Frequently Asked Questions

This section answers "Frequently Asked Questions" by callers to the Health Rights Hotline. While the answers reflect consumers' rights in California, the information may be helpful to consumers in other states. Be sure to check with your health plan regarding it's policies and procedures.

• What is the Health Rights Hotline?
• How can I take charge of my health care?
• What is managed care?
• How do I choose a health plan?
• How do I choose a doctor under my plan?
• What can I do if I cannot get the care I think I need?
• How do I get prescriptions covered by my health care plan?
• What should I do about the bills I am receiving that I think my plan should pay?
• What can I do if I feel the care I have received has been inadequate or improper?
• What other resources are available to help me if I have difficulties with my health plan?

1. What is the Health Rights Hotline? The Health Rights Hotline is an independent health care consumer resource that serves Sacramento, El Dorado, Placer and Yolo counties in California. The Health Rights Hotline provides free assistance to health care consumers, especially those in managed care systems. Read more about us.

2. How can I take charge of my health care? The starting point is to become an informed health care consumer by talking with your doctor and by understanding your health and any conditions that affect your health, the choices available to you, how managed health care works and your rights and responsibilities. The Health Rights Hotline has Action Guides available to help you take charge of your health care.

3. What is managed health care? A system for providing health care delivery that may include set payment to doctors, financial incentives for consumers to use certain doctors, and coordination of health care services. There are different types of managed care systems. The most common are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). Generally, HMO members must sign up with a medical group and see doctors within that group. Some plans may allow members to see doctors "out-of-plan" at increased cost to the member. In most HMOs, the member chooses a "Primary Care Provider" who becomes the doctor primarily responsible for the member's care. The Primary Care Provider may refer the member to specialists, if necessary. In PPOs, the member will pay less to see doctors in the plan and will pay more to see doctors out of the PPO. In PPOs, and in some HMOs, your ability to get care may be controlled by a "utilization review committee," a group that decides if health care services are necessary and are covered under the plan. For a glossary of managed care terms (developed by the Georgia Business Forum on Health), click here.

4. How do I choose a health plan? You may have different plans available to you through your employer, insurer, Medi-Cal or Medicare. To choose a plan that will serve your needs, you need to decide what is important to you. Important considerations may be the individual doctors or medical groups available under the plan, the distance between your home and the doctors' offices and hospitals, whether the doctor you would like as a primary care physician or certain specialists and hospitals are available, and the benefits or services provided under the plan.

Ask the group making the health plans available to you (employer, insurance broker, the Health Care Financing Administration for Medicare, etc.) for a comparison of covered services and benefits, and for a list of hospitals and doctors, including specialists, that participate in the plans offered to you. (This information is often not available to non-members through plans themselves.) If you know your medical condition, check the plan benefits to see if there are any restrictions on coverage for the type of treatments, including medications, you may need. You should also check to make sure that the medical groups in the plan have specialists for your condition.

5. How do I choose a doctor under my health plan? Most health plans require you to sign up with a specific medical group and a "primary care provider" or doctor who is responsible for providing your basic health care. You can simply select a doctor from the health plan list, but you are better off if you put some effort into finding a doctor who is right for you.

To find a primary care provider who is right for you, begin by figuring out what is important to you. You may want a doctor with an office near your home or a doctor who specializes in treating patients with a particular condition. Once you have decided what is important to you, look at the list of primary care providers in your plan. Check to see which ones have offices in your area. Call the medical group or the hospital you want to find out more information about the doctors. (Some hospitals and medical groups have referral services and can provide you with information about a doctor's background, specialties and credentials.)

Other people who share the same health concerns you do, and who have experience with doctors in your community, may be helpful in your search for a doctor. If you belong to a support group for a health condition, you can ask other members of the group about their experiences with local doctors.

After you have identified a few doctors that interest you, call the doctors' offices and ask each if he or she is accepting new patients. If the doctor is taking new patients, ask if the doctor is available for an interview. Many doctors will make "after-hours" consultation interviews, at no charge, for a patient who is looking for a doctor. When you meet the doctors, try to openly discuss any concerns or questions you may have.

It is helpful to prepare a list of questions about the doctor's office policies (e.g. days and times open), medical group and health plan procedures (e.g. getting referrals to specialists) and the doctor's experience in caring for patients with any specific conditions you have. Although the doctor may not have all the answers, by asking different questions, you will be able to see how well the doctor listens and responds to your concerns, and how willing the doctor is to help you find the answers to your questions.

6. What can I do if I cannot get the care I think I need? Begin by talking to your doctor. If your doctor agrees that you need certain care or a referral has been denied, ask your doctor for assistance in determining why the care or referral has been denied. The care may have been denied because it is not a covered benefit, or because your group or plan believes it is not medically necessary for your condition. Your doctor should be able to help you figure out why care or a referral has been denied. If necessary, your doctor should also be able to help you appeal the plan's decision (see below).

If your doctor recommends a treatment you do not agree with, you may want to get a second opinion. You can call your plan and ask to be referred to another doctor for a second opinion. You also have the right to change your primary care provider if you are not satisfied with your doctor. If you are in a health plan regulated by the California Department of Managed Health Care, you have a right to an "independent review" of the plan's decision by an independent organization outside of your plan. You should call your plan's customer service department for information about changing doctors or appealing a decision.

It is important to keep a written record of all the steps you take in trying to get the care you believe you need. If you have taken steps within your plan to receive treatment you feel is needed but you are still not getting the care, you may want to file a grievance or appeal. See the Health Rights Hotline Action Guides on What to Do If You Have A Problem With Your Health Plan and How to Appeal A Health Plan or Medical Group Decision. Depending on the type of health plan you are in and how you get your coverage, you may also have rights to appeal outside of your plan. If you are covered through Medicare or Medi-Cal, you have very specific appeal rights. In California, if you have been in your plan's appeal process for thirty days and have not gotten an answer, the California Department of Managed Health Care may be able to help you. (See FAQ #10 for information on Resources to Help You Resolve Your Health Care Problem.")

7. How do I get prescriptions covered by my health care plan? How do I get prescriptions covered by my health care plan? Some plans, especially dental and mental health plans, do not have pharmacy benefits and will not cover the costs of prescriptions. Check your health plan documents (often called an Evidence of Coverage (EOC) or Summary Plan Description (SPD)) for specific information concerning your pharmacy benefits. If your plan has pharmacy benefits, it may be necessary to have your prescription written by a plan doctor and filled at a "participating pharmacy," a pharmacy that contracts with your plan. The drug may also need to be on the "formulary," the list of drugs that your plan will cover. However, if a drug your doctor has prescribed is not on the formulary, you should still be able to get the prescription covered if you are allergic to the formulary drug or if there is not a formulary drug for your condition. Ask your doctor to contact your plan for approval of a drug that is not on the formulary, or call your plan's customer service department. For a sample letter on "Requesting coverage for a non-formulary prescription drug", click here.

It is important to show your plan card at your pharmacy before you get your prescription filled. In addition, if you are enrolled in Medi-Cal or Medicare, be sure to show your eligibility cards.

8. What should I do about the bills I am receiving that I think my plan should pay? If you receive a bill that you believe the health plan should pay, you should first read the bill. Check to see it is an actual bill and not just a statement from the provider saying that your insurance company has been billed or an Explanation of Benefits from your plan stating that a bill has been paid. If it is a bill from the provider, contact your plan or insurance company to find out if they have been billed and if they have paid the bill. If you have more than one insurance company or payer involved, contact the customer service department of each.

If you get an Explanation of Benefits (EOB) that shows that the plan is not covering something they have been billed for, there will be code numbers indicating why the amount is not covered. Check the EOB for an explanation of the code. If you disagree with the reason the bill is not being covered by your plan or insurance company, call or write a letter to your plan or insurance company's customer service department. If the problem is still unresolved after contacting the plan, you may want to ask your employee benefits department, your insurance broker or other resource listed in FAQ #10 below to help you. For a sample letter on "billing problems", click here.

9. What can I do if I feel the care I have received has been inadequate or improper? If you feel that the care you have received is inadequate or improper because of something your doctor has done or not done, you should begin by talking to your doctor. You should be able to talk to your doctor about any problems or concerns you have with care provided by your doctor or someone who works with your doctor. If you have difficulty talking with your doctor directly about your concerns, write a letter to your doctor. For a sample letter on a "quality of care complaint", click here.

If the problem is particularly serious, you may want to make a formal complaint with the medical group, your health plan, local and specialty medical societies to which your doctor belongs, and/or the state medical board. If you feel that the problem is so serious that you want to talk to an attorney, you can call the local bar association for a referral.

10. What other resources are available to help me if I have difficulties with my health plan? If you have not been able to resolve difficulties by talking with your doctor, your medical group or your health plan, you might want to get help from another person or organization. Your employee benefits department or your insurance carrier or broker may be able to assist you. The Health Rights Hotline is an independent assistance program with experienced counselors, however we can only help individuals who live or work in the Sacramento metropolitan area. Most states have agencies that oversee health plans; these agencies may have programs to help you resolve difficulties with the plans they regulate. In many states, the State Department of Insurance oversees health plans. In California, the Department of Managed Health Care regulates HMOs and the Department of Insurance regulates insurance companies. Some employer sponsored health plans are regulated by the United States Department of Labor. In addition, all states have programs that assist Medicare enrollees. In California, the program is called HICAP, or Health Insurance Counseling and Advocacy Program, which is a program of the California Department of Aging. You may also want to contact your state medical board for complaints concerning specific doctors. In some cases, it may be appropriate to consult an attorney. See our Resources and Links for links to these and other resources.