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

QUALITY ASSURANCE

  • Is the plan accredited by the National Committee on Quality Assurance (NCQA)?

Tip: Accreditation is just one way to assess the quality of a managed care plan. The accreditation process is very expensive and some plans choose not to participate. This does not necessarily mean that the managed care plan is bad, but it does make it more difficult to judge the quality of care provided by the plan.

Tip: The NC Institute of Medicine and the NC Department of Insurance have information that you can use in comparing health plans. 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.

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