Through The Maze A Guide to Health Care and Insurance Rights and Resources for Californians with Disabilities Edition II Through The Maze A Guide to Health Care and Insurance Rights and Resources for Californians with Disabilities Edition II Through The Maze, Edition II: A Guide to Health Care & Insurance Rights & Resources for Californians with Disabilities Principal Authors: Robin L. Goldfaden, Anne Cohen, Alexius Markwalder Design and Layout: Christine Wagner Copyright ©2008 by Disability Rights Advocates, a nonprofit corporation. Free copies for the disability community in California were made possible by The California Endowment. To order other copies of Through the Maze, Edition II, please write to: Disability Rights Advocates - Attn: Through the Maze 2001 Center Street, Third Floor, Berkeley CA 94704. Or contact DRA by e-mail: general@dralegal.org Please note that the information provided in this guide is not a substitute for legal advice. Consult a lawyer if you have a problem. Collaborint Presents: DRA LOGO DESIGN Dra’s health access Project is generously funded by The California endowment. What is the health access Project at Dra? Disability Rights Advocates (DRA) is a nonprofit corporation that protects the civil and human rights of people with disabilities throughout the United States and the world. DRA is run by people with disabilities for people with disabilities. We work to end discrimination in access to public accommodations, employment, transportation, health care, insurance, education, and housing. Headquartered in the San Francisco Bay Area, DRA has successfully challenged unfair practices by many of the largest and most powerful companies and institutions in the nation. We serve all disabilities, and focus on systemic change. DRA has an affiliate office in Budapest, Hungary. To address the numerous barriers to quality health care and insurance that people with disabilities face every day, DRA created its Health Access Project. The Project is an outreach and education campaign developed around three publications. The first, Disability Watch, Volume 2, is a statistical report on the status of people with disabilities in the United States. Disability Watch takes a close look at the problems people with disabilities encounter as they try to access health care and health insurance. Next, Through the Maze, Edition II tackles these problems by educating people about their rights to accessible health care and about the laws that can help them access quality insurance. Finally, the Legal Treatise offers more technical information about the laws and rights in Through the Maze. Through these handbooks, the Health Access Project aims to help people with disabilities enforce their rights and identify and benefit from resources in their communities. As part of the Health Access Project’s outreach and education campaign, DRA will conduct workshops for people with disabilities across California. and individual donations. DRA is a private nonprofit organization supported by tax-deductible grants These workshops will train participants about their rights and give them tools needed to advocate for the respect and enforcement of these rights. Collaborint Presents: DRA LOGO DESIGN Color -final 2001 Center Street Berkeley CA, 94704 www.dralegal.org Introduction Getting good health care is a challenge for many people with disabilities. Sometimes the problem is a physical barrier, such as a steep ramp or an examination table that is too high. Other times, a lack of interpreters or alternative formats such as Braille causes ineffective communication between the patient and the health care provider. And sometimes a health care provider’s poor understanding or bad attitude about disability gets in the way. Because of these and other types of barriers, going to the doctor can be an uphill struggle. High health care costs and problems with insurance make the problems worse and lead many people with disabilities to go without the health services they need. By introducing you to federal and state laws that protect Californians with disabilities, this handbook can help. When you know your rights, you can be a better advocate for yourself and your family. The handbook has three main sections: • Section 1: access to health Care Section 1 explains your right of access to health care facilities and the services they provide. It also discusses your right to emergency care and includes tips for choosing a provider and handling access problems. • Section 2: Private Insurance Section 2 helps you learn about insurance rights in California, including: (1) protections when you get health insurance through a job or apply on your own, (2) benefits that health plans must include, (3) access to primary care doctors, specialists, and second opinions, (4) challenging an insurer’s refusal to pay for your care, and (5) continuing your coverage when you lose access to an employer’s group health plan. This section also introduces you to long-term care insurance and Medigap insurance, which supplements Medicare. • Section 3: Public health Programs Section 3 discusses programs that offer free or low-cost insurance or health services in California. It includes information about durable medical equipment (DME), the relationship between immigration status and public health benefits, and transportation. This handbook is a resource you can keep and turn to when you have questions about access to health care, insurance, or public health benefits in California. Because the information presented here can be complicated, do not be surprised if you need to read some sections more than once. Quotation marks are often used for special terms, many of which are defined in the text. When a deadline for taking action is noted, assume that the clock starts ticking on the date that is on the notice of the decision you want to challenge (not the date you receive the notice). Because many topics relate to one another, you will often see references to other handbook pages. The table of contents and index can also help you find the topics that matter to you. The following icons appear next to paragraphs containing telephone numbers, websites, deadlines, and other key information. web Very Good to Deadline Telephone Website/ Financial In Important! Know Number E-mail Information California This handbook does not tell you all there is to know about the law, and it is not legal advice for your individual situation. The laws governing health care and insurance are complex and frequently change. (Check DRA’s website for updates on the law.) It is important that you get accurate and up-to date information if you encounter a problem or need to make a decision about your health care, insurance, or public health benefits. Sometimes, you may need a lawyer or other advocate. The handbook identifies sources of information and help. Many resources are listed in the text, where they relate to the topic being discussed. More general disability and health resources are included in the Resource Guide that starts on page 147. This guide comes in alternative formats (Braille, large print, and computer disk) and in Spanish, and it is available online at www.dralegal.org. It is part of the Health Access Project at Disability Rights Advocates (DRA), a nonprofit law center dedicated to protecting the civil rights of people with disabilities. DRA conducts workshops about health care and insurance rights. In addition to this handbook, DRA has other publications, including Disability Watch, Volume 2 (a statistical report about people with disabilities) and a legal treatise on health care and insurance rights for people with disabilities. The legal treatise is a more technical version of this handbook. To order a free handbook or check if a workshop is scheduled for your area, call DRA at: 510-665-8644 (voice), 510-665-8716 (TDD), or e-mail general@ dralegal.org. Table of Contents What is the Health Access Project at DRA? v Introduction vii Section 1: access to health Care Section Highlights 2 Introduction to Access Rights 3 Who must provide access • Your right to auxiliary aids and services • Dealing with negative attitudes about disability • The laws that promise access • Program access • No segregation in an institution when community-based care is more appropriate Physical Access 7 Barrier-free medical buildings • Standards for architectural access • Accessible medical equipment and health procedures Communication Access 9 Improving communication • Passing notes, reading lips, and relying on interpreters • Telecommunication devices (TDDs) • Captioning and assistive listening devices Service Animals 12 Access for People with Multiple Chemical Sensitivity or Environmental Illness 13 Your Right to Emergency Care 13 Emergency medical conditions • Stabilizing your condition • Transfers • Paying for emergency care Getting Quality, Accessible Health Care 15 Choosing a health care provider • Informed consent • Getting to your appointment • The appointment • Preparing for a hospital visit • Advance directives • Rights for nursing home and long-term care facility residents • Tips to help you be your own advocate • Filing a lawsuit to enforce your access rights • Getting help with an access problem Section 2: Private Insurance Section Highlights 24 Part I: health Insurance Choosing Your Health Insurance 25 Types of plans • Plan costs • Medical groups • Getting “medically necessary” care • Information the plan must give you • Reading your plan information carefully • Disability-based insurance discrimination Getting Health Insurance Through Your Job or a Family Member’s Job 30 Protection from group plan discrimination • Waiting and affiliation periods • Self-insured (or “self-funded”) group plans • Enrolling in a group health plan High Deductible Health Plans & Health Savings Accounts 33 Getting Health Insurance on Your Own 36 The health insurance application • Guaranteed access to an individual health plan Major Risk Medical Insurance Program (MRMIP) 38 Help for those who get sick and can no longer afford their premiums (HIPP and CARE/HIPP) 40 Your Right to Continue Your Health Plan 41 Pre-Existing Conditions 42 How long a pre-existing condition exclusion can apply • How the law helps • Shortening the pre-existing condition exclusion with creditable coverage • When a pre-existing condition exclusion cannot apply Benefits Your Health Plan Must Include 45 Access to Health Care Providers 50 Picking and working with a primary care doctor • Direct access to a gynecologist or obstetrician without a referral • Access to specialists • Standing referrals for specialists • Access to an AIDS/HIV specialist • Access to a specialist who is not part of your plan • Your rights when your plan terminates your provider • Continuing treatment with a provider who is not part of your new group plan • Getting a second opinion • You cannot be singled out for reduced care Making Claims for Health Benefits and Challenging Coverage Denials 54 Which laws protect you • Claim reviews, appeals, and lawsuits under federal law (ERISA) • Claim reviews, grievances, independent medical reviews, and lawsuits under California law • Tips for challenging a health plan’s coverage denial Help with a Health Insurance Problem 67 Maintaining Health Coverage While on Leave from Work 68 Keeping Health Coverage When You Are Losing Employer-Provided Insurance (COBRA/Cal-COBRA) 69 Senior COBRA 77 Converting from a Group Plan to an Individual Plan 79 Continuing Benefits If the Group Plan Contract Ends While You Are Totally Disabled 81 Keeping Health Insurance for a Child with a Disability 81 Part II: Medigap Insurance (Medicare Supplemental Insurance) Filling Gaps in Medicare Coverage 83 The 12 standard Medigap plans • Benefits • Medicare Select • Exclusions for pre-existing conditions • When you have a right to buy Medigap insurance • Group vs. individual Medigap insurance and your right to renew • Reasons why some Medicare beneficiaries may not need Medigap insurance • Whether to get Medigap insurance Part III: Long-Term Care Insurance Insurance for Personal Care 92 Section 3: Public health Programs Section Highlights 96 Medicare 97 Help with Medicare costs • What is not covered • Signing up for Medicare • If you qualify for Medicare but have other insurance options • Part A • Part B • Providers who do not accept Medicare • Medicare+Choice (Part C) and Medicare HMOs • Claim reviews, appeals, and your right to a hearing • Federally qualified health centers • More information and help with Medicare • Keeping Medicare as you transition back to work Prescription Drug Discount Programs 104 PACE (Programs of All-Inclusive Care for the Elderly) 108 Medi-Cal 109 Medi-Cal services • Medi-Cal costs • Eligibility • Different Medi-Cal programs • Applying for Medi-Cal • Fee-for-service vs. managed care • Appeals and the right to continue benefits during the appeal County Mental Health Plans 122 Programs for People with Disabilities 124 In-Home Supportive Services (IHSS) • Genetically Handicapped Persons Program • Regional Centers • Early Start • California Department of Rehabilitation and the Client Assistance Program • Projects for Assistance in Transition from Homelessness • AIDS Drug Assistance Program • CARE/HIPP Programs for Children 129 Healthy Families Program • California Children Services • HIV Children’s Program • CaliforniaKids • Kaiser Permanente Cares for Kids Child Health Plan • Local School Districts Programs for Pregnant Women, New Mothers, and Their Young Children 134 Access for Infants and Mothers (AIM) • Women, Infants, and Children (WIC) • BabyCal Other Health Care Resources 135 Health Care Clinics • County Medical Services Program • Breast Cancer Early Detection Program • California Department of Aging • Veterans Health Administration Durable Medical Equipment (DME) and Assistive Technology (AT) 137 Public Health Benefits Available for Immigrants 139 Finding and Paying for Transportation 142 appendices: Working with a Lawyer 144 Index 147 Resource Guide 163 xiv 5 Section 1: access to health Care Section 1: access to health Care Section highlights People with disabilities have the right to accessible health care facilities and services. Some of the topics discussed here include: • Your right to health services that are free from discrimination based on disability. See page 3. • Your right to the “auxiliary aids and services” that make it possible for you to have access. You cannot be charged for these aids and services. See page 3-4. • Your right to access programs that are run by or receive financial assistance from the government. See page 6. • Your right to be free from segregation in an institution when placement in a community setting is more appropriate. See pages 6-7. • Your right to physical access. Your use of a health care facility should not be blocked by barriers such as stairs, steep ramps, heavy doors, high counters, or inaccessible restrooms. Many kinds of medical equipment and procedures can be made accessible. Access features should be clearly identified. A health care provider cannot require you to bring an attendant to your appointments. See pages 7-9. • Your right to effective communication. Health information should be available in alternative formats such as Braille, large print, audio tapes, and computer disks. Health care providers generally must pay for a qualified sign language interpreter if you need one to communicate clearly. Although the provider can choose the type of aid or service used for communication, the method selected must be effective for you. See pages 9-12. • Your right to be accompanied by your service animal when you visit a health care facility, even if there is a “no pets” policy. A facility can exclude the animal only when it is a threat to the health or safety of other people. See page 12. • Your access rights if you have multiple chemical sensitivity or environmental illness. See page 12-13. • A hospital emergency department’s duty to treat you to stabilize an emergency medical condition, even if you do not have insurance and cannot afford to pay. See pages 13-15. • Tips on picking a doctor, preparing for an appointment or hospital stay, making informed health decisions, nursing home rights, and being your own advocate. See pages 15-20. • Your right to sue if your health care or insurance provider does not fulfill its duty to provide access for people with disabilities. See page 20. Introduction to access rights People with disabilities are often mistreated when they seek health care. If this happens to you, it helps to know your rights: • You cannot be refused health care just because you have a disability. • You have a right to health services as good as those available to others. • You have a right to receive services in an integrated setting. • You have a right to be treated equally and with dignity and respect. Who Must Provide access All health care facilities—including places where you get mental, dental, eye, and alternative care—must be “accessible” (free from barriers that make it difficult or impossible to use the facility or to get the goods and services offered at the facility). Any person or group that owns, leases, or operates a health care facility is responsible for access, even a health care provider whose office is part of her home. A health care provider cannot refuse to treat you just because you have a disability. A provider may refer you to another provider if (1) you are seeking or require treatment or services outside of the referring provider’s area of specialization, and if (2) the referring provider would make a similar referral for a nondisabled person who seeks or requires the same treatment or services. A physician who specializes in treating only a particular condition cannot refuse to treat you for that condition. If the reason a provider will not work with you is that he is not taking on any new patients, then the provider is not discriminating on the basis of disability. Some doctors do not accept certain kinds of insurance or public health benefits. If you have insurance and want it to pay, your choice of doctors may be limited (see pages 25-30, 50-54). If your insurer limits which health care providers you can see, it should make sure its network of providers includes some who are accessible. If you cannot find one, your insurer should help you locate an accessible network provider within a reasonable distance of your home or job, or the insurer should agree to cover the cost of care from an out-of-network provider who is accessible. Be sure to follow your insurer’s rules for seeking out-of-network care. Your right to auxiliary aids & Services People with disabilities have a right to “auxiliary aids and services,” which are forms of assistance or equipment that are needed for equal access. Examples of auxiliary aids and services include: an examination table that lowers to allow transfers, help getting on a table, a sign language interpreter, Braille, help filling out forms, or extra time for appointments. (Many people use the term “reasonable accommodations” to refer to these aids and services.) Your provider must offer auxiliary aids and services unless doing so would cause an “undue burden” (a great deal of difficulty or expense) or would require the provider to dramatically alter the nature of the services it normally offers. The “undue burden” standard considers the provider’s overall financial resources. Just because a doctor makes less money from your appointment than the cost of the aid or service does not automatically mean there is an undue burden. If providing a particular aid or service is an undue burden, your doctor must offer an alternative. For example, if it is too expensive to provide Braille materials, the provider can offer an audio tape or computer disk. You cannot be charged for auxiliary aids and services. (The provider may qualify for a tax break.) Your health care provider must provide the aids and services you need, even if your insurer does not cover the cost. Dealing with Negative attitudes about Disability When you seek health services, you may deal with people who are uninformed, insensitive, disrespectful, or make you feel like a burden. A health care provider may talk to a family member or other companion instead of you. A provider may not give you enough information because he thinks you cannot make your own health decisions. Or your provider may mistakenly assume that because you are disabled, you do not need to know about birth control and sexually transmitted diseases. Some providers too quickly dismiss your health concerns or focus only on your disability and fail to take care of your other health needs. Some providers may have difficulty accepting that they do not have a “cure” for your disability so they push procedures that are not right for you. Also, some are not sensitive to the fact that many people with disabilities have a long history of negative health care experiences. To avoid these problems, look for a provider who: • Understands your disability and how it relates to your overall health. • Treats you as a partner in your care, sharing information and letting you make decisions. • Makes sure that access problems do not stand in the way of you getting the right care. • Does not make uninformed assumptions about you. • Treats you with dignity and respect. • Makes access a priority. Remember, you know your body better than anyone else. Take charge of your health care. If you are not satisfied with your provider, find another (see choosing a health care provider on pages 15-17). The Laws That Promise access Californians with disabilities get their right to accessible health care from: • Title III of the Americans with Disabilities Act of 1990: “No individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodations of any place of public accommodation by any person who owns, leases (or leases to), or operates a place of public accommodation.” (42 U.S.C. § 12182) • Title II of the Americans with Disabilities Act of 1990: “No qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by any such entity.” (42 U.S.C. § 12132) • Section 504 of the Rehabilitation Act of 1973: “No otherwise qualified individual with a disability…shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” (29 U.S.C. § 794[a]) • Unruh Civil Rights Act: “All persons within [California] are free and equal, and no matter what their sex, race, color, religion, ancestry, national origin, disability, or medical condition are entitled to the full and equal accommodations, advantages, facilities, privileges, or services in all business establishments of every kind whatsoever. (Cal. Civil Code § 51) • Disabled Persons Act: “Individuals with disabilities or medical conditions have the same right as the general public to the full and free use of…public buildings, medical facilities, including hospitals, clinics, and physicians’ offices, public facilities, and other public places.” (Cal. Civil Code § 54) • Section 11135 of the California Government Code: “No person in the State of California shall, on the basis of…disability, be unlawfully denied the benefits of, or be unlawfully subjected to discrimination under, any program or activity that is funded directly by the state or receives any financial assistance from the state.” • ADAAG (Americans with Disabilities Act Accessibility Guidelines) and Title 24 of California’s building code define the elements of architectural access. Program access State and local governments, and programs and activities that receive state or federal financial assistance, cannot discriminate on the basis of disability. You have a right to participate in and enjoy the benefits of any program, service, or activity of a state or local government (including a department or agency). This is your right to “program access.” You also have this right for any program or activity that receives federal or state financial assistance (including Medicare or Medi-Cal payments). The definition of “program or activity” is very broad; any hospital, clinic, or health care practice that receives federal or state financial assistance is covered by the law. To provide program access, a covered health care provider (whether it is public or private) may need to change its policies, remove architectural or communication barriers, and/or offer auxiliary aids and services. When it comes to health care, your right to program access is most important when you seek care from a hospital or clinic or other health care program run by the state or local government. These programs do not have to remove physical barriers if they have other ways to give you access to their services, programs, and activities. For example, a clinic can move its nutrition class to the first floor, instead of installing a lift or elevator to the second floor, where the class is usually held. Program access is also important with private health care programs that receive federal or state funds; these programs must make sure that people with disabilities are not excluded from, or denied the benefits of, their programs and activities, even if some physical barriers cannot be removed. A program that has a duty to provide program access must make its application process accessible. For example, if you need an application form with large print or help completing the application for Medi-Cal, you should receive this assistance. No Segregation in an Institution When Community-Based Care Is More appropriate Some people with disabilities are in institutions but would rather live in their communities. In a case called Olmstead v. L.C., the U.S. Supreme Court said that in many cases it is illegal discrimination to require a disabled person to be institutionalized in order to get needed care. Olmstead requires the State to place you in a community setting, instead of an institution, if: • The State’s treatment professionals decide a community placement will work, • You do not prefer to be in an institution, and • Community placement is reasonable given the State’s available resources and the needs of other people with disabilities. If you have a problem with Medi-Cal when you try to get yourself, a friend, or a family member out of an institution, file a complaint with the Office of Civil Rights at the U.S. Department of Health and Human Services, 50 United Nations Plaza, Room 322, San Francisco, CA 94102 (415-437-8310; 415-4378311 [TDD]; 415-437-8329 [Fax]; www.hhs.gov/ocr/rights.html). Physical access Barrier-Free Medical Buildings You have a right to use a health care facility without having your access blocked by physical and structural communication barriers. Areas you should be able to use in hospitals, clinics, and health care providers’ offices include: • Main entrances and waiting areas. • Exam rooms and other treatment areas. • Labs and pharmacies. • Patient rooms and bathrooms. • Physical, occupational and speech therapy rooms. • Pathways and hallways connecting parking areas and public transportation drop-off points to main entrances and parts of the building used by the public. • Emergency exits or paths to rescue-assistance areas. • Restrooms. • Elevators. • Public telephones. • Drinking fountains. • Parking. • Public cafeterias and gift shops. Signs with large raised letters and Braille should direct you to accessible entrances, travel routes, restrooms, and rescue-assistance areas. Warnings detectable by people with vision disabilities should alert them to path of-travel hazards. Medical buildings should also have flashing alarms, visual doorbells, and other notification devices. Floor numbers should be clearly marked near elevator exits. If you have a vision disability and want assistance, a staff person should help you get oriented. Each health care facility must maintain the features and equipment that make the facility accessible to and useable by people with disabilities. For example, elevators should work, accessible doors should not be locked, and otherwise accessible paths of travel should not be blocked by items like furniture or potted plants. Standards for architectural access The strictest standards for physical access apply to newer and remodeled buildings, but access rules also apply in older buildings. In older facilities, a barrier must be removed if the removal is “readily achievable,” which means it can be done without much difficulty or expense. Barrier removals that are often readily achievable include: adding a ramp, rearranging equipment or furniture, widening doors, repositioning telephones, installing special door hardware, putting a raised toilet seat and grab bars in the restroom, lowering towel dispensers, creating accessible parking, and removing problem carpeting. The law has very detailed guidelines that say whether a space is accessible. The fact that a building received a permit from the local inspector does not necessarily mean it satisfies all the legal requirements for access. It helps to know what kind of access you need and to call first to be sure you will get it. For more information or to report a problem, call the ADA Hotline (800-514 0301; 800-514-0383 [TDD]) or the State Architect’s Office (916-445-8100). accessible Medical equipment & health Procedures Health care providers often rely on medical equipment that was not designed to meet the needs of people with disabilities. But advances have been made. Many types of medical equipment can now be made more accessible for people with disabilities. Examples are examination and x- ray tables that move up and down, mammography machines for seated patients, scales for wheelchair users, open MRIs, eye-exam chairs that can be moved to allow room for a wheelchair, handheld eye-examination equipment, and blood pressure cuffs that can be used on a leg instead of an arm. Your provider should have accessible medical equipment unless it would impose an “undue burden” (see page 4). The factors that are relevant in deciding if there will be an undue burden include the cost and feasibility of acquiring the accessible medical equipment and the provider’s overall resources. Larger and richer facilities have a greater capacity to have a range of accessible medical equipment. For example, a major hospital should be able to satisfy most, if not all, of the equipment needs of its disabled patients. Even if you rely on a smaller health care provider, you should encourage it to purchase some accessible medical equipment. The cost for some important accessible equipment (like exam tables and scales) is not too high for most providers, and the accessible equipment can also be used by patients who do not have disabilities. If you cannot get on an exam table by yourself, your provider or his staff should help you to transfer safely. Be sure your provider also arranges help off the table. If you need the assistance, a staff person should help you maintain a stable position and make sure there is no risk of a fall. Your provider cannot require you to bring an attendant to your appointment, but you can bring one if you want. If a procedure or a piece of medical equipment cannot be made accessible, you have a right to the next best alternative. This may mean doing a different kind of test or having extra appointments. For example, women who cannot do breast self-examination may need a provider to check more often for breast cancer. Sometimes you will need a referral. For example, if your provider does not have an accessible mammography machine, ask which nearby provider has one you can use. If you need to go outside your health plan’s network to get accessible care, your insurance should pay (but make sure you follow the plan rules for getting out-of-network care). Communication access Good communication with your providers is important. You need effective communication to: • Explain symptoms and personal and family medical history. • Understand a diagnosis and treatment options. • Give “informed consent” for treatments and procedures (see page 16). • Communicate before and after major medical procedures. • Understand instructions about medications and follow-up care. • Benefit from psychotherapy. • Learn about costs and insurance. It is against the law for a health care provider to withhold “auxiliary aids and services” if you will be excluded, denied services, or segregated without them. (See pages 3-4 for more on auxiliary aids and services and the “undue burden” exception.) You have a right to the aids and services needed to communicate effectively with the provider. Sometimes you have this right even if you are not the patient, such as when you are learning about your child’s health or joining your wife or girlfriend in Lamaze classes. Auxiliary aids and services for effective communication include: • Qualified interpreters. • Videotext displays. • Captioning for video presentations. • Telecommunication devices for the deaf (TDDs). • Qualified readers. • Health information in Braille, large print, audio tapes, or computer disks. • Written information with clear explanations. • Note takers. The health care provider decides which aid or service will be used, but she must pick one that allows effective communication. Whether a particular aid is the right choice depends on the situation. You know best what works for you so your provider should consider your input. But if you are offered an aid or service that works, you must accept it even if you prefer another. Improving Communication Health care providers should try to use clear language, take the extra time needed, and confirm your understanding of the information they provide. Explanations may be clearer if the provider uses pictures, three-dimensional models, communication boards, or audio or video tapes. Some people with speech or hearing disabilities find it works well to take turns at a computer terminal or use a text display to type messages back and forth. Using a mirror during examinations helps some people who are deaf or hard of hearing follow what is happening. If you have a vision disability, it may help to get familiar with the equipment being used and to have the provider explain each step of the procedure before it happens. Let your provider know what works for you. Passing Notes, reading Lips, & relying on Interpreters Methods of communicating effectively vary from person to person. Passing notes works for some, particularly those who are late-deafened. For many individuals, however, passing notes is difficult and ineffective, especially when complicated medical terms are involved or a patient has a low reading level. It also can be frustrating because it can take a long time and lead to 0 the patient getting incomplete information. Some people can read lips, but this method often fails. Even good lip readers cannot understand a significant amount of what others say. Lip reading is even harder when complicated medical terms are used. Given the importance of the information shared by a patient and a health care provider and how much can be missed by the lip reader, one should be very cautious about relying on this approach. Those who are able to read lips may need an oral interpreter who is skilled at carefully articulating words for individuals with hearing loss. For many, using a qualified sign language interpreter is the only effective way to communicate. It is quite likely that a person who is deaf will need an interpreter if an important health matter is at issue and/or the person has a low reading level. A qualified sign language interpreter can (1) interpret effectively and impartially, (2) translate both sign and spoken language, and (3) use any special vocabulary that is needed. The interpreter must use the same sign language as the person with the disability; finger spelling or signed English generally will not work for someone who uses American Sign Language. Using a friend or family member to interpret works in some cases, but this approach can lead to serious problems. That person may not be able to interpret complicated medical terms or may be too personally involved to translate accurately and impartially. Also, you may not want your friend or family member to learn the confidential information that is being shared by you and your provider. Let your doctor know if relying on a friend or family member is not good for you. Remember that you are not legally responsible for providing an interpreter even if you have a friend or family member who is able to interpret. Health care providers who want to avoid paying an interpreter may pressure you to bring your own interpreter or to rely on passing notes or reading lips. Remember your right to effective communication, and let your provider know if the method he suggests will not work for you. If you know in advance that you will need an interpreter, tell your provider so he will have enough time to make the arrangements. Telecommunication Devices (TDDs) People who are deaf or hard of hearing, or who have speech disabilities, have a right to accessible telephone services. If a hospital, nursing home, or other health care facility gives patients regular access to telephones for outgoing calls, it must provide TDDs and telephones that are compatible with hearing aids or telephones with amplifiers. If your health care provider does not have a TDD, it can receive incoming calls from TDD users through relay systems, which let people using TDDs communicate with people using voice telephones. Because telephone companies must provide relay systems, these systems should be available for making appointments and getting basic information from a health care provider. See the Resource Guide on page 163 for the phone numbers to the California Relay System. Captioning & assistive Listening Devices At a facility where people can watch television, patients who are deaf or hard of hearing must have access to captioned television. If a health care provider uses videotapes, conferences, or other presentations to provide information, it must make them accessible to people with disabilities. Ways to do this include using sign language interpreters and assistive listening devices that fix distance and background noise problems. Videos must include captions. A spoken description should be provided when important visual material is presented. Service animals A service animal is any dog or other animal individually trained to help a person with a disability. Service animals can help guide people with vision disabilities, alert people to sounds, pull wheelchairs, carry and pick up objects, and provide help with balancing. You have a right to have your service animal with you when you visit a health care facility (even if the facility has a “no pets” policy and even if local or state laws do not allow animals). You should not be separated from other people just because you are with a service animal. There may be parts of a health care facility (such as emergency and operating rooms and intensive care units) where you cannot bring your service animal because it might be too disruptive or might interfere with patient treatment. A health care provider can completely exclude your service animal only if it poses a direct threat to the health or safety of others. This decision must be based on the individual animal, not on experiences with other animals. If your service animal is kept out, you still have the right to get services at that facility. access for People with Multiple Chemical Sensitivity or environmental Illness Like people with other disabilities, people with disabling multiple chemical sensitivity or environmental illness have the right of access to health services. It may be hard to make a medical building free of the chemicals that make you sick, and your provider may not be able to prevent all the other patients from wearing scented products. But there are steps that can and should be taken. Some may involve a change in the health care provider’s usual practices. For example, your doctor can give you an appointment that is earlier or later than regular office hours so you will not be exposed to chemicals used for cleaning or to other patients who wear scented products. Some providers may be willing to make home visits or may be able to treat you at an alternate site that is less toxic. Find a provider who will work with you so you can get the health services you need without being exposed to chemicals that are a problem for you. Be sure your doctor is aware of your disability so she can avoid prescribing something that may cause a bad reaction. Your right to emergency Care You have a right to emergency care, even if you do not have insurance and cannot afford to pay. A hospital with an emergency department must accept any patient with an emergency medical condition if the hospital has the facilities and personnel to provide the care. The hospital must evaluate the patient, provide emergency care, and make only appropriate transfers. You should not be asked about your ability to pay until you have gotten the emergency care you need. Hospitals must inform you of your emergency- care rights, which come from California law and a federal law called Emergency Medical Treatment and Labor Act (EMTALA). EMTALA applies to any hospital that participates in the Medicare program. emergency Medical Conditions If you go to a hospital emergency department and ask for examination or treatment, a qualified health care provider must give you a screening exam to see if you have an “emergency medical condition.” A medical condition is an emergency if there are acute symptoms (including pain) severe enough that not getting immediate medical attention could seriously jeopardize your health or cause serious damage to a bodily function, organ, or part. An emergency medical condition can be due to a psychiatric problem or substance abuse. A medical condition is also an emergency if there are acute symptoms (including pain) severe enough that the health of a pregnant woman or her fetus will be in serious jeopardy without immediate medical attention. Under the law, there is also an emergency medical condition if a pregnant woman is having contractions and there is not enough time for a safe transfer to another hospital before delivery, or if a transfer may pose a threat to the health/safety of the woman or the fetus. Stabilizing Your Condition If you have an emergency medical condition, the hospital must try to stabilize your condition. You are considered stabilized when the treating provider concludes that your condition is not likely to deteriorate significantly as a result of or during a transfer. A pregnant woman who is having contractions will be considered stabilized once she has delivered the baby and the placenta. Transfers The hospital cannot transfer you to another facility before your emergency medical condition is stabilized, unless (1) your doctor thinks a transfer is better for your health or (2) you, or your representative makes an informed decision that you want to go elsewhere. If the hospital decides to transfer you, the receiving hospital should be prepared to treat you, and the transfer should be done in a manner that minimizes health risks. If you do not have an emergency medical condition, the hospital can refer you elsewhere. Paying for emergency Care The law discussed here makes sure that hospitals do not delay or deny urgent care in an emergency. The law does not deal with how you pay for that care. If you do not have insurance, you will have to work out a payment plan with the hospital or see if you qualify for public health benefits. Some hospitals will reduce the charges if you can pay right away. If you have insurance, follow your plan’s instructions for getting emergency care covered. Notify your health plan as soon as possible (usually within 24 to 48 hours, but check the plan rules) that you received emergency care. After your condition is stabilized, the plan may decide to have your follow-up care provided at a different facility. A health plan generally must follow these rules: • It cannot require doctors to get “prior authorization” for emergency services and care needed to stabilize an emergency condition. (“Prior authorization” is the insurer’s approval for a plan member to receive a treatment, test, or surgical procedure before it has actually occurred.) • It must pay for emergency services unless you did not need the care and should have known there was no emergency. • If the plan requires prior authorization for reimbursement for medically necessary care, you must have 24-hour access to getting authorizations for care you need when you have had an emergency and your condition is stabilized but the treating doctor says it is not yet safe to discharge you. getting Quality, accessible health Care Choosing a health Care Provider You should feel comfortable with your health care provider and confident in his or her abilities. When looking for a doctor, dentist, or therapist, it often helps to get recommendations from other providers, friends and family, disability organizations, or people with similar health issues. You will want to make an informed decision about whether a particular provider is a good match for you. Some questions you may want to ask are: • Is the provider accepting new patients? • Does the provider accept your insurance? • If you do not have insurance, how will the bill be handled? Some providers may reduce the charge if you can pay at the time of your visit. • Does the provider have experience with your disability? Is he aware of current information about and treatments for your health conditions? • Will you have all the access you need? Are there any physical barriers that will block your access to the health services you need? Are the exam tables accessible? Will you get assistance on and off the table? Will you get help completing forms? Can a staff person help you get dressed? If you need a sign language interpreter, will one be provided? Is health information available in alternative formats? Can you bring your service animal? • Does the provider speak the language you are comfortable using? If not, will he use a translator? • How far will you have to travel to see the provider? Is there accessible parking? Is the office near public transportation? Does the provider offer any transportation? If you want to coordinate appointments, you may prefer a provider near your other providers. • What are regular office hours? If necessary, can you be seen earlier or later? • How long is the wait for an appointment? What if you develop a serious problem? • Can you contact the provider when her office is closed? Who covers for 5 her when she is away? • How long will your appointment run? If you need extra time, will you get it? • Will your choice affect which other doctors you can see? • Where does the doctor have hospital privileges? • Will you have to pay for missed appointments? • What kind of experience and training does the provider have? Is there an area in which she specializes? Contact the Medical Board of California (MBC) (916-263-2687; 916-322-1700 [TDD]; 916-263-2944 [Fax] (8 a.m.-5 pm. PST); www.medbd.ca.gov) to find out if a person is licensed to practice medicine. From the MBC, you can also obtain certain malpractice and hospital disciplinary information. In addition, you can learn whether a doctor is facing formal charges by the MBC or has been disciplined by the MBC or another state’s medical board. You can learn if a doctor is board-certified as a specialist from the American Board of Medical Specialties (www.certifieddoctor.org). Especially when choosing a primary care doctor, you want someone who understands your disability and how it affects your overall health. Some people with disabilities are survivors of sexual abuse, and many have had disturbing and upsetting health care experiences; providers should be aware of and sensitive to these issues. Ask yourself if you feel comfortable with the provider. Are you getting enough time and attention? Does she respect your input and treat you like a partner in your care? Remember, it’s your health— you should be fully informed and included in all decisions. Check Your Guide to Choosing Quality Health Care and other resources at www.healthfinder. gov/smartchoices/qualitycare/provider.htm for more on picking and working with doctors. Informed Consent You have a right to decide what kind of care you receive. Before treating you, a doctor must inform you, in a clear and understandable way, about the benefits and risks of different approaches. You must have enough information to make a meaningful decision. Ask questions about your condition, the doctor’s recommendation, alternatives (including no treatment), benefits and risks, success rates, who will perform the procedures you are considering, possible pain and side effects, and what to expect after the treatment. If you are not 100% convinced, get a second opinion (see page 52). Before making a decision, you may want to check other sources. Books, articles, and the Internet can help, but verify the source’s accuracy. For information about specific health issues, the following may help: • www.healthfinder.gov • www.mayohealth.org/home • www.medlineplus.gov • nfonet.welch.jhu.edu/advocacy.html • cpmcnet.columbia.edu/texts/guide • www.health.gov/nhic/Pubs/clearinghouses.htm • www.ihr.com/publcons.html Remember, you have the final say about your treatment; the more you know, the better decisions you can make. getting to Your appointment If your health care provider offers transportation assistance for patients, that service should be accessible. If you need help getting to an appointment, check with a local independent living center to see what transportation services are available. See pages 142-143 for more transportation information. The appointment Take some time to prepare for your appointment. Confirm in advance that the provider will take care of your access needs. Make a list of the topics you want to discuss, including any symptoms you want checked. Decide whether you want to write down the information you get. If you want to tape record the appointment or bring a friend with you for support, check first with the provider. Do not assume your provider has all the information that is important for your care. For example, she may not know you are taking a medication prescribed by another doctor. Tell the provider if you are taking any medications, including over-the-counter drugs or herbal or homeopathic medicines. Offer information you think the provider should know, even if she does not ask. Ask any follow-up questions you have. To confirm that you understand your provider’s explanations, you can repeat back the information she has given you. If any procedure, treatment, or medication is discussed, make sure you have enough information to make an informed decision. If you want a referral for a specialist or a second opinion, just ask. Follow up to get test results. Preparing for a hospital Visit If you expect a hospital stay, plan ahead. Confirm that the hospital will provide an accessible room and take care of any special needs. If you need a sign language interpreter, find out how the arrangements will be made. You may also want to request a room with a TDD and access to captioned television programs. Bring any items you will want to have during your stay. Get the names of the providers who will be responsible for your care and ask who to contact if you have a problem. Find out when you can expect to leave the hospital and how the bill will be handled. Before you leave the hospital, be sure you have all the information you need for your post-release care and medications. advance Directives Think about preparing an “advance health care directive,” a legal document that lets you say what medical care you do or do not want if you become too sick to communicate. Advance directives can state your wishes directly and/or let you pick a person you trust to make decisions for you. For a free English or Spanish copy of the Advance Health Care Directive form, contact California Healthcare Association (www.calhealth.org/res_pubs_ frmspstrs.htm; 800-494-2100). You may be able to get help with the form from California Advocates for Nursing Home Reform (www.canhr.org; 800-474-1116 [consumer hotline]; 415-777-2904 [Fax]). rights for Nursing home & Long-Term Care Facility residents If you stay in a long-term care facility (like a skilled nursing facility), you have the right to: • Be treated with dignity and respect. • Receive services in the way that least restricts your personal liberty. • Receive complete information about your health and the chance to participate in planning your care. • Have your records kept confidential. • Be free from verbal, mental, sexual, and physical abuse. • Be free from physical or chemical restraints (psychotherapeutic or antipsychotic drugs) that are used for discipline or staff convenience and are not needed for your medical symptoms, unless there is an emergency that threatens immediate injury to you or another resident. • Make complaints and recommend changes. • Be informed about services and charges. • Be informed about and manage your financial affairs. • Have daily visiting hours and spend private time with friends, family, clergy, service providers, and others. • Participate in social, religious, and community activities. • Have reasonable access to telephones and TDDs, make and receive confidential calls, and send and receive personal mail without having it opened. • Be transferred or discharged from the facility only if (1) you recover to the point of no longer needing nursing home care, (2) a transfer or discharge is needed for your welfare and the facility cannot take care of your needs, (3) the health or safety of other residents is at risk, (4) you do not pay for your care, or (5) the facility stops operating. • Get reasonable notice of a discharge or transfer. If your facility is closing, you have a right to be notified and to receive services that will protect you from being harmed by the move to a new place. For example, the facility that is going to stop caring for you must make sure you will be able to get the right care and services elsewhere. If you think your rights as a nursing home resident have been violated, contact the Office of Patients’ Rights (916-575-1610; 916-575-1613 [Fax]; OPRinforequest@pai-ca.org; www.pai-ca.org/OPR/PRdescription.htm) or the district office of the Department of Health Services Licensing and Certification Division, the state agency that enforces nursing home laws. California Advocates for Nursing Home Reform (CANHR) (800-474-1116; 415-777-2904 [Fax]; www.canhr.org) has information about choosing a nursing home, Medi-Cal, and residents’ rights, and it can help with complaints. CANHR also has a lawyer referral service that can help consumers with elder law and long-term care concerns. For more information on nursing home quality and to locate a nursing home, check www.medicare.gov/NHCompare/home. asp Tips to help You Be Your own advocate Keep your own files about your medical history and care, including test results, medical reports, and summaries of your medical visits. Document all your meetings and conversations with providers and insurers. Always get the name of the person who takes your complaint and/or gives you information, and write down what you are told, especially if you are having a problem. Whenever possible, communicate in writing and keep copies of the letters you send and receive. If you are having an access problem, discuss it with your provider or the person who runs the health care facility. Large facilities may have patient relations offices you can contact. If a representative is unhelpful, ask for a supervisor. Be assertive, and remember your rights. Your disability is not a reason for a health care provider to keep appropriate services from you. If you encounter a barrier, try to work with the provider to overcome it. If the provider, facility, or insurer still refuses to take reasonable care of your access needs, send a letter (1) explaining the problem, (2) proposing a solution if you know of one, (3) stating the steps you have already taken, (4) asserting your right to access (you can refer to the laws that require access [see page 5]), and (5) setting a reasonable deadline for you to receive a response. If you can, send the letter by certified mail, return receipt requested. Always keep a copy of the letter. If you cannot resolve an access problem with a doctor, you can file a complaint with the Medical Board of California, which investigates complaints about quality of care and violations of the law. The Board can discipline doctors. Call 800-633-2322 or write to Medical Board of California, Central Complaint Unit, 1426 Howe Ave., Suite 54, Sacramento, CA 95825 3236; www.mbc.ca.gov or caldocinfo.ca.gov; for complaints on Medicare: 800-633-4227. Filing a Lawsuit to enforce Your access rights If a person, company, organization, or agency responsible for providing access violates your rights, you can file a lawsuit in federal or state court. Although it helps to have a lawyer, you can represent yourself. If you do not have a lawyer, one option is filing a discrimination complaint in Small Claims Court, using the Unruh Civil Rights Law and the Americans with Disabilities Act (see page 5). If you prove your case, you are entitled to at least $1,000 in damages and can get as much as $5,000. At the same time, you can send the message that defendants must pay a price if they refuse to provide the access the law requires. If you want to pursue a case in Small Claims Court, get a “Small Claims User Packet” from the clerk at the county courthouse, follow the packet’s instructions, and pay a small fee when you file your case. For more on filing a lawsuit, see “Working with a Lawyer” on page 144. 0 getting help with an access Problem If you cannot work out an access problem on your own, you may be able to get help from: • ADA Hotline: www.usdoj.gov/crt/ada/adahom1.htm; 800-514-0301 (voice); 800-514-0383 (TDD) • Disability Rights Advocates (DRA): www.dralegal.org; 510-665-8644 (voice); 510-665-8716 (TDD); 510-665-8511 (Fax) • Disability Rights Education & Defense Fund (DREDF): info@dredf.org; www. dredf.org; 800-348-4232; 510-644-2555 (voice/TDD); 510-841-8645 (Fax) • Disability Rights Legal Center: 213-736-1334 (V); 213-736-8310 (TDD); 866-999-DRLC (Toll Free); 213-736-1428 (Fax); DRLC@lls.edu; www.disabilityrightslegalcenter.org • Protection & Advocacy, Inc. (PAI): www.pai-ca.org; 800-776-5746 (Tel); 800-719-5798 (TDD) • Your local independent living center, which you can find through the California Foundation for Independent Living Centers: www.cfilc.org; 916-325-1690 (voice); 916-325-1695 (TDD) • A local legal services organization or a private attorney referred by your local bar association or a certified lawyer referral service: 415-538-2250 (V); 415-538-2250 (in California); 866-442-2629 (outside California); (http:// calbar.org/2con/referral.htm). Section 2: Private Insurance Section 2: Private Insurance Section highlights This section discusses private insurance. Part I covers comprehensive health insurance, Part II covers Medigap insurance, and Part III covers long-term care insurance. Some of the topics discussed here include: • Group health plans cannot exclude you or charge you more because of your disability. See page 31. • Individual plans cannot reject you or charge you more unless they can justify their decision. See page 37-38. • There are situations in which you have the right to buy an individual health plan even if you have an expensive condition. See pages 38-40. • You may be able to get help paying premiums if you get sick and cannot afford them. See pages 40-41. • The law limits how long your plan can exclude coverage for health problems you had before you enrolled. See pages 42-45. • Your plan must include certain benefits. See pages 45-49. • Choosing your doctors. Getting referrals and second opinions. Going to an obstetrician-gynecologist without a referral. Getting continuous care and going out-of-network. See pages 50-54. • People with disabilities cannot be singled out for inferior care. See page 54. • Challenging your plan’s refusal to cover the care you need. See pages 54-68. • Continuing coverage while you are on leave from work. See pages 68-69. • Continuing coverage through COBRA if you are about to lose coverage you got through your or a family member’s employment. See pages 6975. Getting COBRA for a child who is losing “dependent” status. See page 75. Extending COBRA if you become disabled. See page 76- 77. Extending COBRA if you are age 60 or older when your COBRA begins. See pages 77- 79. • Keeping health insurance for a disabled adult child. See page 81–82. • Which group plans must let you convert to an individual plan. See pages 7981. • How Medigap insurance supplements Medicare. See page 83. Comparison shopping to get the best price on your Medigap plan. See pages 83- 85. When you have a right to buy Medigap even if you have an expensive condition. See pages 88- 90. • Long-term care insurance: help with activities of daily living. See pages 92-93. Private Insurance Part I: health Insurance Choosing Your health Insurance The type of health insurance you have affects the quality and cost of your care. If you have a choice of health plans, you should consider several factors before deciding which is the right plan for you. These factors include services offered, choice of providers (also called a “network”), location of providers and costs. You might also consider: 1. Does the plan cover care for your (or a family member’s) disability and other health conditions? 2. What is the plan’s level of coverage for: • Care and counseling for mental health; • Services for drug and alcohol abuse; • Obstetrical-gynecological care and family planning services; • Physical therapy and other rehabilitative care; • Home health, nursing home, and hospice care; • Chiropractic or alternative health care, such as acupuncture; or • Experimental treatments. 3. Does the health plan offer health education and preventive care such as, helping people quit smoking, lose weight, or manage their diabetes? 4. Will you be able to see your current doctors? If not, does the plan have doctors with whom you will be happy? 5. Can you afford the premiums and other plan costs? 6. Are other people satisfied with the plan? how to learn more about plan quality Two sources of information about plan quality are (1) how consumers rate their plans and (2) what health care results the plans achieve. You may also want to know if a plan is “accredited” (has the seal of approval from an organization that evaluates plans). You can find out more about plan quality and how to choose a plan from: 5 • Healthfinder (www.healthfinder.gov [search for “quality care”]) • Agency for Healthcare Research and Quality (800-358-9295; 888-586-6340 [TDD]; www.ahrq.gov/consumer) • Joint Commission on Accreditation of Health Care Organizations (630-7925000; www.joint commission.org) • National Committee for Quality Assurance (888-275-7585; www.ncqa.org) • Pacific Business Group on Health (415-281-8660 [tel]; 415-287-0960 [fax]; www.healthscope.org) • URAC (American Accreditation Healthcare Commission) (202-216-9010 [tel]; 202-216-9006 [fax]; www.urac.org) • American Association of Health Plans (202-778-3200[tel]; 202-331-7487 [fax]; www.aahp.org) Office of the Patient Advocate [issues an annual HMO report card] 1-866HMO- 8900; http://www.opa.ca.gov/). Types of Plans Health insurance plans are usually described as either indemnity (also called fee-for-service) or managed care. Indemnity health plans These plans, also called fee-for-service, generally do not restrict where you get your care. You pick your doctors and hospitals, but you may pay high out-of-pocket costs. In addition to a monthly premium, you usually pay for a set amount of services each year before the insurer starts paying (also called a deductible). Once you pay this set amount the plan will pay a percentage of your health care costs, generally 80 percent. However, in order to ensure the health plan pays these costs, you must keep records of your medical expenses, keep receipts, and fill out forms to get reimbursed. There are three major types of indemnity health plans: basic, major medical, and comprehensive. Basic plans cover costs associated with hospital care such as room charges, x-rays, medications, and in-patient or out-patient surgery and care. Major Medical plans generally cover only long-term care for illness or injury and will cover both in-patient and out-patient expenses. Comprehensive plans generally combine both the basic and the major medical coverage. They are generally characterized by a low deductible, a co-insurance feature, and high maximum benefits. While indemnity insurance offers a wide range of choice, the cost of premiums, in addition to the fact that most policies exclude coverage for preventative health care, often makes indemnity coverage impractical or too expensive. Managed care health plans These plans have agreements with certain doctors, hospitals, and health care providers to give a range of services to plan members at a reduced cost. In general, you will have less paperwork and lower out-of-pocket costs if you select a managed care plan, but you may have more restrictions on the types of doctors you can select. Many managed care plans require approval in advance (“prior authorization” [see page 15]) for services, and some limit visits for certain services. The three main types of managed care plans are an Health Maintenance Organization, Point Of Service and a Preferred Provider Organization. health Maintenance organization (hMo): An HMO requires you to choose a primary care physician (PCP) to manage your care. Your PCP coordinates your medical care and provides you with any necessary referrals to see specialists who also participate in the plan (within the network). You need the HMO’s permission to use doctors and hospitals the health plan does not contract with (commonly called going “out-of-network”) if you want the HMO to pay for out-of-network services. However, there are some exceptions to this rule if you need emergency care. Point of Service (PoS) plan: A POS allows you to be a member of an HMO but still see doctors who are not part of the HMO’s network. You usually pay higher out-of-pocket costs for this flexibility. Even in a POS plan, however, you need a primary care doctor’s referral to see a specialist. Preferred Provider Organization (PPO): A PPO encourages you to use network doctors, but usually allows you the option of using out-of-network providers (at a higher cost) and allows you to see a specialist without a referral. Medical groups These groups are often called an Independent Practice Association or IPA. These are groups of doctors that contract with health plans, such as HMOs, to provide health services out of the doctor’s own office. An important difference between medical groups and health plans is how they decide the health care you receive. Health insurance plans decide what medical benefits to cover and how much they will cost you. The medical group often decides how care is delivered and where you receive it. Some medical groups have rules their doctors must follow. For instance, the doctors may need the group’s approval to make referrals (especially outside the medical group) or to provide certain treatments or tests. If you are in a medical group, you may be limited to the doctors in that group unless you have your plan’s permission to go out of the group (see page 52). Medical groups often have “patient assistance offices.” If you have a problem with your medical group, you can complain to both your medical group and your health insurance plan. The medical group you choose can affect the care you receive. The Office of the Patient Advocate (OPA) rates a number of the largest medical groups in California. Check out these Medical Group Ratings to learn about the medical groups in your area. If you already have a doctor, use this web site’s Directory of Doctors to find the medical group he or she belongs to and check the quality of that medical group. The Office of the Patient Advocate (1-866-HMO-8900 http://www.opa.ca.gov/) In California, the Department of Managed Health Care (DMHC) (888-HMO 2219; 877-688-9891 [TDD]) oversees all HMOs and some non-HMO Blue Cross and Blue Shield health plans. DMHC has an Office of Patient Advocate to represent the interests of persons enrolled in the health plans licensed by DMHC. The Department of Insurance (800-927-HELP [4357] or 800-482-4TDD) regulates other insurance, including fee-for-service health plans. Neither department has authority over self-funded plans (see page 31), which are regulated by the federal government. Plan Costs Health plan costs vary, depending on the type of plan you have. Payment of “premiums” is generally required for you to be a member who can receive the benefits of the plan. Premiums are usually paid on a monthly or quarterly basis. If you have health insurance through your job or through a family member’s job, the employer may pay all or part of the premium. Other health plan costs can include: • Co-payment – a fee you pay each time you get certain services. For example, you may pay $10 per doctor visit. The fixed amount you pay for a prescription may vary depending on the type of medication. Brand name medications generally cost more than their generic alternatives. • Deductible – an amount you must pay for your health care each year before the plan starts to pay (with some plans, not all medical expenses count toward the deductible). For example, if you have an annual deductible of $1,000 and need only $800 of care in a particular year, your plan will not help pay because the cost of your care has not exceeded the deductible. • Co-insurance – your share of the cost. For example, you may pay 20% of your medical costs while your plan pays 80%. Although some plans have an “out-of-pocket maximum” that limits what you pay in a given year for covered care, some have lifetime caps on what they will pay. A lifetime cap can be a problem for someone with an expensive health condition. getting “Medically Necessary” Care Even for benefits your plan includes, you and your insurer may disagree about “medical necessity”—whether a particular service is needed for your health. What is medically necessary depends on the person. A disability can create a need for care that people without disabilities do not require. For example, because of your disability, you may need extra blood tests or office visits, dental work done with anesthesia in a hospital, or a longer hospital stay. If you need care that is a covered benefit, your plan should pay for it, even if a nondisabled person would not need it. If you need to fight to get your insurer to pay for the care you need, your doctor can be an ally. Even if the care you need is not normally a covered benefit, it may be worth pushing to have it covered. If you have a problem getting your plan to pay for medically necessary care, see pages 36-37 (private insurance), pages 97-105 (Medicare), or pages 109-123 (Medi-Cal). Information the Plan Must give You The contract between the plan and you (or your employer) explains the coverage provided by the plan, the plan’s policies and procedures, and your rights and responsibilities. The document you receive is often called an “Evidence of Coverage” (EOC) or a “Summary Plan Description” (SPD). If your insurance is through an employer, you usually get an SPD. If you want more than this summary, you can ask your employer or plan administrator for the rest of the plan documents (there may be copying charges, up to .25¢ per page). If you have any questions, contact the plan’s customer service department or, if applicable, your employer or insurance agent for an explanation. If there are important changes, you must be told about them. Keep your plan information so you can refer to it when you have a question or problem. reading Your Plan Information Carefully You will want to learn about: (1) The plan’s benefits (For example, is mental health care covered? Are prescription drugs? Preventive care? Regular check-ups for you and your children? Durable medical equipment and assistive technology purchases and maintenance?). (2) Coverage limitations (For example, will the plan pay no more than $25,000 for HIV/AIDS treatment? Is there a limit on the number of covered visits? Does it pay for chiropractic care and acupuncture? For in-vitro fertilization?) (3) Limitations on your choice of doctors and rules for using providers outside the plan’s network or your medical group. (4) Whether you need referrals to see certain doctors. (5) How to get a second opinion. (6) How to arrange to have the plan pay for your care. (7) Your costs and what to do if you receive a bill from a doctor or hospital. (8) When you need “prior authorization” or “pre-approval” to have your care covered. (9) Whether a “formulary” is used for prescription drugs (see page 47). (10) What to do if the plan refuses to pay for care you need. Disability-Based Insurance Discrimination Many people hoped the Americans with Disabilities Act (ADA) would end disability discrimination by insurance companies. Unfortunately, courts in California have ruled that the ADA generally does not regulate insurance. As a result, this law is unlikely to help if you are challenging a disability-based application denial or inflated premium or a plan’s unequal coverage for specific conditions like AIDS, psychiatric disabilities, or infertility. Fortunately, other laws offer some help: Group plans cannot exclude you or charge you more based on your disability (see page 30). California laws prohibit an insurer from arbitrarily rejecting your individual application or charging more on the basis of disability (see pages 29-30). Also, some people are guaranteed access to insurance (see pages 37-38), and both federal and state laws require plans to include certain benefits (see pages 45-46). getting health Insurance Through Your Job or a Family Member’s Job The best health insurance often comes through employment. Employers do not have to offer health insurance. Once they do, however, the coverage must be available equally for all employees who work the same number of hours as each other. For example, if an employer offers a health plan to full- time employees and you work full-time, the plan must be available to you in the same way as it is for your co-workers. When your health insurance is through a health plan sponsored by an employer or union (a “group plan”), you get protection from the Health Insurance Portability and Accountability Act (HIPAA), a federal law that applies to group plans with two or more current employees (a similar state 0 law applies to group plans that include only one current employee). HIPAA is part of a larger federal law called ERISA, which is also discussed in the handbook (see pages 55-57). Some HIPAA protections may not apply to self-insured plans sponsored by certain state, county, and local governments. If you are in such a plan, get more information from your employer. Protection from group Plan Discrimination: • An employee or dependent (husband, wife, or child) cannot be kept out of a group plan based on “health status” factors, which include an existing physical or mental condition, disability, medical history, claims experience, receipt of health care, evidence of insurability, or genetic information. • You cannot be charged a higher premium based on your health status or that of your dependents (the plan can offer discounts to members who participate in programs that improve health). • You cannot be required to take a physical examination to enroll in the plan. • Insurers cannot refuse to renew a group plan just because some of the plan’s members become sick or disabled (but premiums may rise for the group as a whole). Waiting Periods Although there may be a waiting period before you can enroll in a group plan and begin to receive benefits. It cannot be based on your health status or that of your dependents. If an HMO does not exclude coverage for conditions you had before joining the plan, it can impose an waiting period for up to 60 days. During a waiting period, the plan is not required to cover any health services, but it cannot charge you any premiums. A waiting period begins on your enrollment date under the group plan; if you switch to HMO coverage more than three months after your enrollment date, the HMO cannot impose an waiting period on you. These protections come from HIPAA and California law. Self-Insured (or “Self-Funded”) group health Plans A “self-insured” (or “self-funded”) group health plan is created when an employer (or union) sets aside its own money to pay directly for its employees’ health care (instead of getting a plan from an insurance company that helps pay). By creating a self-insured plan, the employer assumes the risk for the cost of its workers’ health benefits. Usually, only large employers self-insure. An employer with a self-insured plan can make a contract with an insurance company to administer the plan (to do things like pay claims and collect premiums); this can be confusing—with an outside insurer managing the plan, you may not realize it is self-insured. Check your plan information to see if your employer’s plan is self-insured because some different rules apply to self-insured group plans, which are regulated by federal law only, not by state law. For an introduction to ERISA, an important law for members of self-insured group health plans, see pages 55-57. enrolling in a group health Plan For a limited time, health plans can exclude coverage for pre-existing conditions, which are certain health problems you had before joining the plan (see pages 42-45). The time you enroll in a group plan affects how long such an exclusion can apply to you. “Regular enrollment” is when you join a group plan as soon as you have the chance. “Late enrollment” is when you enroll after the earliest date on which coverage can become effective. (Switching during open enrollment from one of your employer’s plans to another does not make you a late enrollee.) “Special enrollment” is when individuals who previously said they did not want coverage are allowed to join a group health plan without having to wait until the next open enrollment period. “Special enrollment” can also happen when a person becomes a new dependant through a marriage, birth, adoption, or placement for adoption. The length of time a group health plan can exclude a pre-existing condition is shorter for regular and special enrollees than it is for late enrollees. Group plans must give employees a description of their special enrollment rights by the time they are offered the opportunity to enroll. A special enrollment opportunity happens when: • An employee (or dependent) loses other health insurance coverage he had when he previously declined enrollment in the group plan. (The other coverage may be lost due to a job loss, reduction of hours, divorce, separation, or death. The special enrollment right also applies if an employer ends its contributions to the other coverage.) At the time you are first offered enrollment, the employer or plan may ask for a written statement that you are declining it because you have other health insurance coverage. If you do not provide this written statement when it is requested, you may lose the special enrollment right that you would otherwise have if you lose your other coverage and want to join the group plan at a later date. • A person becomes a new dependent of an employee (or, in some cases, a retiree) based on a marriage, birth, adoption, or placement for adoption. Whatever the basis for special enrollment, you must ask for it within 30 days of qualifying for it. Your special enrollment rights come from HIPAA and California law. If the contract for your group plan (that is not self-insured) covers your spouse or dependents, California law requires that the plan grant immediate accident and sickness coverage for your newborn and any minor child placed with you for adoption. (Read the plan rules carefully—you may need to complete enrollment forms within 30 days to continue the coverage and avoid a pre-existing condition exclusion for the child.) Group plans (that are not self-insured) cannot exclude a dependent child just because he does not live with the employee or subscriber. high Deductible health Plan (hDhP) and health Savings account (hSa) This section discusses how a High Deductible Health Plan combined with a Health Savings Account serve as a system to personally finance health care services. The High Deductible Health Plans discussed in this section can offer access to doctors in many ways and vary in the types of services covered. Before enrolling in a HDHP/HSA system, think about your out-of-pocket costs and the doctors who would be available to you. “high Deductible health Plan” (hDhP) A High Deductible Health Plan (HDHP) is sometimes referred to as a “catastrophic” health insurance plan. You can purchase an HDHP as an individual on the private market, or through your employer. This type of health insurance requires you to pay three different kinds of costs: (1) premium; (2) deductible; and (3) out-of-pocket costs. Premiums: With this plan, HDHPs charge a monthly premium, much like a traditional health plan (indemnity or managed care). The premium is the amount you pay per month to be a member of the health insurance plan. HDHP’s generally have lower premiums than traditional health plans. If you have very few medical expenses and are generally healthy, you may save money by joining an HDHP If you have a chronic condition, joining an HDHP may cost you more money than a traditional managed care plan. Deductibles: Unlike managed care plans, such as an HMO, an HDHP requires you to pay a deductible before the plan pays for any of your health care. Typical deductibles are $1,000 for individuals and $2,000 for families. Having an HDHP means that until you reach your deductible, you will be responsible for paying for your health care costs, including doctor’s visits, prescription medications, medical tests, and equipment. Once you meet your deductible, the health insurance will cover your medical expenses as defined in the policy. In order to prove to your health plan that you have met or exceeded your deductible, you must save receipts from all medical transactions. out-of-pocket costs: Like a managed care plan, HDHPs charge out-ofpocket costs, such as co-pays. Co-pays are fees, typically $5 to $25, for prescription drugs or visits to your doctor.1 “health Savings accounts” (hSa) When you join an HDHP, you will have the opportunity to start a Health Savings Account (HSA). An HSA is a type of savings account that offers you tax advantages for money you set aside to pay for your medical expenses that are not covered by your HDHP HSAs are available only to individuals who are (1) enrolled in an HDHP; (2) not eligible for Medicare; (3) not covered by another health plan; and (4) not claimed as a dependent on someone else’s federal tax return. You own and control the money in your HSA. Therefore, you decide how to spend the money, but you must spend it on “qualified medical expenses.” This typically includes any expenses you have acquired while meeting your deductible. Check your policy for a list of “qualified medical expenses,” or contact your health plan to verify if an expense qualifies. Examples may include: • Dental expenses, such as teeth cleaning, oral surgery, braces, or cosmetic dental procedures. • Physical therapy, such as hydrotherapy, chiropractor services, or medical massage therapy. • Alternative treatments, such as acupuncture, aromatherapy, homeopathy, traditional Chinese medicine or nutritional consulting. • Transportation and lodging expenses related to health care. • Charges acquired as part of a preventive health program, such as vaccines, blood tests, metabolism tests, other lab tests, fees paid to a health institute, or physician-prescribed vitamins. • Nonprescription medications, such as aspirin or cough syrup. • Disability-related expenses, such as wheelchairs, telephone or TV In a given year, these costs could be as high as $5,000 for an individual and $ 0,000 for families, depending on your health plan’s maximum coverage limits.. These amounts are adjusted every year to reflect changes in the cost of living (inflation). equipment to assist hard-of-hearing individuals, or the cost and care of service animals. • Maternity expenses not covered by your health insurance policy. • Premiums to pay for qualified long-term care. Your HSA account can also be used to pay these expenses for your spouse or a dependent member of your family, even if he or she is not covered under your HDHP. You cannot use your HSA to pay your monthly premiums unless you become unemployed and elect COBRA coverage for your HDHP. Both you and your employer can contribute to your HSA. While there is no minimum contribution, the maximum total contributions may not exceed the limit established by law, which is generally the amount of your deductible. If you are self-employed or unemployed, you can also contribute to an HSA. In addition, your family may contribute to your HSA. Tax-free contributions to your account can be made annually. Unused funds and interest carry over, without limit, from year-to-year. When you leave your job, you can keep the funds contributed to your HSA. However, if you withdraw funds for non-medical expenses, you must pay taxes on the amount withdrawn plus a 10 percent penalty. The penalty does not apply if the withdrawal is made after your death or disability, or you are 65 years of age or older. Tax advantages of hSas HSAs can help you save money on insurance premiums and income taxes. HSAs allow you to legally avoid paying federal income tax by depositing into a savings account up to 100 percent of the health plan’s deductible. The deposited amount can then be claimed as an “above the line” tax deduction for the previous year’s income taxes. That means you get a federal income tax deduction for money you contribute, even if you take the standard deduction and do not itemize deductions. Many states also allow you to take a state income tax deduction for HSA contributions. In addition, interest earned from funds in your HSA is tax-free. If your employer makes an HSA contribution for you, it is “excluded” from your income and is not subject to any income tax or FICA. health Savings account vs. health reimbursement arrangement Although an HSA and Health Reimbursement Arrangement (HRA) are both tax-deferred accounts used to pay for qualified medical expenses, they are 5 not the same. First, to be eligible for an HSA, an individual must be enrolled in a qualifying HDHP an HRA can be used by anyone regardless of the type of health plan in which an individual is enrolled. In addition, HSAs can be funded by both employers AND employees, while HRAs are funded only by employers. The unused balances in both accounts roll over each year to be used for future medical expenses, but only HSA funds can be moved and remain with you if you switch jobs. You do not get to keep HRA funds if your job ends. getting health Insurance on Your own If you do not have access to an employer’s group health plan, you can apply for an “individual” health plan for you and your family. You have less protection this way, but you still have rights. An insurer generally can deny your individual application, or charge you more because you have an expensive health condition. But you cannot be refused coverage, offered limited coverage, or charged a higher rate based on your disability unless the insurer has evidence that your particular disability justifies a denial, coverage limitation, or higher premium. (The same is true when you apply for life or disability insurance.) For example, if you have End-Stage Renal Disease, the insurer may have a justifiable basis for denying your application. But if, for example, you are deaf and your deafness has no negative effect on your health, the insurer cannot deny your application or charge you a higher premium based on your being deaf. California law includes some additional protections for persons seeking health insurance. Health plans cannot refuse to cover you, limit your coverage, or charge you more just because: • You are HIV positive (but an insurer can reject you if you have been treated for HIV). • You are blind or vision impaired. • You have a family history of breast cancer, or you have had diagnostic procedures for breast disease but have not been diagnosed with breast cancer. • You have genetic characteristics associated with disability in you or your children. (An insurer cannot ask you about your genetic characteristics except for therapeutic purposes.) • You have experienced domestic violence. If your individual plan contract covers your spouse or dependents, California law requires it to grant immediate accident and sickness coverage for newborns and any minor children placed with you for adoption. (Read the plan rules carefully—you may need to complete enrollment forms within 30 days of the child’s birth or placement with you to continue the coverage.) The health Insurance application • You can be asked questions about your health and medical history if the questions are reasonable and are needed to assess the insurance risk posed by your health condition. The insurer may ask for your medical records. • You cannot be asked if you have HIV, and an insurer cannot make you take an HIV test. But an insurer can ask if you have received medical treatment for AIDS, AIDS-related complex, or an immune system disorder, and the insurer may ask if you are taking HIV-related medications. guaranteed access to an Individual health Plan Although insurers generally can refuse to sell you health insurance based on an expensive health condition, you are guaranteed access to an individual health plan (with no pre-existing condition exclusion) if: • You have had health coverage for at least 18 months without a break in your coverage for 63 days or longer. • Your most recent coverage was under a group health plan (or a government or church plan). • You “elected” and “exhausted” COBRA or Cal-COBRA coverage or you were not eligible for COBRA or Cal-COBRA (see pages 69-71 for more on COBRA and Cal-COBRA). • You currently are not eligible for coverage under any group health plan, Medicare, or Medi-Cal. • Your most recent coverage was not canceled because of fraud or because you did not pay your premiums. • You do not now have any other health insurance coverage. This right to an individual health plan for “eligible individuals” (who meet the conditions above) comes from the Health Insurance Portability and Accountability Act (HIPAA). The law allows insurers to limit your choice to two plans (either the two most popular or the two most representative). Although HIPAA does not limit premiums for these plans for eligible individuals, California law does. For example: • For plans that offer services through a preferred provider arrangement, premiums cannot exceed the average premium paid by a subscriber of the Major Risk Medical Insurance Program (MRMIP, see pages 38 41) who is the same age and lives in the same geographic area as the eligible individual. But for eligible individuals between ages 60 and 64 the premium cannot exceed the average premium paid by a MRMIP subscriber who is 59 years old and lives in the same geographic area as the eligible individual. • For plans that do not offer services through a preferred provider arrangement, premiums cannot exceed 170% of the standard premium charged to an individual who is of the same age and lives in the same geographic area as the eligible individual. But for eligible individuals between ages 60 and 64 the premium cannot exceed 170% of the standard premium charged to an individual who is 59 years old and lives in the same geographic area as the eligible individual. The premium may be adjusted for family size but may not exceed: • The average of the MRMIP rate for families of the same size that live in the same geographic area as the eligible individual (this applies to plans that offer services through a preferred provider arrangement) • 170% of the standard premium charged to a family of the same size that lives in the same geographic area (this applies to plans that do not offer services through a preferred provider arrangement). If you do not qualify for guaranteed access under HIPAA, you may still be eligible for a conversion policy (see pages 79-81). For more information about HIPAA and individual coverage, contact the Department of Managed Health Care (www.hmohelp.ca.gov; 888-HMO 2219 [voice]; 877-688-9891 [TDD]). Remember, to preserve your right of guaranteed access to an individual health plan, you must “elect” and “exhaust” COBRA or Cal-COBRA coverage if it is available to you. Read about COBRA and Cal-COBRA on pages 69-82. Major risk Medical Insurance Program (MrMIP) MRMIP (pronounced “Mr. Mip”) is a health insurance program for Californians who cannot get affordable insurance due to costly health conditions. With MRMIP, you and the state each pay part of the premiums. MRMIP is expensive and usually has a waiting list, but it may be your best insurance option if you do not qualify for public health benefits. To shorten your time on the waiting list, you can apply for deferred enrollment if you are not now eligible but expect you soon will be. To be eligible for MRMIP, you must: (1) be a resident of California; (2) not be eligible for Part A and Part B of Medicare (unless eligibility is based solely on End-Stage Renal Disease); (3) not be eligible to continue group health plan coverage under COBRA or Cal-COBRA; and (4) be unable to get adequate health coverage. You can show you are unable to get adequate health coverage if, within the 12 months preceding your application: (1) you were denied individual coverage; (2) your health insurance was involuntarily terminated (but not because of fraud or not paying premiums); (3) you were offered a premium for an individual health plan that was higher than you would pay for MRMIP; or (4) you are a “group of one” (not including dependents) that was denied group coverage (you are a group of one if you run a business and are its only employee). Your MRMIP application should include a copy of the letter that shows you meet one of these four conditions. The law forbids an employer or insurer from referring an employee or employee’s dependent to MRMIP for the purpose of separating the employee or dependent from any group health plan coverage provided in connection with the employee’s job. MRMIP Benefits & Coverage Limitations: MRMIP health plans offer benefits for inpatient and outpatient hospital and physician services. The plans vary, so learn what each covers before choosing one. The annual cap on coverage is $75,000; the lifetime cap is $750,000. If you enroll in a PPO plan, pre-existing conditions are not covered for the first 90 days. With an HMO, there is a 90-day waiting period when no health services are covered. You will not have the exclusion or waiting period if (1) you were on MRMIP’s waiting list for six months or longer; (2) you had health insurance for at least 90 days when you applied to MRMIP or within the 62 days preceding your application (if you had another health plan for at least 30 days but less than 90 days, the waiting/exclusion period is shortened but not eliminated); or (3) you had coverage through a program like MRMIP in another state within the last year. Co-payments MRMIP HMOs have fixed co-payments for some services and co-insurance up to 20% for others. MRMIP PPOs may require a fixed co payment for some services and co-insurance up to 25% for others. For all MRMIP plans, the maximum out-of-pocket expenses for a calendar year are $2,500 for an individual and $4,000 for a household. Coverage for Dependents MRMIP can cover a spouse and dependent children. You must let MRMIP know within 30 days about changes in the number of dependents. Coverage for a newborn or adopted child begins right away; coverage for other dependents starts within 90 days of your notifying MRMIP. A child is no longer a dependent if he or she marries or turns 23, but coverage for an unmarried child over 23 can continue if he cannot support himself because of a disability that developed before age 23. If You have a Disagreement with Your MrMIP Plan First follow the plan’s rules for resolving disputes. Then, if the dispute is about coverage, eligibility, or a decision to disenroll you or transfer you to a different plan, file an appeal with the Managed Risk Medical Insurance Board. For an application or information about appeals, contact the Managed Risk Medical Insurance Board (800-289-6574 [English/Spanish]; 888-877-5378 [TDD]; 800-400-0815 [voice relay]; www.mrmib.ca.gov). help for Those Who get Sick & Can No Longer afford Their Premiums You may be able to get help from the HIPP (Health Insurance Premium Payment) Program, a Medi-Cal program that pays private health insurance premiums when paying the premiums is cheaper than covering all the costs of the care that a Medi-Cal participant needs. The private health coverage for which HIPP will pay premiums includes Medicare supplemental policies (see pages 83-91) for people on Medi-Cal. Qualifying for the hIPP Program The Medi-Cal program will evaluate whether you should be in the HIPP program. To qualify for HIPP: (1) you must be on Medi-Cal; (2) your Medi-Cal share-of-cost, if any, must be $200 or less; (3) you must have an expensive medical condition; (4) at the time you apply, you must have a health insurance policy, COBRA continuation policy, or COBRA conversion policy in effect or available to you; (5) your policy must cover your expensive medical condition; (6) you must apply in time for the state to process your application and pay the premiums; (7) your insurance cannot be through the California Managed Risk Medical Insurance Board (which administers MRMIP [see pages 38-40], Healthy Families [see pages 129-131], and AIM [see page 135]); (8) you cannot be in a Medi-Cal related prepaid health plan, County Health Initiative, Geographic Managed Care, or County Medical Services Program. Apply for Medi-Cal (see pages 116-117) if you are not already on it when you get sick and need help paying your premiums. For HIPP information, call 800-952-5294. Limits on What the hIPP Program Will Pay The program will not make payments that are overdue and will not reimburse you for premiums you paid before you applied for HIPP. It cannot pay your child’s premiums if a court has already ordered an absent parent to pay them. Keep in mind, if you have Medi-Cal, you must apply for and keep any other insurance that you can have at no cost. If the state begins paying your premiums and you then drop your private health insurance without the approval of the Department of Health Services, you can lose your Medi- Cal benefits. You must give any money you get from your insurer to the 0 Department of Health Services if you are in the Medi-Cal program. For more Medi-Cal information, see pages 109-123. Care/hIPP Program for People with hIV/aIDS The CARE/HIPP Program is like HIPP, but it has some different eligibility requirements and benefits. CARE/HIPP lets you keep your health insurance coverage as you make the transition to public health benefits (including the HIPP Program and Medicare), and helps you maintain the continuity of your care. To qualify, (1) your income cannot exceed 400% of the federal poverty level (see page 129), (2) your assets (excluding one house and one car) cannot total more than $6,000, (3) you must be disabled and unable to work full-time due to HIV/AIDS, (4) you must have applied to a public or private disability program, such as State Disability Insurance or Supplement Security Income, (5) you cannot be getting help from the AIDS Drug Assistance Program (see page 118) for any outpatient prescription drug that can be covered by private health insurance, and (6) you must have private health insurance coverage that includes outpatient prescription drug coverage and does not exclude HIV-related treatment. You can participate in CARE/HIPP for a maximum of 29 months. For information, call the California AIDS Hotline (800-367-AIDS [2437]); www.aidshotline.org. Your right to Continue Your health Plan Your plan cannot cancel or refuse to renew your coverage on the basis of your getting sick or becoming disabled. Except for short-term limited duration insurance, you have the right to continue your plan, unless: • You do not pay your premiums or contributions, or your payments are late; • You commit fraud or intentionally misrepresent an important fact; • There is good cause, as defined by the plan contract; • You move out of the plan’s service area; • You end your membership in the association through which you got your coverage; • The insurer stops providing services for new plans (in which case, you [or the employer holding the contract for the plan] must be given 180 days’ notice before coverage is discontinued); or • The insurer withdraws a particular health benefit plan from the market (in which case you [or the employer holding the contract for the plan] must be given 90 days’ notice before the plan is discontinued, and the insurer must make its other plans available regardless of claims experience or health- related factors). If you cancel your policy, you lose your right to renew it. Pre-existing Conditions During a pre-existing condition exclusion period, a plan can refuse to cover pre-existing conditions but must cover health services that are part of the plan’s benefits and are for conditions not related to a pre-existing condition. A “pre-existing condition” is a health problem you had before joining a plan. The law defines this term more narrowly as any physical or mental health condition for which medical advice, diagnosis, care, or treatment (including prescription drugs) was received or recommended during the “look-back period.” The “look-back period” is the maximum period of time that a plan can examine for evidence of a pre-existing condition. The look-back period is the six months immediately preceding your enrollment (or the first day of a waiting period) in a group plan covering at least two current employees or an individual plan covering at least three people. If, for example, you had cancer years ago but have not seen a doctor about it in at least six months, your plan cannot exclude coverage for cancer treatment needed after you enroll. But if you saw a doctor for anything related to your cancer (even just to be sure you were still in remission) within the six-month period before your enrollment, then your cancer is a pre-existing condition for which coverage can be excluded. The look-back period can be as long as a year if you join a group plan with only one current employee or an individual plan covering only one or two persons. Do not confuse (1) the limitation on how far back a plan can look for purposes of applying a pre-existing condition exclusion, and (2) how far back it can look to see if you have had a health problem that justifies denying your application for an individual health plan. The look-back period limits which pre-existing conditions can be temporarily excluded from coverage once you are enrolled in the plan. Although a group plan cannot exclude you based on your health status (see page 30), an insurance company can refuse to sell you an individual plan based on your having an expensive health problem (see page 36) unless you have guaranteed access to an individual plan (see pages 37-38). how Long a Pre-existing Condition exclusion Can apply You must be told in writing if your plan has a pre-existing condition exclusion. The exclusion can last up to six months from the enrollment date for individual and group plans covering at least three people. It can apply up to 12 months if you are part of a self-insured plan or have an individual or group plan covering one or two people. The enrollment date is the first day of coverage but, if there is a wait before coverage becomes effective, it is the first day of the waiting period. If you are a “late enrollee” (see page 32), the pre-existing condition exclusion period can last as long as 18 months for self-funded group plans. If you are a late enrollee for a group plan that is not self-funded, the plan can exclude you from coverage for up to 12 months from the date you apply for coverage; after the plan enrolls you, it can impose a pre-existing condition exclusion for up to six months. You can shorten or avoid the pre-existing exclusion period if you have “creditable coverage” (see below). If you are joining a plan with a preexisting condition exclusion that will affect you, COBRA may help you continue your old coverage until the new plan covers your pre-existing condition. See pages 69-76. how the Law helps Many people used to stay in their jobs because they feared that a new employer’s health plan might not cover pre-existing conditions. With HIPAA and related state laws, there is more freedom to change jobs because a pre-existing condition exclusion can apply for only a limited time. This does not mean that a new job will come with the same health benefits you had with your old job. The law does not require employers to offer health insurance, and employers have a lot of freedom to decide what benefits are provided. HIPAA also helps people get and keep health insurance through group plans by forbidding the exclusion of employees and dependants based on their health or disability (see page 31). In some cases, HIPAA guarantees access to an individual plan (see pages 37-38). Shortening the Pre-existing Condition exclusion Period with Creditable Coverage “Creditable coverage” (which includes most private health plans and public health benefit programs) gives you credit for prior health coverage and shortens how long a plan can exclude coverage for a pre-existing condition. Creditable coverage helps when you are moving from one group plan to another or from a group to an individual plan or from an individual plan or public health benefits to a group plan. You show creditable coverage to your new plan with a “certificate of creditable coverage,” a statement from your old health plan(s) that documents prior health coverage. Often, you get this certificate automatically, but you may have to ask for it. Keep the certificate in a safe place; you will need it if you join a new plan. If you lose the certificate and cannot replace it, you can use other documents (like pay stubs showing a deduction for health insurance, forms explaining your previous benefits, or your doctor’s verification that you had insurance) to show creditable coverage. Creditable coverage does not include coverage that you had before a “significant break” in health insurance coverage. This is usually a gap of 63 or more days in coverage. But, under California law, it is a break of more than 180 days if you are enrolling in a new group plan and your previous health coverage ended because you lost your job or your employer stopped offering, or contributing to, your health benefits. Days in a waiting or affiliation period when you do not have other coverage are not creditable coverage but are not counted as part of a break in coverage. You may be able to avoid a significant break in coverage by electing COBRA coverage (see pages 69-76) or purchasing an individual health plan (see page 37-38). You can add together different periods of coverage if they are not separated by a significant break. Even if you do not have a significant break in coverage, when you join a self- insured group plan, a pre-existing condition exclusion may apply for certain types of benefits (mental health, substance abuse treatment, prescription drugs, dental care, and/or vision care) if your old plan did not include those benefits. For example, if your old plan did not cover prescription drugs, but your new self-insured plan does, it can apply a pre-existing condition exclusion for the prescription-drug benefit. If a plan has a pre-existing condition exclusion, it must calculate your creditable coverage, let you know how long the exclusion will apply, explain how it reached its decision, and tell you about any available appeal process. When a Pre-existing Condition exclusion Cannot apply For group plans, a pre-existing condition exclusion cannot apply to: • A condition related to pregnancy or maternity care; • A newborn, an adopted child under age 18, or a child placed for adoption before turning 18, if the child became covered under the plan within 30 days of the birth, adoption, or placement for adoption, as long as the child does not then have a break in coverage for 63 or more days. (Under California law, a parent’s group health plan [that is not self-insured] that covers a spouse or dependents must grant immediate accident and sickness coverage for newborns and minor children who are newly adopted or placed for adoption. The plan may require you to complete enrollment forms for the child within the first 30 days of this coverage so be sure to get your child enrolled on time to avoid a pre-existing condition exclusion.) Benefits Your Health Plan Must Include As long as all similarly situated employees are treated alike, employers can usually change the mix of health benefits offered, even if the change leaves you with worse coverage. Employers and insurers are generally free to offer different benefits for different conditions or to exclude all coverage for certain conditions or treatments. For example, your plan may cap benefits for AIDS but not other diseases. Or it may exclude coverage for in-vitro fertilization or acupuncture. But the law requires health plans to include certain benefits. Important examples are below. (This is not a complete list of the benefits your plan may need to include. For example, it does not discuss the basic benefits, such as preventive and emergency health services, that must be part of an HMO plan.) all Individual and group health Plans Must Include the Following Benefits: Breast Cancer Treatment and reconstructive Surgery after a Mastectomy: If your plan covers mastectomies, it must cover related reconstructive surgery for both the breast that had the mastectomy and the other breast (to create a symmetrical appearance) and prostheses and treatment of physical complications during any stage of the mastectomy (including lymphademas). This coverage right comes from the Women’s Health and Cancer Rights Act (for self-funded and other group plans) and California law, which requires that individual and group plans (that are not self-funded) cover screening, diagnosis, and treatment for breast cancer. hospital Stays related to Childbirth: Health plans generally cannot limit coverage for hospital stays for childbirth to less than 48 hours following a vaginal delivery or 96 hours following a cesarean section. You and your doctor may decide that you want to leave earlier, but you cannot be pressured to do so. This protection comes from the Newborns’ and Mothers’ Health Protection Act (for group plans including self-funded plans) and state law (for individual plans and non-self-funded group plans). Under California law, you may be discharged earlier than 48 or 96 hours after the delivery if your plan covers a post-discharge follow-up visit for you and your newborn within 48 hours of the discharge, when prescribed by your doctor. The doctors who treat you must consult you before making the decision to discharge you. The post-discharge visit is provided by a licensed health care provider whose practice includes postpartum and newborn care. This visit must include parent education, assistance and training in breast or bottle feeding, and any needed maternal or neonatal physical assessments. Your doctor must inform you of the availability of the post- discharge visit. You and the doctor should decide whether the visit should be 5 in your home or at a doctor’s office or plan facility. In making this decision, your family’s transportation needs and environmental and social risks should be considered. under California Law, Individual and group health Plans (That are Not Self-Insured) Must Also Include the Following Benefits: Mental health Care: Diagnosis and medically necessary treatment for children and adults with severe mental illness and for children with serious emotional disturbances. Mental health care benefits (such as outpatient and hospital services and prescription drugs) must be provided on the same basis as benefits for other medical conditions (e.g., same maximum lifetime benefits, co-payments, deductibles). See Mental Health Parity section on pages 48-49 for more information. Diabetes: Equipment and supplies for managing and treating diabetes, even if the items are available without a prescription. If the plan covers prescription drugs, it must cover medically necessary insulin, glucagon, and other diabetes medications. Plans must cover appropriate outpatient self- management training, education, and nutrition therapy. reconstructive Surgery: Reconstructive surgery to correct abnormalities caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease if surgery is needed to improve function or create a normal appearance. Cancer Screening: All generally recommended screening tests; breast cancer screening, diagnosis, and treatment; screening and diagnosis of prostate cancer (including prostate-specific antigen (PSA) testing and medically necessary digital rectal exams); and an annual cervical cancer screening test if you are referred for it and your plan covers cervical cancer treatment. osteoporosis: Diagnosis, treatment, and management of osteoporosis, including medically appropriate bone mass measurement technologies. anesthesia and hospital Charges for Dental Care: General anesthesia and facility charges for dental procedures performed in a hospital because your medical condition requires general anesthesia for the procedure. This coverage is available only for (1) children under age seven, (2) developmentally disabled individuals, or (3) persons with health conditions that make general anesthesia medically necessary. PKu Testing and Treatment: Testing and treatment (including the extra cost of special formulas and food products) of phenylketonuria (PKU), a metabolic disease that causes mental retardation and other problems if treatment does not start within the first few weeks of a baby’s life. If Your Plan Includes Prescription Drug Coverage: California law requires individual and group (not self-insured) plans that include a prescription drug benefit to: • Not limit or exclude coverage for a drug just because it is prescribed for a different use than the one for which it was approved by the Food and Drug Administration (FDA), as long as (1) the FDA approved the drug, (2) your doctor prescribed it to treat a life-threatening condition, and (3) it has been recognized as a treatment for your condition. • Cover prescribed pain management medications that are medically necessary for terminally ill patients. • Not limit or exclude coverage for a drug that it previously approved for your condition if (1) the prescribing doctor continues to prescribe the drug, (2) it is appropriately prescribed, and (3) it is a safe and effective treatment for your condition (but a generic drug may be substituted, and your doctor may decide another drug is appropriate). • Have an effective procedure for you to seek timely approval for coverage of non-formulary prescription drugs. (A “formulary” is a list of prescription drugs covered by a plan.) • Cover a variety of FDA-approved birth control methods if the plan covers outpatient prescription drugs. (Certain church employers can have group plans that exclude coverage for birth control.) In addition to the mandatory benefits discussed above, a hospice care benefit must be included in group health plans licensed by the Department of Managed Health Care (see page 28) and issued, amended, or renewed after December 31, 2001. Remember, even for benefits your plan must include, you may still have co-payments, co-insurance, and deductibles, just as you do for your plan’s other benefits. You may still need to show particular treatments are medically necessary, and you may need prior authorization (see pages 14-15, 29). Mental health Parity Law: If you are currently enrolled in a health care plan, such as an HMO, PPO or POS, and have a mental health condition, you should be aware of California’s mental health parity law (AB88). Mental health parity in California has two requirements. 1. HMOs, PPOs and POS plans must provide mental health care services that are necessary for the diagnosis and treatment of “severe mental illness” or “serious emotional disturbances of a child” including: • Outpatient services; • Inpatient hospital services; • Partial hospital services; and • Prescription medications, if covered by the plan for other health conditions. To find out what mental health benefits you are entitled to under your insurance, carefully review the Evidence of Coverage/Contract and Disclosure Form given to you by your plan. 2. HMOs, PPOs and POS plans must provide the same coverage for “severe mental illness” or “serious emotional disturbances of a child” as provided for other medical health care services covered under the plan. In other words, these plans must apply the same copayments, deductibles and maximum life benefits (caps) for mental health care services as applied to other medical benefits covered under the plan. The mental health parity law defines “severe mental illness” as: • Schizophrenia; • Schizo-affective disorder; • Bipolar disorder (manic-depressive illness); • Major depressive disorders; • Panic disorders; • Obsessive-compulsive disorder; • Pervasive developmental disorder or autism; • Anorexia nervosa; and • Bulimia nervosa. The mental health parity law defines “serious emotional disturbances of a child” as a child who has one or more mental disorders, other than a substance use disorder or developmental disorder, that result in behavior inappropriate to the child’s age according to expected norms, and who meets certain other criteria. See Welfare and Institutions Code 5600.3(a)(2) for further details on the other criteria. Mental health parity applies only to HMOs, PPOs and POS plans. It does not apply to self-insured employer plans and Medi-Cal. To find out if your health care plan is self-insured, talk to your Human Resources department. If you are enrolled in a Medi-Cal managed-care plan, consult your plan materials, or contact the plan for additional information about available mental health services. getting the Care you Need If your health care plan will not authorize coverage for the diagnosis or medically necessary treatment of one of the above conditions, you should contact your health plan’s Member Services Department for assistance, which can help you decide if the recommended care is covered by your plan. If, after talking to the Member Services Department, your plan continues to deny, delay, or modify the medically necessary care your provider requested, you have the right to file a grievance. For routine matters you must first file a grievance with your health plan. Your health plan must resolve your grievance within 30 business days. If the plan’s original decision is upheld or remains unresolved after 30 days, you have the right to file a request for an Independent Medical Review (IMR) through the Department of Managed Health Care. You should contact the California HMO Help Center, a part of the Department of Managed Health Care, for assistance in requesting an IMR. Call 888- HMO-2219 / 877-6889891 (TDD) or visit their website http://www.hmohelp.ca.gov/. Also, for more information about filing a grievance or requesting an IMR, see pages 57-65 in this book. If you have an “imminent and serious” threat to your health, you may contact the HMO Help Center immediately without having to file a grievance with your health plan. For additional information on mental health conditions, laws, and resources you may contact: The National Alliance for the Mentally Ill (NAMI) Website: http://www.nami.org/ Phone: 703-524-7600 Info Help Line: 1-800-950-NAMI (6264) California Coalition for Mental Health (MHAC) Website: http://www.mhac.org/ Network of Care Website: http://www.networkofcare.org/ Email: info@networkofcare.org access to health Care Providers Many health plans place restrictions on your access to health care providers. State laws limit the extent to which insurers can do this. These laws govern all plans except those that are self-funded (see page 31). Pages 41 to 49 discuss state law protections that help you get medical opinions and treatment from appropriate providers. As you read about these protections, keep in mind that many plans require prior authorization (see pages 14-15) for certain health services, including visits to specialists and out-of-network providers; get these advance approvals in writing to avoid a problem later. Health plans must ensure that you can get health care within a reasonable time and appropriate referrals without difficulty. Plans must also provide “continuity of care,” which means there are no major or harmful gaps in your care. Maintaining continuity of care is important when you are losing access to a provider who is in the midst of treating you for a serious health condition. In some cases, for a limited time, you will be able to continue getting treatment from a provider you had before joining a new plan or from a provider whom the plan has terminated. Picking and Working with a Primary Care Doctor Much of the time you will work with your primary care doctor. Primary care doctors take care of your general health needs and maintain the continuity of your care. They provide preventive and primary care, address psychosocial issues, and treat the majority of health problems, including acute and chronic conditions. They also decide when you need referrals for specialists, who focus on treating specific health conditions, parts of the body, or age groups. Your health plan must let you pick any available primary care doctor who contracts with the plan in the service area where you live or work. You may be assigned a doctor if you ask for one who is not available when you enroll in the plan, but you can switch if you do not like that provider (follow any plan rules for changing doctors). For tips on picking your doctor, see pages 15-16 and page 50. An obstetrician-gynecologist can be your primary care doctor as long as she meets your plan’s requirements for being a specialist with primary-caredoctor status. Direct access to a gynecologist or obstetrician Without a referral Your plan cannot make you get prior approval to see one of its obstetricians, gynecologists, or family practice doctors who provide obstetrical and gynecological services. Your plan may require the doctor providing your gynecological/obstetrical care to inform your primary care doctor about your condition, treatment, and any need for follow-up care. If your plan limits coverage for visits to other doctors to whom you have direct access, it can have the same (but not any stricter) limits for your obstetrical/gynecological visits. access to Specialists Many health plans make you get a referral to see specialists. You will often need to bring a written referral to the appointment with the specialist. If your primary care doctor and the specialist you want to see are in the same plan but different medical groups, your plan may have a special procedure you need to follow. Make sure the specialist is in your plan and the right medical group before making the appointment. Standing referrals for Specialists Every plan must have a way for you to get a “standing referral” to a specialist or specialty care center if you have a condition or disease that (1) requires specialized medical care over a prolonged period of time and (2) is life- threatening, degenerative, or disabling. A “standing referral” lets you see a specialist for multiple visits without a new referral for each visit. You should be able to get a standing referral if your primary care doctor, in consultation with the specialist and the plan’s medical director, decides that the specialized medical care is needed for your health. The plan has three business days to decide about the standing referral after it receives the request from you or your primary care doctor, your medical records, and other relevant information. Along with the standing referral, you may get a treatment plan. The treatment plan can limit the number of specialist visits, or how long the visits are authorized, and it can require the specialist to give regular reports to your primary care doctor. access to an aIDS/hIV Specialist California HMOs must allow HIV-positive members to get standing referrals to a doctor who specializes in treating HIV/AIDS. access to a Specialist Who Is Not Part of Your Plan Your plan generally does not have to refer you to a specialist or specialty care center that is not employed by or under contract with the plan unless the plan does not have the type of specialist you need. Your rights When Your Plan Terminates Your Provider If your HMO is ending its contractual relationship with your primary care doctor or her medical group, it must first give you notice of 30 days and let 5 you know how to select a new doctor. If you are getting treatment for an acute condition, a serious chronic condition, a high-risk pregnancy, or a pregnancy that is in its second or third trimester, you may be able to continue getting care from a provider whom your plan is terminating, but you must first ask the plan. Consult your plan’s Evidence of Coverage (see page 29) or ask a plan representative how to get approval to be covered for treatment with a terminating provider. If the care is for an acute condition or serious chronic condition, the plan should let you have services from the terminated provider for up to 90 days or longer if necessary for a safe transfer to another provider. If the care is for