Insurance expert and Montgomery County criminal defense lawyer Jay Glickman has laid out this guide for any readers who may be thinking of joining an HMO. If you are thinking of joining an HMO, consider the following:
Q: What is an HMO?
A: An HMO is a group that contracts with medical facilities, physicians, employers, and sometimes individual patients to provide medical care to a group of individuals. This care is usually paid for by an employer at a fixed price per patient. Patients generally do not have any significant “out-of-pocket” expenses.
Q: This sounds like a great deal. What’s the catch?
A: The catch is rationed care. An HMO is usually a for-profit corporation with responsibilities to its stockholders that take precedence over its responsibilities to you. The HMO, directly and indirectly, controls the amount of health care that the doctor is allowed to provide to you.
Q: I’ve been going to my doctor for a long time. If I change my insurance to an HMO, can I continue to go to the same doctor?
A: Probably not. Unless your personal physician happens to be a member of the HMO, you can no longer continue to see that doctor under the terms of the plan.
Q: My doctor is a member of the HMO my employer is offering. My company is also offering traditional insurance. Shouldn’t I sign up for the HMO since my doctor is a member?
A: Once you are a patient in an HMO, your relationship with your doctor may be restricted. For example, if the doctor is a specialist, you probably cannot continue to go to that doctor. Many HMOs require you to choose a primary care doctor, usually a family practitioner, from their list.
The primary care doctor, sometimes called a “gatekeeper,” controls your access to medical care within the plan. Unless the “gatekeeper” decides your medical problem is outside his or her own sphere of expertise, you will not get approval to go to a specialist.
Even if your original doctor is a family practitioner, you may still notice a change in your relationship. The doctor may not be as free to order special tests for you, may not be able to refer you to a specialist, or allow you to go to an emergency room.
You may also find that there is considerable turnover at the HMO, especially if it has “gatekeeper” doctors. Such doctors frequently feel frustrated because of the conflict of interest engendered by their position.
Q: I prefer to go to a particular hospital. Can I still go there if I join an HMO?
A: It depends on the plan. Many HMOs limit you to selected hospitals where they have arranged discounts. If your hospital is not on the list, you’re out of luck. Moreover, if you need care when you’re away from home, be prepared for some red tape. Unless your situation fits the HMO’s definition of an emergency, the HMO will probably not pay your bill.
Q: What is the advantage of conventional insurance over an HMO?
A: You can choose any doctor. You can go to virtually any hospital, anywhere in the country. You can continue seeing the same doctor you always have even if you change jobs or insurance plans. You have the assurance that your doctor’s medical recommendations are being made entirely in your best interest.
Q: My enrollment for medical coverage comes up soon. I am being asked to choose between an HMO, a PPO (Preferred Provider Organization), and standard 80/20 medical insurance. How do I decide?
A: Talk to your doctor. Doctors know a lot about health care coverage because they see it from the inside. Don’t sign up with a plan simply because there are no out-of-pocket expenses – care may be rationed in many ways and access to care limited. Your personal physician is your advocate in health care and can help you determine the real value of the options open to you.
Q: My doctor has recommended a course of treatment. What should I do to prevent possible later problems with my Group Health Plan?
A: Your Group Health Plan sets the limits on what it will cover. You should become familiar with your Group Health Plan early in the treatment process.
If you do not have a copy of your plan, make a written request via certified mail return receipt requested to your Personnel Department at work. You need to make a written request to get a copy of both the summary plan description and the plan. Both documents are important.
Follow the plan’s directions, and look for any “pre-certification” requirements. (If your plan has pre-certification requirements, you will need to get the approval of the group health plan before treatment begins.) You should make written inquiries and insist on written responses.
Q: You say I have to get the summary plan description and a copy of the Plan. What if my company refuses to give copies to me?
A: The plan administrator may make a reasonable charge for any copies you request. The plan administrator must make every effort to provide you with the information or documents you request within 30 days after you request them. The plan will notify you if it needs more time to comply with your request. If you do not receive the materials you request within 30 days, you may sue in a federal court.
Q: Will my group health plan cover all forms of treatment?
A: You should always check your group health plan to see what it will and will not cover. Group health plans that cover treatment for cancer, for example, generally cover most recognized forms of treatment: e.g., chemotherapy, radiation therapy, surgery, and so forth.
However, most group health plans have provisions that exclude certain forms of treatment. Your plan may exclude experimental treatment or treatment not proven medically beneficial. Group health plans place limits on the amount of money they will pay on any particular claim.
Q: My group health plan has denied coverage for treatment, saying it is experimental, investigative, or of no beneficial use. What should I do?
A: Contact your doctor’s office and explain the problem. The group health plan may need additional information from your doctor explaining the procedure.
Q: What if my doctor says I need this treatment and the plan will not listen to my doctor?
A: Be persistent. Usually, claims must be processed within ninety (90) days. Any claim denial must be in writing, and must explain the basis for denial of the claim and the steps that you can take to appeal the decision. Your appeal must be in writing. Be sure to keep a copy of the letter.
If the group health plan makes an initial denial of your claim, you may want to contact an attorney familiar with “ERISA” immediately. The reason for this is that some courts only will consider evidence the group health plan had before it during the appeals process.
Q: My group health plan has denied my claim, contending I have a “preexisting condition.” What is a preexisting condition?
A: Many group health plans define a preexisting condition as any condition for which you sought treatment, or should have sought treatment, during a specified period before the plan began covering you.
Most group health plans have a preexisting condition clause saying that, for a certain period in the future, it will not cover any preexisting condition. After the plan covers you for the required length of time, it will cover your preexisting condition. You may contest the denial of a claim that the plan says is preexisting, just like you can contest other denials.
Q: Our doctor says a family member requires round-the-clock home nursing services. My group health plan covers skilled nursing care. My group health plan says the care is custodial care not skilled nursing care. It refuses to pay. What is custodial care?
A: This is a common question of families with a seriously ill member. A court recently found that constant nursing attention that included restraining the patient, inserting a catheter, deciding when to administer a prescription drug, closely monitoring her for malnutrition and dehydration and attending to her pressure sores was not custodial care.