Many Pennsylvanians get their health care from managed care plans such as HMOs. State Law gives these consumers 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:

The phone number is on your card or in your member handbook. Explain your problem.

Tell them you want to file a formal complaint or grievance. Insist that they write down the problem and send you a copy.

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.

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" grievance group. Be careful! You must ask for this review within 15 days of the plan's second review decision. You can appeal these other types of problems 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.

Your plan must make a decision within 48 hours if they denied care or services because they claim you don't need them and your life, health or ability to regain maximum function is in jeopardy. Speak up if you think your situation is urgent!

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.

These are examples of the types of concerns that consumers bring to their health plan's attention:

• "My doctor says I need five hours of home health care, but my plan will only pay for two."
• "My doctor has recommended a bone marrow transplant for my cancer, but my plan says it's experimental."
• "There are no specialist in my plan who can treat my illness."
• "My 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!"

• 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 for your doctor or another expert to 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.

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.

Pennsylvania Health Law Project

801 Arch Street, Suite 610A

Philadelphia, PA 19107-2421

(215) 625-3663

Help Line: 1 (800) 274-3258

Copyright (c) 1999

Pennsylvania Health Law Project

March 1999. PHLP is a Pennsylvania public interest law firm. Most laws differ from state to state. Even federal laws can be administered differently in different states. We are providing this information as a public service. We try to make it accurate as of the date indicated for each brochure. Sometimes the laws change. We cannot guarantee or promise that this information is always up-to-date and correct. If the date provided is not within the past year, call us and ask for an update. The information in this brochure is for public education only and should not be taken as legal advice. If you need legal assistance or advice on a specific problem, you should consult an attorney.