QUESTIONS TO
ASK YOUR PLAN

Introduction
General 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 SPECIALISTS

  • Does the plan contract with medical and surgical specialists who can treat my condition (describe your health condition)? What specialists are in the plan?

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 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)
  • 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 wait 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).

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