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

GENERAL ADVOCACY TIPS

  • ESTABLISH a strong relationship with your primary care provider.

Tip: It is critical that your primary care provider understands your needs and is willing to help you navigate the managed care system. You may need to change providers if you change health plans. If possible, you should interview potential primary care providers before selecting a new provider. Make an appointment to introduce yourself and tell the provider about your medical history and care. Make sure that the provider is willing to act as your advocate and partner in obtaining any medical services that you might need. By establishing a positive relationship with your primary care provider early on, you are more likely to avoid later problems.

  • Contact other people for advice on choosing a plan.

Tip: The NC Institute of Medicine and the NC Department of Insurance have information that you can use in selecting a health plan. For example, the NC Institute of Medicine has information comparing the benefits covered and excluded under the most commonly purchased HMO plan. This information can be accessed through http://www.nciom.org/hmoconguide/backh.html. The NC Department of Insurance has two guides comparing health plans: "Managed Care Plan Handbook: A Comparison Guide for North Carolina Consumers" and "HMO Performance Report." These guides can be ordered from the NC Department of Insurance by calling: 1-800-622-7777 or 1-800-546-5664.

  • Review all written materials and keep all written correspondence from your managed care plan.

Tip: Ask for the managed care plan’s Evidence of Coverage (EOC) or policy contract before you select a plan. This document contains detailed information about the covered benefits and exclusions for a particular plan. Sometimes you will only receive a summary of the benefits unless you ask for the more detailed EOC.

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