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

APPEAL AND GRIEVANCE

Tip: Every plan is required to have a clear grievance process for members to appeal a managed care plan’s decision to limit care or the amount of reimbursement. Health plans are also required to have grievance systems, if you have concerns about other aspects of the health plan’s operation (such as the quality of care you are receiving, or obtaining reimbursement for health care bills that you paid).

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