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

MEMBER SERVICES

• Does the managed care plan coordinate services for its clients with disabilities or complex health care needs? Is there a case manager or care coordinator? What is this person’s role in my care?

• Is consumer information developed by the managed care plan available in formats accessible to people with physical, sensory, communicative, and/or cognitive impairments?

• How do members rate the managed care plan ("consumer satisfaction")?

Tip: The NC Department of Insurance collects and reports consumer satisfaction data from HMOs in a report entitled: "HMO Performance." You can order a copy by calling 1-800-622-7777 or 1-800-546-5664. It is important to understand that most health plans have relatively high member satisfaction levels. But these numbers may not be a good indication of the experiences of people with special health care needs. Most HMO enrollees, and consequently, most of the people who respond to the member satisfaction surveys, are relatively healthy. An enrollee who is healthy and rarely uses health services will have fewer interactions with the HMO, and thus are likely to have fewer problems within the system. HMOs do not generally sample people that have special health problems separately from the regular consumer satisfaction survey.

• What is the rate of people leaving the managed care plan?

Tip: The NC Department of Insurance collects and reports data on the number of individuals and groups that withdraw from a health plan, as well as the numbers of providers who left a plan voluntarily and involuntarily. This report is called "Managed Care Handbook: Comparison Guide for North Carolina Consumers" and can be ordered at 1-800-622-7777 or 1-800-546-5664. The Guide is also available through the internet at: www.ncdoi.com.

People may leave health plans for a variety of reasons. For example, a health plan may have raised its premiums, forcing an employer or individual enrollees to choose a lower-cost plan. An HMO may stop covering a particular part of the state, forcing some enrollees to choose another plan. Doctors may leave the plan because they are unhappy with the HMO’s reimbursement rate. So, disenrollment numbers, by themselves, should be read with some caution.

• Does the managed care plan offer support programs for families of persons with disabilities?

• Do members have access to their medical records?

• How does my managed care plan serve me if I am also covered by Medicare or Medicaid?

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