Under this legislation, managed care and insurance companies are required to release to release cast amounts of information to enrollees and must release even more upon the written of an enrollee. In 1998, NYPIRG helped push passage of legislation in expanding the protections in the Patients Bill of Rights. Under the legislation, as of July 1, 1999, health care consumers have an opportunity to appeal disputes with their MCO to a panel of independent medical experts. This panel will be independent of the MCO and will be able to review certain MCO denials of medical services and coverage. When you are shopping for an MCO, it’s often hard to get useful information about the plans. You can now get some information on the quality of health care offered by MCOs. The State Health Department now issues an annual "Quality Assurance Reporting Requirements (QARR) report." The report examines how well plans are performing by disclosing items such as lead screening rates, HIV testing of pregnant women the board certification levels of physicians in the plans and the turnover rate of consumers. You can get the QARR report by contacting the Department at:
Bureau of Quality Management and Outcomes Research
Definitions Subscriber (enrollee): The person who contracts with a managed care organization for health care services.
MANAGED CARE ORGANIZATIONS Staff or group model HMO: The most restrictive of MCOs, staff or group models require that enrollees choose a primary-care physician to act as a gatekeeper. Staff or group model HMOs pay physicians a salary or a set amount per patient (capitation). Group or staff models often have their own medical centers with specialists and primary-care physicians, so all care can be received in a central location. Independent practice association: The "IPA" is less restrictive than the group or staff model HMOs. In an IPA, individual; physicians are under contract to a separate group (the IPA), that in turn contacts with an HMO. Enrollees receive a list of participating primary-care physicians from which to choose, and visits take place in the individual physician's office. Referrals are granted for care to specialists within the IPA. By far, the largest number of MCO members are in IPAs. With IPAs, physicians often belong to more than one MCO, and may also continue to see fee-for-service patients in their offices. Network model HMO: A network model HMO provides medical services within a "network" that can include its own health centers as well as outside participating physicians, medical groups, and multi-specialty medical centers. Point-of-Service HMO: Also called "self-referral options", point-of-service plans permit members greater choice and flexibility than standard MCOs. You may use doctors within the network at little or no cost, or go "out of plan" to non-HMO providers, paying additional costs chase their health insurance directly, New York State law requires managed care plans to offer you a POS option. Preferred Provider Organization (PPO): A PPO is a network of doctors and hospitals that have agreed or give the sponsoring organization (ex. employer or insurance company) discounts on their usual rate. Enrollees pay more out of pocket if they leave the network. Some PPOs use gatekeepers and some allow enrollees stays within the network. PPOs offer the most freedom of any managed-care organization, but they also have higher premiums and less coordination of care. Fee-for-service or indemnity plan: An indemnity plan is the traditional insurance pan, in which an insurance company agrees to pay for all or a share of the cost of services, and the plan pays the provider or reimburses you when you file a claim for what you’ve paid a provider. Indemnity plans are generally limited in scope, covering doctor’s visits and hospital stays which is an amount that you must pay our of your own pocket before the insurance company pays anything. Moreover, indemnity plans often require pre-authorization for certain surgeries. Indemnity plans will pay doctor fees based on a schedule—so in some cases they may not pat as much as the doctor charges, and you have to make up the difference. Another aspect of indemnity plans is coinsurance, which is a portion of each service charge for each visit. Coinsurance is also paid out of pocket. Gatekeeper: Your primary-care provider, who decides which tests you will have, which specialists you should see, and whether or not you should be admitted to a hospital. Gatekeepers are used to coordinate a patient’s care, avoid providing unnecessary care, and ensure that appropriate care is provided at a low level cost. Managed care organizations rely on primary care providers to save money. Primary care physicians are typically family practitioners, internists, or pediatricians. Specialist: A physician who offers services beyond what your primary-care physician can provide and is accessible through referrals made by your gatekeeper. Quality Assurance: The tern applied to the monitoring of overall plan performance and individual provider performance through government oversight, patient satisfaction surveys, data from grievance procedures and independent reviews. Utilization review: The procedure through which managed care plans determine whether medical care is appropriate and necessary, through mechanisms such as: pre-admission certification; concurrent review (to make sure stays are no longer than they should be, and tests and procedures are absolutely necessary); care management (MCOs monitor long-term illnesses and conditions to ensure cost-effective treatment); second surgical opinions (to ensure the medical necessity of surgical procedures).
Finding an MCO to suit your needs Often times plans that place more limits on seeing providers are more predictable and usually have lower fees. When deciding whether to use a managed care organization or a fee for service program, you also need to take into account a few additional factors. First, you should be aware of how many physicians you have to choose from and how each provider makes this information available to you. Also, you need to know how you will receive specialty care with each program. Finally, you should compare the payment plans, focusing on when and how you pay as well as how much. You have the right to know how decisions are made by your MCO regarding their policies on care, including the MCOs procedure for deciding whether or not to use experimental or investigational drugs, devices, or treatments. Upon your request, the MCO must also tell you which experimental drugs, devices, and procedures it uses. You are also entitled to hear about all conditions and possible courses of treatment in that may be available to benefit you, including optional therapies, consultations, and tests. The so-called "gag-rule," which prohibited providers from discussing every possible option in order in order to cut MCO costs, was made illegal in 1996.
How much will the plan cost you?
What are the implications of going outside the plan for you medical needs?
What happens if you have an emergency?
How do MCOs chose their doctors?
How are the doctors paid?
Which hospitals are part of the plan?
How easy is it to get access to specialty care if you have a serious illness or condition? Managed care organizations typically mandate that patients have a "gatekeeper," to a primary-care physician who takes the role of you personal health care coordinator. Gatekeepers make referrals to specialists if they themselves cannot provide the treatment that you require. If you have a serious condition that entails seeing a specialist on a regular bases and your plan agrees, your specialist can act as your gatekeeper and primary care provider. Specialists acting as gatekeepers are often cardiologists, oncologists, or obstetrician/gynecologists. If your care necessitates both a primary-care physician and repeated visits to a specialist, your MCO must make a standing referral available to you, to eliminate the need for a new referral every time you visit your specialist. Standing referrals are only available for those with a serious condition or a second-trimester pregnancy.
What about Medicaid, Medicare, or ERISA managed care coverage? MEDICARE: One way to lower your out-of-pocket costs if you are on Medicare is to enroll with an MCO that contracts with Medicare. There are two types of contracts that MCOs hold with Medicare, and knowing which one your MCO has is important. In a risk contract, the MCO receives a fee from Medicare in exchange for covering medical care for Medicare recipients. The MCO preventative care benefits are generally more comprehensive than Medicare and Medigap policy benefits, and may include preventative services, vision and dental care, and prescription drugs. Since hospitalization and nursing home benefits may differ, read the fine print. Once a Medicare recipient enrollees in an MCO with a risk contract, the member is required to remain in the provider network. Only emergencies and urgently needed care are excepted from this policy of "locking in" enrollees. Medicare beneficiaries may disenroll from a risk contract at any time without giving a reason. Cost contracts offer greater flexibility for Medicare recipients. All care services within the MCO network are covered and services received outside the provider network are covered by Medicare. This out-of-network reimbursement is subject to the regular Medicare coverage and co-payment policies. Both risk and cost contracts require that you continue to pay the usual Part B Medicare premium. The Medicare MCO may require an additional premium, but Medicare coverage deductibles and coinsurance do not apply when contracting with an MCO.
To get the name of managed care organizations that contract with Medicare, call your local Social Security office, your local Area Agency on Aging, or the regional office of the Department of Health and Human Services. Their telephone numbers should be in the government section of the phone directory. The New York State Office for the Aging is located at: State Office for the Aging
To request The Medicare Managed Care Directory, write to:
ERISA: The Employee Retirement Income Security Act (ERISA) is a federal law which regulates employee benefit plans—and includes coverage of health benefits as well. This law prohibits states from regulating health benefits for employees of companies which pay directly for employee health costs. If you are covered by an "ERISA-plan" and want to find out about your rights, contact:
or the The Pension Benefit Guarantee Corporation pays for insufficiently funded pension plans when companies providing pensions can no longer afford to support the plans.
If something goes wrong Your MCO is obligated to alert you of any and all procedures for filing grievances with them. They cannot discriminate against you for filing a grievance or an appeal against them. Your MCO must give you written notice detailing the process of filing, the time frame within which a grievance must be filed, and you right to designate a representative to file for you. This should be included in your member handbook. Your doctor is free to share his or her feelings about the MCO without fear of disciplinary action and can even support your case in filing for grievances or appeals if he or she chooses to do so.
Complaints Insurance Superintendent
There are other, non-governmental sources of information about managed care plans. The Consumers' Checkbook discloses how federal employees feel about the plans offered to them and offers helpful hints on choosing managed care plans. You can get it by contacting: Consumers' Checkbook "More and more information is available to consumers through the Internet. The Internet can be extremely useful in allowing consumers access to important information that can help them improve their health. However, as with any source of information, it pays to be careful. When it comes to your health, it pays to be extremely careful when using the Internet. Be considerate of the concerns raised by medical professionals. Some health care professionals are concerned that consumers will use the Internet as a substitute for real medical care. Here are some tips suggested by Bruce Maxwell, author of How to Find Health Information on the Internet, and Dr. Franklin Tessler, Albany Medical College, for evaluating online health information:
|
|