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Here
are tips to help get the best care for you and your family:
Stay Informed
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Read
your health insurance policy and member handbook. Make
sure you understand them, especially the information
on benefits, coverage, and limits. Sales materials or
plan summaries cannot give you the full picture.
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See
if your plan has a magazine or newsletter. It can be
a good source of information on how the plan works and
on important policies that affect your care.
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Talk
to your health benefits officer at work to learn more
about your policy.
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Ask
how the plan will notify you of changes in the network
of providers or covered services while you are part
of the plan.
Look
for a doctor who...
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Has
received high ratings for quality of care.
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Has the training and experience to meet your needs.
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Takes steps to prevent illness—for example, will
talk to you about getting the screening tests that are
right for you.
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Can
get you admitted to or treat you at the hospital of
your choice.
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Is
part of your healthcare plan, unless you are willing
to pay extra.
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Will
work with you to make decisions about your healthcare.
Talk to your doctor
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Ask
your doctor about regular screenings to check your health.
Discuss your risk of getting certain conditions. What
lifestyle choices and changes might you need to make
to lower your risks or prevent illness?
-
Ask
questions and insist on clear answers.
-
Ask
about the risks and benefits of tests and treatments.
Tell your doctor what you like and dislike about your
choices for care.
-
Make
sure you understand and can follow the doctor's instructions.
You may want to bring another person along or take notes
to help you remember things.
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Keep
Track
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Write
down your concerns. Start a health log of symptoms to
help you better explain any health problems when you
meet with your doctor.
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Set
up health files for family members at home. This will
help you to monitor care. Include health histories of
shots, illnesses, treatments, and hospital visits. Ask
for copies of lab results. Keep a list of your medicines,
noting side effects and other problems (such as other
drugs and foods that should not be taken at the same
time).
How Do I Obtain Care? Learning what you
can expect from your health plan and how it works are key
steps to getting the care you need. Ask these questions:
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When
are the offices open? What if I need care after hours?
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How
do I make appointments? How quickly can I expect to
be seen for illness or for routine care?
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If
I need lab tests, are they done in the doctor's office
or will I be sent to a laboratory?
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Will
most of my appointments be with the primary care doctor?
Will nurse practitioners or physician's assistants sometimes
give care as well?
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Is
there an advice hotline? Some plans have toll-free phone
services that help members decide how to handle a problem
that may not require a doctor's visit.
Find out how your plan provides care outside the service
area and what you must do to get care. This is especially
important if you travel often, are away from home for long
periods, or have family members away at school.---> What
if I Have to Go to the Hospital?The time to find out
what rules your plan has on hospital care is before you
need it.
When choosing a treatment, make sure
you understand:
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Your
diagnosis.
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How soon you need to be treated.
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Your treatment choices.
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Whether the treatments are based on the latest scientific
evidence.
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The benefits and risks of each treatment.
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The costs of each treatment.
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How
much experience your doctor has in treating your condition.
Planned
Hospitalizations
Unless it is a medical emergency, your health plan or primary
care doctor will probably have to give advance approval
(preadmission certification) for you to go to the hospital.
Otherwise, the cost of your hospital care may not be covered.
Ask these questions:
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What
hospitals are part of the plan network?
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Is
there a limit on how long I can stay in the hospital?
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Who
decides when I am to be discharged?
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Will
needed follow-up care, such as nursing home or home health
care, be covered by the plan?
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If
I have a serious medical problem, will the plan provide
someone to oversee care and make sure my needs are met?
Ask
how your plan handles getting a second doctor's opinion on
whether surgery or another treatment is needed. Are second
opinions encouraged or required? Who pays?
Try
to look for a hospital that:
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Is
accredited by the Joint Commission on Accreditation
of Healthcare Organizations.
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Is rated highly by the State and by consumer
groups or other organizations.
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Is
one where your doctor can treat you.
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Is
covered by your healthcare plan.
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Has
a lot of experience and success with your condition.
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Monitors
quality of care and works to improve quality.
Emergency
or Urgent Care
If
you have a true medical emergency, you should go to the nearest
hospital as fast as possible. It is important for you to know
what kind of medical problems are defined as emergencies and
how to arrange for ambulance service, if needed. Most plans
must be told within a certain time after emergency admission
to a hospital. If the hospital is not part of the plan network,
you may be transferred to a network hospital when your condition
is stable. Ask these questions:
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How
does the plan define "emergency care?" What
conditions or injuries are considered emergencies?
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How
does the plan handle "urgent care" after normal
business hours? Urgent care is for problems that are not
true emergencies but still need quick medical attention.
Check with your plan to find out what it considers to
be urgent care. Examples may include sore throats with
fever, ear infections, and serious sprains. Call your
primary care doctor or the plan's hotline for advice about
what to do. The plan may also have urgent care centers
for members.
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How
do I get urgent care or hospital care if I am out of the
area? How must I tell the plan and how soon after I get
the care?
What if I Am Not Satisfied with My Care?
Getting
the best care and services means understanding how your health
plan works, what your rights are, and how to complain if you
need to. You have the right to get copies of test results
as well as medical information about yourself. If you are
in a managed care plan, you can ask to change your primary
care doctor if you are unhappy with the relationship. You
may also be able to switch plans during open enrollment. Most
plans have an appeals process that both you and your doctor
may use if you disagree with the plan's decisions. If your
plan refuses to provide or pay for services, you can complain
or file a grievance about any decision you feel is unfair
or you can appeal it. You
can contact the member services division of your plan for
more information or to complain. Use your plan's complaint
process fully before taking other action. Be
sure to keep written records of:
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All
correspondence with the plan.
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Claims
forms and copies of bills.
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Phone
conversations—the date and time, the people you
speak with, and the nature of each call.
If
the plan does not satisfy you, you may decide to bring the
matter to the attention of your employee benefits manager,
your state insurance commissioner, your state department of
health, or the legal system. If you are a Medicare or Medicaid
beneficiary, you have additional ways through those programs
to file a grievance about the care received from a plan or
provider. For information, contact your state's medical Peer
Review Organization or state Medicaid Program.
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Some of the above material is from Choosing
and Using a Health Plan. AHCPR Publication No. 97-0011, March
1997. Agency for Health Care Policy and Research, Rockville,
MD, and the Health Insurance Association of America, Washington,
DC. Works by the U. S. Government are not eligible for U.
S. copyright protection.
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