QUESTIONS TO ASK
YOUR PLAN:
PEOPLE WITH SPECIAL HEALTH NEEDS

General Information
about Managed Care

Advocacy Tips
Key Plan Elements
Selecting a Primary
Care Physician

Access to Specialists
Access to Hospitals and Specialized
Treatment Centers
Covered Services
Costs
Appeal and Grievance
Member Services
Quality Assurances
Provider Payment Systems
Glossary

INDEX

UNDERSTANDING
MANAGED CARE

CONSUMER PROTECTIONS

MEMBER RESPONSIBILITIES

QUESTIONS TO
ASK YOUR PLAN

QUESTIONS TO
ASK YOUR PLAN:
PEOPLE WITH
SPECIAL HEALTH NEEDS

BACKGROUND
INFORMATION: NC HMOS

HOW TO INTERPRET
THE INFORMATION

HMO COVERAGE OF SPECIFIC SERVICES

COMMON EXCLUSIONS

ENROLLMENT TRENDS

DISENROLLMENT TRENDS

UTILIZATION REVIEW INFORMATION

FINANCIAL DATA

GLOSSARY

INTERNET RESOURCES

INTERNET RESOURCES:
INDIVIDUALS WITH DISABILITIES

STATE FUNDED HEALTH PROGRAMS FOR
YOUNG CHILDREN
AND THEIR FAMILIES

NC DEPARTMENT
OF INSURANCE

NC STATE EMPLOYEES
HEALTH PLAN

NC DEPARTMENT OF MEDICAL
ASSISTANCE (MEDICAID)

NC HEALTHCHOICE

NC COUNCIL ON DEVELOPMENTAL
DISABILITIES

MEDICARE

YOUR COMMENTS

NORTH CAROLINA
INSTITUTE OF MEDICINE

ACCESS TO HOSPITALS AND SPECIALIZED TREATMENT CENTERS

• Do I have access to "centers of excellence"–hospitals that specialize in the treatment of my disorder (for example, neurological disorders, intractable pain or spinal cord injuries)?

• How much choice do I have in choosing a hospital in the event that hospitalization is necessary? (HMO, POS)

• Do I need approval from my primary care provider before going to the hospital for non-emergency care?

Tip: Find out who needs to give approval for non-emergency hospitalizations. Do you have to get prior approval from the health plan or is your doctor authorized to make the referral?

• Will the managed care plan cover visits to specialized treatment centers that are in a different state?

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