HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

You have the right to receive information about your care and your health plan. In some circumstances, your doctors, medical group, and health plan are legally required to give you specific information concerning your health care coverage, when you ask. Examples of the sort of information you may have the right to receive (depending on what state you live in and the type of health) are: a summary of your plan benefits, often called the Evidence of Coverage (EOC) or the Summary Plan Description (SPD); the plan contract which details the benefits under your plan; the plan formulary or list of prescription drugs covered by your plan; and information about financial incentives or other arrangements between the plan and the plan providers that may affect your care.

If you have asked for information that you have a right to get from your provider, medical group, or health plan, but you have not received the information you requested, you might want to ask, in writing, for the information. If you have already asked for the information, and it has not been provided, you can consider your written request a "grievance." This letter provides a basic format for requesting information from your medical group or health plan. Be sure to add your own facts to this letter.  

• All of the language suggested may not apply to you. Use only the parts of the letter that are appropriate based on your facts.
• Places where you can insert your information are identified by brackets ("[ ]"), and the description of the information to add is underlined. You should delete the brackets and the sample description, and fill in your own information, where it applies.
• The letter includes advice to you that is in parenthesis ("{ }"), with the text of the advice in italics. You should delete these sections from your letter.
• The sample letter is addressed to the "Customer Service Department." Your health plan may use a different name for the department that receives complaints, grievances and appeals from its members. Check your health plan documents or member handbook [usually called the Evidence of Coverage (EOC) or Summary Plan Description (SPD)], or call your medical group or health plan, to find out to whom your letter should be sent.
• Check your health plan documents or member handbook (EOC or SPD) for your plan's requirements for filing a complaint, grievance or appeal. You should follow your health plan's procedures, including any time limits, when you file a complaint, grievance or appeal.
• There are different laws that apply to different types of health care coverage. The laws that apply in your circumstances may depend on where you live, what type of health plan you have, and how you get your coverage. Check your EOC for information about the agency that regulates your health plan, then check with the agency to see what set of laws apply to your case. Remember, it is not necessary to quote the law in your letter, but doing so may help make your case stronger.

For example, the legal standards that relate to information that Californians in Health Maintenance Organizations (HMOs) have a right to receive upon request are found in Cal. Health & Safety Code '' 1363, 1363.01, 1367.5, 1367.20. These sections of the law apply only to licensed California plans regulated by the California Department of Corporations.

If you are in a plan provided by your employer (and not a government or church employer) there are special rules under federal law called ERISA about the information that must be provided to you. If you are in an "ERISA Plan", you should direct your request for information to the plan administrator.

• California law requires your health plan to include statements about requesting information from your plan in your plan's Evidence of Coverage and Disclosure Form. Thus, for certain information (a copy of the plan contract, a copy of the plan formulary, and certain other information), both the law and your plan's written policies will support your request for information. If you have requested such information from your medical group or health plan, and you have not received the requested information, the medical group or health plan may be in violation of both the law and written plan policies, which you can note in your letter.
• Health plans are required by law to provide certain information, and some requirements also apply to medical groups and doctors. This letter is directed to medical groups and health plans, but it can be adopted to be sent to individual doctors. (Information that must be provided by doctors is noted on the list of information that can be requested, in the text of the sample letter.)
• Requesting Medical Records - In most states, doctors and other providers are legally required to provide you with a copy of your medical records, upon written request. A fee may be charged for the copies. (In California, the law that requires doctors to provide a copy of medical records to patients is found at California Health & Safety Code ' 123100 and the sections that follow.) This sample letter focuses on obtaining the information about your coverage; it is not intended for use in requesting medical records. Most doctors have a form for requesting medical records, and that form includes the information necessary under the law for the doctor to release your records to you.
• Attachments - You may attach to your letter copies of any plan policies or laws that support your right to receive the information you are requesting. Check your member handbook or state or federal law for provisions that support your request.
• Sending Copies - Consider sending copies of your letter to others who may be helpful in helping you to obtain the information you are requesting. Suggestions for who you might want to send copies to are listed at the end of the letter.

Health Rights Hotline
Sample Letter for Requesting Information
(see tips for using this letter)

[Date]

[Medical Group or Health Plan]
Customer Service Department
[address]

Dear Customer Service Department:

I am writing to [request information OR file a grievance regarding your failure to respond to my request for information] concerning the terms of my health plan coverage. On [date], I telephoned [medical group OR health plan] and made a verbal request for the information, but the information has not yet been provided to me.

My Evidence of Coverage states that I am entitled to the material I have requested. In addition, [California OR other] law requires the [health plan OR medical group OR plan providers] to provide me with a copy of {name the information you would like, from the following list -- if you do not reside in California, check your state laws to find out about the information to which you are entitled:

Please send me the information I have requested as soon as possible. Thank you for your prompt attention to this matter.

Sincerely,

[Your name]

cc: {Possible individuals and/or groups to whom you can consider sending copies of your letter:}

[Your employer or insurance broker]
[State regulatory agency]

Attachment(s): {copy and attach any provisions from your Evidence of Coverage or member handbook that states you are entitled to the information you are requesting}