Minnesota Attorney General's Office
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St. Paul, MN 55101
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Your Rights as a Patient in an HMO
Your health is important. If you have health coverage, it's helpful to understand how it works. Start here. We'll help you understand what type of policy you have, how to read your policy, and what your rights are in an HMO. We will also show you how you can fight back to get the health care you need.
I. Understanding What Type of Policy You Have
Different types of private health care coverage are available in today's marketplace. You have somewhat different rights depending on the structure of your plan. For example, you may have private health care coverage through an individual policy or a group policy. These differ a little bit. With an individual policy, you purchase a policy from a health carrier. Under a group policy, a "group," is most typically an employer that either purchases a "fully-insured" policy from a health carrier or becomes "self insured." Either way, you, as an employee, have coverage through the group plan. Let's look at these types of health insurance one at a time.
You may purchase an individual policy from a health maintenance organization (HMO), insurance company or nonprofit health services corporation such as Blue Cross Blue Shield of Minnesota. In exchange for the premium you pay, the health carrier agrees to cover you and your dependents if you become sick or injured.
Remember that there are three separate relationships. First, you have a policy issued to you by a health carrier. This legally binding contract will have different names, depending on the type of health carrier that issues it. Second, you have a "doctor-patient" relationship with your medical providers. Finally, your medical providers also have contracts with the health carrier, typically called participation agreements.
You may be covered under a group policy. The most common group coverage is provided by employers to employees. Group coverage may be one of two types: fully insured or self insured. Federal law says your coverage document must tell you if your plan is self insured.
FULLY-INSURED GROUP COVERAGE
Fully-insured group coverage is different from individual coverage because the employer is also part of the relationship. An employer purchases a "fully-insured" group policy from a health carrier to cover employees of the organization. The employer may pay all or part of an employee's premium. The policy is called "fully insured" because the health carrier assumes the risk of providing coverage to the employees. (In a self- insured group plan the employer assumes the risk and financial obligation to provide coverage to employees.)
In a fully insured group plan, the health carrier issues a contract, typically called a master contract or policy, to the employer. In it, the health carrier agrees to provide coverage to the employees subject to various conditions. In turn the employees and their dependents are covered under what are typically called certificates of coverage.
SELF-INSURED GROUP COVERAGE
Some employers provide coverage to their employees through a self-insured health care plan. This means the employer pays for its employees' health care with its own money. A self-insured employer must file a master plan with the United States Department of Labor and provide to employees a Summary Plan Description that details the terms of coverage. Self-insured health plans are subject to a federal law known as the Employee Retirement Income Security Act of 1974, or "ERISA. Most self-insured employers do not process claims internally. Rather, they typically have agreements with an outside vendor who processes claims for them. These vendors are called third party administrators (or TPAs). The third party administrator may be an HMO, insurance company or nonprofit health services corporation.
II. Read Your Policy
Your policy governs what treatment is covered, what treatment is excluded and what conditions for payment are. Read the policy carefully. Fortunately, most insurance policies are put together in a similar way. Most have a "Coverages" section, an "Exclusions" section, a "Definitions" section and a "Conditions" section. By using these three steps, you can turn reading this lengthy document into a fairly manageable task.
To best understand this important but complex document, follow these three steps:
STEP ONE: IS THERE COVERAGE?
Start by reading the Coverages section. Does the treatment you need appear to be covered? If you encounter technical terms, check the Definitions section for more information.
STEP TWO: IS THERE AN EXCLUSION?
Next, read the Exclusions section. If you believe you have found coverage, is there an exclusion that takes coverage away? Again, refer to the Definitions section if you need terms defined.
STEP THREE: WHAT CONDITIONS APPLY?
If you determine that there is coverage and that no exclusion takes away coverage, review the rest of the policy to determine whether any conditions apply. Conditions may include requirements that you:
- Obtain preauthorization from the health plan for a particular treatment.
- Pay a deductible or copayment.
- Use a particular health care provider.
If you are covered under an individual or group "fully-insured" policy, the health carrier must provide a copy of the policy to you. If you have coverage through an employer's self-insured health care plan, the employer must provide you with a copy of both the summary plan description and the master plan.
III. Your Rights in your Relationship with your HMO
To get a complete rundown of your rights in your relationship with your HMO, see our section "Managing Your Healthcare" which gives a detailed account of your rights.
IV. General Tips on Fighting Back
Let's say you have encountered a problem with your health plan. Maybe you can't get a referral to a specialist. Maybe plan administrators are telling you that treatment is not "medically necessary" or is "experimental." Or maybe they say that the treatment your health care provider recommends is not covered. Here are some general tips to help you navigate the health care maze:
- READ YOUR CONTRACT.
Don't accept the health plan's claim that something is not covered. Read your contract and determine for yourself if the health plan's position is right or wrong. Compare the language in the health plan's denial letter to the language in your contract.
- BE YOUR OWN ADVOCATE. Ask a lot of questions and know your rights. Let the health plan know that you know your rights.
- DOCUMENT YOUR DEALINGS.
You can bet that when you call the health plan, they are taking notes on what you say. You should take notes, too. Get names and numbers and write down what you are being told. Then, if you need to refer back to a conversation, it's there.
- BE AGGRESSIVE.
Be firm. Let the health plan know that you believe it is in breach of its promises to you. These are legal words that tell the health plan you mean business; you know your legal rights and will enforce them if necessary.
- PUT IT IN WRITING.
If you have a complaint against your health plan, put it in writing. This way it will be harder for the health plan to minimize your concerns.
- FIND OUT WHO IS BEHIND THE "NO."
In the case of a self-insured health plan, your employer might want to provide the coverage but maybe its stop loss carrier (which insures the employer) does not. Or maybe your physician wants to make a referral but the HMO is telling her she can't. Find out who is really behind the refusal to let you have the care you need. It will make solving the problem easier.
- GET YOUR DOCTOR TO BE YOUR ADVOCATE.
Develop a strong relationship with your doctor. When you encounter a problem with your health plan, ask your doctor to step in to help.
- ENLIST AN ALLY.
Enlist an ally such as a friend, family member, or a lawyer to assist you, especially if you are sick.
- GO TO THE TOP.
If you don't get the resolution you need from people lower in the organization, go straight to the top. If an employer's self-insured plan is telling you "no," get the President or CEO of your company to intervene. The bigshots at the top may not even know that the administrator they employ is denying you coverage.
Your health plan has informal appeal and grievance processes. You may want to try using these forums, although you should keep in mind that the decision-makers often are not truly "independent" as they may be staff of or paid by the health plan that has already denied your treatment.
- BE A SQUEAKY WHEEL.
The adage that "the squeaky wheel gets the grease" holds true with your health carrier. By complaining to the health plan administrators, government officials and your medical providers, you are more likely to get the attention you deserve.
- SPEND YOUR OWN MONEY IF YOU NEED TO.
Your health is more important than money. If you need treatment that a health plan won't let you have, consider spending your own money to get the treatment. You can fight the health plan later to get reimbursed. If your health plan won't let you see a specialist, consider finding one and making an appointment on your own, using your own money to go