HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

Please read this introduction section on using the sample letters. The introduction provides guidelines for using the letters and tips on how you can make the letters the most effective.

The following sample letters are for use by consumers who are having problems with their health care coverage. Consumers experiencing a difficulty with health care coverage should always begin by talking to their doctor, medical group, and health plan. At some point, the use of a formal letter may be appropriate and necessary to resolve a problem or address an issue. The sample letters are intended to help those who are at the "letter writing" step in the process of resolving their problem.

Each sample letter is intended to be adapted to the consumer's specific situations. General situations in which each letter may be helpful are noted in the introductory comments on each individual letter. Consumers must consider, and apply, their specific facts to appropriately use any of the sample letters. Following are some tips and information to help a consumer who is considering writing a letter.

Tips to consumers:

• Before writing a letter to a health plan or medical group, you should read your plan member handbook [the Evidence of Coverage (EOC) or the Summary Plan Description (SPD)] that you got when you enrolled in the plan. Your member handbook will give you information about your coverage, your rights and responsibilities in the plan, and how to file an appeal or grievance. If you don't have a member handbook, call your health plan's customer service department or your employer and ask for a copy.
• If you use a sample letter, you should adapt the letter to your particular situation. You should consider the facts specific to your case -- your health condition, treatment history, your dealings with your medical group or health plan, what you are seeking, and the laws that apply to your situation.
• The laws that apply to your individual situation depend on a variety of factors, including the state you live in, the type of plan you are in, and how you get your coverage. Your plan member handbook (EOC or SPD) should tell you which governmental agency is available to assist you if you have a problem with your health plan.

The different types of health care plans include:

• Health Maintenance Organizations (HMOs) regulated by state agencies (The Department of Managed Health Care in California);
• Traditional insurance, Preferred Provider Organizations (PPOs), or "indemnity plans," regulated by state agencies (the Department of Insurance in California).

The different ways coverage is paid for include:

• Individually purchased insurance or health care coverage, regulated by state agencies that oversee HMOs and insurers;
• Employer paid coverage offered through an insurance company, regulated by the U.S. Department of Labor and state agencies that oversee HMOs and insurers;
• Employer paid coverage that the employer self-insures, sometimes called self-funded or self-insured plans, usually regulated by the U.S. Department of Labor;
• Medicaid (or Medi-Cal in California), regulated by state agencies (in California, the Department of Health Services, and, for those in HMOs, The Department of Managed Health Care);
• Medicare, regulated by the U.S. Health Care Financing Administration (HCFA) and, for those in HMOs, state agencies (The Department of Managed Health Care in California).
• If you are planning to refer to your legal rights in your letter, you must know which laws apply to you. As noted above, your plan may be regulated under different federal or state laws. In some sample letters, we have given examples of using code sections from the Knox-Keene Act, part of California's Health & Safety Code that applies to HMOs licensed in California. We also provide a list, with brief descriptions, of some of the Knox-Keene sections that may be helpful to consumers in California HMOs.
• Sending your letter certified mail, with return receipt requested, will provide proof of when your letter was received by your medical group or health plan.

The sample letters that follow are:

1. Billing Problems - a letter to use if you have been billed for all or part of a service that you believe should be covered by your health plan or medical group.
2. Appeal of a Denial of Services as "Not Medically Necessary" - a letter to use if you believe you have been inappropriately denied a service, treatment or procedure based on your provider, medical group, or health plan claiming the service, treatment, or procedure is not medically necessary to treat, monitor or diagnose your condition.
3. Appeal of a Denial of Services as "Not a Covered Benefit" - a letter to use if you believe you have been inappropriately denied a service, treatment or procedure because your provider, medical group, or health plan claims the service, treatment, or procedure is not a covered benefit under the terms of your health plan contract.
4. Request for Coverage of a Non-formulary Prescription Drug - a letter to use if you are having trouble getting coverage for a prescription drug because the health plan or medical group says it is not on the "formulary," or list of approved drugs.
5. Quality of Care Complaint - a letter to use if you want to voice a complaint about the quality of care your have received.
6. Request for Information - a letter to use if you want to request information from a provider, medical group or health plan (such as a copy of the contract, the formulary or list of approved drugs, or information about financial incentives that may affect your care).
7. Cover Letter to State Regulatory Agency - a letter to use if you want to send a copy of a grievance or appeal letter to a state regulatory agency, requesting the assistance of the agency in resolving the problem.
8. Cover Letter to State Licensing Board - a letter to use if you want to make a complaint to a state licensing board, requesting that the board investigate a professionally licensed health care provider involved in the problem.

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