Healthcare Access services focuses primarily on the rights of consumers who are members of Health Maintenance Organizations (HMOs) such as Kaiser Permanente, Health Net, Blue Cross, Blue Shield, San Francisco Health Plan and Chinese Community Health Plan. With the support of a grant from the Office of the Patient Advocate, staff conducts workshops, participates in information fairs, disseminates written materials about maximizing the services of an HMO, and works with individual consumers who are having difficulty obtaining appropriate services. Information available includes:
- HMO member rights and responsibilities
- Commonly used terms
- Choosing an HMO
- Becoming a partner in your healthcare
- Obtaining a medical interpreter if you do not speak English
- Appealing decisions about your care, with which you disagree
- Getting necessary accommodations based upon disability
ILRCSF also provides information regarding Medicare D. Program Staff can communicate with consumers about these issues utilizing English, Spanish, Chinese and American Sign Language (ASL).
Contact email@example.com for assistance.
- California Patient’s Guide
California Patient’s Guide is a guide to health care rights.
- Disability Rights Advocates
Disability Rights Advocates is a guide to the health care rights of people with disabilities.
- HICAP (Health Insurance Counseling and Advocacy Program)
HICAP provides help for Medicare members.
- HMO Help Center
HMO Help Center provides information and help 24 hours a day for health plan members.
- Medi-Cal Managed Care Ombudsman
Medi-Cal Managed Care Ombudsman gives assistance if you have a problem with your Medi-Cal plan.
- MRMIP (Major Risk Medical Insurance Program)
MRMIP is an insurance program managed by Blue Cross, for people who are turned down by individual plans because of a pre-existing condition.
1-800-Medicare provides information and help for people with Medicare.
- Office of the Patient Advocate (OPA)
OPA provides information on getting quality health care in California
Utilizing Resources to Address Barriers to Service
HMO’s have grievance procedures. If you are having difficulty accessing a service, or cannot obtain a service that is covered by your plan, you can save yourself a lot of aggravation by knowing and following the process, rather than making random contacts with people who may not have the capacity to assist you. I’m going to go through a rough overview of the process. What is most important is that you come away with the understanding that there is an appeals process, and there are numerous agencies that can assist you, including ILRCSF.
Before you begin a formal process, make sure you have exhausted the less formal ways of getting what you need, such as discussing concerns with your doctor, asking for him/her to advocate on your behalf, etc. If it can be accomplished this way, it may be far less stressful. You may also want to get some advice from ILRCSF, Office of Patient Advocacy, or HMO Member Services. When you make calls to get assistance, keep a log – make sure you document your conversation – date, time, who you spoke to, what they told you, and how to reach them again. When you speak with people during this process, be clear, concise, and respectful, so they can understand, and help resolve the issue. These service providers can be a wealth of information, and can sometimes offer assistance that can resolve an issue with ease, rather than requiring the entire complaint process be followed.
If you still cannot get a service you think you need
- Ask your HMO Member Services to send you a complaint form
- Your HMO must take action within30 days after it receives your complaint.
- If your problem is urgent, ask for an Expedited Review. Your HMO must take action within 3 days.
- If your HMO still won’t help or doesn’t reply within the required time period, your appeals process varies. Call the HMO Help Center. It is not part of the HMO’s. It is state agency, part of CA’s Department of Managed Health Care. Assistance is available in many languages. There are 2 exceptions to using this agency:
- If you have a Medicare HMO contact HICAP (Health Insurance Counseling and Advocacy Program)
- If you have a Medi-Cal HMO, call the Medi-Cal Managed Care Ombudsman
- If you file a complaint with the HMO Help Center, you will get a response within 30 days, or sooner, if the situation is urgent.
- One of the things the HMO Help Center can help you to do, is access the Independent Medical Review, a process in which independent doctors compare the treatment offered by your HMO, with the one you are requesting, to see which is more likely to be of benefit.
- People with MediCare, can be guided through a review process by HICAP
- People with Medi-Cal HMO’s should contact Medi-Cal Fair Hearing
- The next option in the appeals process is binding arbitration, which settles cases out of court. Before you engage in this option, it is advisable to speak to an attorney. There are several good resources available to you, including Disability Right California (800-776-5746) and Bay Legal (415-354-6360).
How Can ILRCSF help you?
ILRCSF can help you to navigate the process, complete and organize necessary documentation, write letters and can provide legal referrals.
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