Talking to Your Managed Care Plan
As a Medicare beneficiary, you have a choice of receiving your Medicare benefits through either a fee for service or a managed care health care delivery system. An increasing number of Medicare beneficiaries are choosing Medicare-contracted managed care plans. In managed care, the functions of the insurer and health care providers (doctors, hospitals, laboratories, etc,) are combined into a single network. Managed care plans tend to provide a greater number of services at a lower cost than most fees for service options. But managed care plans also place certain restrictions on their members, requiring them to see only the plan’s providers and using “gatekeeper” physicians to make referrals for specialty services.
Most managed care plan members are satisfied with their managed care plans. But because you may have occasion to object to the service that you have received from your plan, you should be prepared to talk to your physician and managed care plan representatives. This pamphlet provides some tips on how to talk to your managed care plan, and what your rights are if you are unhappy with your plan.
Read the plan’s materials carefully.
Upon joining a managed care plan, you will receive several important pieces of materials, including the plan’s Handbook and Directory of Providers, and a “lock-in” notice from the Health Care Financing Administration.
It is important that you read each of these documents. The plan’s Directory of Providers lists the providers (primary care physicians, specialists, dentists, laboratories, hospitals, etc.) that your plan has contracted within your area. If you are in a risk plan, the providers listed in the directory are the only ones you can see (unless you have a point-of-service option).
At least as important is the plan’s Handbook. This guide explains the plan’s rules and benefits. If you have any questions or problems with plan, the handbook might have the answer.
Upon joining a Medicare managed care plan, you will receive a notice from the Health Care Financing Administration explaining the “lock-in” requirements of your managed care plan and your rights within the plan.
Save all three of these documents, and make sure you receive the annually updated editions of the plan’s Handbook and Directory of Providers. In addition, from time to time the plan may send you notices explaining changes in plan rules or benefits. File all these materials in a safe place.
Keep a “tip” sheet handy.
When emergencies occur, people are very often rushed or nervous. A ”tip” sheet will help you make sure that you are well-prepared in an emergency situation. Some items that should be kept on the “tip’ sheet are: the plan’s toll free numbers, your membership number in the plan, where to go in case of emergency, medications you are taking, allergies, blood type, and the phone number of your local health insurance counseling office. Make copies of your “tip” sheet and keep a copy in each of the following places: in your wallet, by the phone, in your car, and with your health insurance and medical records.
Ask questions, be inquisitive.
Be prepared for your doctor visits. Make a list of concerns that you wish to discuss. Make sure that all of your questions about the complaints are answered. Since, neither you nor your doctor can remember everything, take notes during your visit to the doctor. Don’t forget to ask about treatment options. If these are options that your primary care physician does not recommend, be sure to ask why. Also, find out how you can change doctors or get second opinions if you are not satisfied with your primary care provider.
Know your rights.
As a member of a Medicare managed care plan, you have the right to know:
- The plan’s rules and benefits.
- The plan’s process for credentialing providers.
- Your doctor’s full professional judgment on your health.
- All services that requires deductibles, co-payments, and co-insurances.
- How to get emergency and urgent care services while out side of the plan’s
service area.
- How to file grievances and appeal plan decisions.
- Why the plan is denying, discontinuing, or delaying services.
- How to get out of the plan.
Be Assertive! Speak up when necessary!
If you are not satisfied with a response from your doctor or from a plan representative, remember that you can always appeal to a higher level and you can always request a written copy of what you are being told. If you ever feel that you are being pressured into agreeing to something that you think is wrong- JUST SAY NO!
Know when and how to appeal plan decisions that you believe are wrong.
Your plan’s Handbook should include a full and clear description of how to appeal plan decision. You have a right to know how you can continue to get services while awaiting the outcome of the appeal, and to know what your financial liability will be if your appeal is not upheld.
If your first appeal or grievance is not addressed by the plan (and you still think you are right), it is important to remember that managed care plans have more than one level of grievance review. If you exhaust the plan’s grievance process and if you believe the plan has been unresponsive to your concerns, you have the right to file a grievance outside the plan.
Know where to get help.
Help is available from a number of agencies. The Louisiana Department of Insurance has an Insurance Counseling and Assistance program known as SHIIP, the Senior Health Insurance Information Program, whose job it is assist senior citizens with health insurance problems. Also within the Department of Insurance is the Consumer Affairs Division that investigates complaints about the insurance practices of managed care plans. In addition, Louisiana has a Quality Improvement Organization that investigates complaints about medical services. You may also contact the nearest Regional Office of the Health Care Financing Administration (HCFA), the federal agency that runs the Medicare program.
Disenroll from the plan if you are not satisfied.
If you are not happy with your managed care plan, leave it. You have other choices. You may always get back into Medicare fee for service (although you may not be able to get the same “Medigap” plan again), or you may join a different managed care plan. It is generally a good idea to consult with your local SHIIP sponsor or the SHIIP office in the Department of Insurance when switching insurance coverage.
Expose discriminatory and misleading plan practices.
Managed care plans are prohibited from discriminatory or misleading practices. If you suspect illegal marketing activities, immediately contact Consumer Affairs at your Department of Insurance and the HCFA Regional Office.
Important phone numbers:
Louisiana Department of Insurance
SHIIP and Consumer Affairs
1-800-259-5301 or (225) 342-5301 in Baton Rouge
HCFA Regional Office (Dallas) – (214) 767-6401
Quality Improvement Organization
Louisiana Health Care Review, Inc.
1-800-433-4958 or (225) 926-6353 in Baton Rouge
SHIIP is financed in part by a grant from the Health Care Financing Administration, Washington, D.C.