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QUESTIONS TO ASK
YOUR PLAN: PEOPLE WITH SPECIAL HEALTH NEEDS General Information about Managed Care Care Physician Treatment Centers INDEX |
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ACCESS TO SPECIALISTS • Does the plan contract with medical and surgical specialists who can treat _______ (describe your health condition)? Tip: This question is particularly important if you have a health condition that requires specialist care. Ask for a listing of specialists. • How much choice do I have in choosing a specialist? (HMO, POS) • Are there restrictions on the use of specialists (for example, does the managed care plan limit the number of visits it will cover without requiring another referral from the primary care provider)? Does the health plan allow standing referrals to specialists? (HMO, POS) Tip: A standing referral allows the member to obtain services from a specialist for a certain length of time (such as six months) without having to obtain additional referrals. Beginning January 1, 2000, all health plans that require patients to obtain referrals before they can see a specialist must have a process to allow patients with chronic, degenerative, disabling or life-threatening diseases or conditions to obtain extended or standing referrals to in-network specialists. The standing referrals may not exceed 12 months, and shall be part of a treatment plan coordinated with the primary care physician, specialist and the health plan. • Does the plan allow for shared management between primary care providers and subspecialists? (HMO, POS) • Does the health plan contract with pediatric subspecialists to care for children with disabilities? (HMO, POS) • How does the health plan determine if it has sufficient providers to meet the needs of the enrollees? Tip: Under state law, enrollees can obtain care from out-of-network provider without paying more, if the health plan lacks sufficient providers to meet the member’s health care needs without unreasonable delay. • What is the approximate waiting time for an appointment with a specialist (specify the type of specialist)? Tip: A shortage of specialists within a managed care plan may translate into long waiting periods between appointments. • Does the managed care plan permit me to obtain a second opinion? Can I use an out-of-network physician for the second opinion? (HMO, POS). |