What to do When You Are Unhappy with Your Health Care HMO
Many Pennsylvanians get their health care from a Health Maintenance Organization (commonly referred to as an HMO). This brochure explains consumer rights if they are members of HMOs that are governed by Pennsylvania law.
As a member of an HMO, State Law gives you important rights. If you have a problem getting quality care from your plan when you need it, speak up! Do it for yourself and for others that may have the same problem. Here's how:
Call your Plan's Member Service Department.
The phone number is on your card or in your member handbook. Explain your problem.
What if I Don't Like What They Tell Me?
Tell them you want to file a formal complaint or grievance. Insist that they write down the problem and send you a copy.
Where Does All This Lead?
Under State Law, the plan must review your problem and issue a written decision. If you are still not satisfied, you can ask for a second review by the plan. Again, the decision must be in writing.
It's Always My Health Plan Making the Decision. Do I Ever Get an Independent Review?
Yes, but you have to hang in there. If your plan has denied care or services because they claim you don't need them, the next review is by an independent "external" organization or state agency. Be careful! You must ask for this review in writing within 15 days of the plan's second review decision. You can appeal to either the Department of Health (1-888-466-2787) or the Insurance Department (1-877-881-6388) . They will figure out which of them should act on your problem.
All This Will Take Time! What if My Situation Is Urgent?
Your plan must make a decision within 48 hours if they denied care or services because they claim you don't need them but your doctor certifies that your life, health or ability to attain, maintain or regain maximum function would be jeopardized by waiting 30 days for a complaint or grievance decision. Speak up if you think your situation is urgent!
Can I Get Help?
Yes! If you give written approval, your doctor or other health care provider can file and pursue a grievance on your behalf. Keep in mind that you give up your right to file your own grievance when you let your health care provider do it for you.
You can also have a family member, friend, attorney, or another person act as your representative.
When Should I Contact My Plan About Problems I'm Having Getting Health Care Services?
These are examples of the types of concerns that consumers should raise with their health plan through a Complaint or Grievance:
- "My doctor says I need five hours of home health care, but the plan will only pay for two."
- "My doctor has recommended a bone marrow transplant for my cancer, but the plan says it's experimental."
- "There are no specialists in the plan who can treat my illness."
- "The plan won't pay for my use of the emergency room, but I thought I had an emergency."
- "I haven't been able get an appointment to see a doctor for over a month!"
Do You Have Any Helpful Tips?
- It's very important to collect information that supports your point of view, and send it to the right person at your health plan. Keep copies!
- If your problem involves a denial of care or services, it is important that the doctor who is prescribing the care or services write a strong letter supporting your need.
- If you get your health care through an employer, be sure to tell the benefits manager of your problem.
Do I Have Other Rights?
Yes! You have many other legal rights that are not discussed here, including the right to lots of information about your plan and its covered services.
For more information on the appeals process if you are in a Medical Assistance HMO, see our booklet, “Appealing a Coverage Decision Made by Your Medical Assistance Plan,” available on our Web site: www.phlp.org.
P ennsylvania H ealth L aw P roject
123 Chestnut Street, Suite 400
Philadelphia , PA 19106
(215) 625-3663
Help Line : 1 (800) 274-3258
Copyright © 2009 Pennsylvania Health Law Project
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