1. SPONSORS
   
   
2. INTRODUCTION
   
   
3. EASY GUIDE
   • Questions & Answers - An Easy Guide to the Consumer Rights in Managed Care Handbook
   
   
4. WHAT IS MANAGED HEALTH CARE
   • Defining Managed Care
   
   
5. TYPES OF MANAGED CARE PLANS
   • What Health Services Are Covered By Your Plan?
   • What Type of Managed Care Plan Do You Have?
     1. HMOs - Health Maintenance Organizations
     2. POS - Point of Service Plans
     3. PPOs - Preferred Provider Organizations
     4. Medicare HMOs
     5. Medicaid HMOs-New Jersey Care 2000+
     6. New Jersey KidCare
     7. Charity Care
   • Laws to Help You Keep Employer-Sponsored Health Care Coverage
     1. COBRA
     2. HIPAA
   
   
6. MAKING MANAGED CARE WORK FOR YOU
   • Tips for Working with Your Managed Care Plan
   • How to Use Your Health Care Plan
   • How to Get General Health Care from Your Managed Care Plan
   • Self Help Tips in Working with Your Health Plan
   • An Overview of Private or Employer-Provided Insurance
   • An Overview of Public Health Care Programs
   
   
7. YOUR LEGAL RIGHTS IN A MANAGED CARE PLAN
   • Your Legal Rights in New Jersey
   • Commercial Insurance
   • The Grievance and Appeals Process for Commercial Insurance
   • How to Deal with Quality of Care Issues-Filing a Grievance
   • How to Deal with a Denial, Termination or Limitation of Covered Health
   • Services-Filing an Appeal
   • Medicaid Managed Care
     1. Your Complaint, Grievance and Appeal Rights
     2. Filing a Grievance/Appeal with Your Plan
     3. You Have a Due Process Right to a Fair Hearing
   • Medicare Managed Care
     1. Thinking About Medicare Managed Care
     2. Medicare Grievance and Appeal Rights
     3. Filing a Grievance Under Medicare Managed Care
     4. How to File an Appeal Under Medicare Managed Care
        1. Appeals on an Emergency Basis
     5. Filing for a PRO Review if You are Denied Coverage for Inpatient Hospital Care
   
   
8. APPEAL TIPS
   • Tips to Increase Your Chances of a Successful Appeal
   • If Your Appeal is Unsuccessful, What to do Next
   
   
9. GLOSSARY
   
   
10. SAMPLES (PHONE CALLS AND LETTERS)
    • A Record Keeping Checklist
    • Commercial Insurance/Grievance on Quality of Care
    • Commercial Insurance/Stage 1 Informal Appeal
    • Commercial Insurance/Stage 2 Formal Internal Appea
    • Commercial Insurance/Stage 3 External Appeal
    • Medicare/Grievance Phone Call
    • Medicare/Step 1 Appeal
    • Medicaid/Grievance on Quality of Care
    • Medicaid/Grievance on Denial of Health Services
    • Log Sheet
    
    
11. RESOURCE GUIDE
    • Advocacy Organizations
    • Government Departments
    • Legal Help
    • Insurance-Related Organizations
    
    
12. ADDENDA
    • Mental Health and Substance Abuse Services
    • Managed Care and the Disability Community

The "To Your Health" program of training, education and counseling has received generous funding from the following sponsors:

This publication is made possible by the New Jersey State Bar Foundation with funding from the IOLTA Fund of the Bar of New Jersey.

The information in this publication is published as a public education service to help explain laws in New Jersey. It does not constitute legal advice, which can only be given by an attorney. The information in this handbook is current as of February 2000.

For managed care plan members who need information and possible legal advice regarding problems/questions related to managed care, please contact the Community Health Law Project's toll free "To Your Health" Hotline at (888) 838-3180.

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The Community Health Law Project (CHLP), established in 1976, is a statewide not-for-profit legal aid society dedicated to providing legal and advocacy services to persons with disabilities and senior citizens.

CHLP created the "To Your Health" program to provide New Jersey consumers of managed care with an overview of patient rights and responsibilities in this new health care environment. Program components include this handbook as well as access to general information and legal counsel through a toll-free hotline, (888) 838-3180. Referencing this handbook will help you to:

• Understand the basics of managed care
• Recognize the different types of managed care plans
• Use your health care plan to your advantage
• Know your rights as a member of a managed care plan
• Appeal a decision of your managed care plan
• Reach out to appropriate resources for assistance

For further information about "To Your Health" and other programs of the Community Health Law Project, contact:

Community Health Law Project
185 Valley Street
South Orange, New Jersey 07079
(973) 275-1175
(973) 275-5210 (Facsimile)
Website: http://www.chlp.org
email: chlp@erols.com

Please note that as you use this handbook, all the works highlighted in bold type throughout the text are defined in the glossary.

©1998, 2000 Community Health Law Project
185 Valley Street, South Orange, N.J. 07079

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without the written permission of the Community Health Law Project, except where permitted by law.

The information contained in the Guide to New Jersey Consumer Rights in Managed Health Care was current as of the date of publication, but is subject to change without notice.

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An Easy Guide to the Consumer Rights in Managed Care Handbook

This Easy Guide should help to answer some of the most common questions asked by persons covered by managed health care, and gives you information on where to look in the handbook for more detail.

To use this Easy Guide: Look for the answer to your question, and then if you want more information, go to the specific pages in this handbook for details.


What is Managed Care?

Managed care is a way of providing for and paying for health care. Managed care plans work to provide health care that is effective in keeping persons healthy while controlling the costs of care.

When you join a managed care plan, you are joining something called a "network." By signing up with a particular managed care plan, you agree to see doctors and use health facilities and hospitals that are part of a network. You must select the doctor who will provide your primary health care from a list provided by the managed care plan. These physicians are usually general practitioners, internists, or pediatricians. This doctor is called a "primary care physician" or "PCP," and is responsible for managing all your health care needs. With very limited exceptions, you must get a referral from your primary care physician in order to see a specialist physician.

For more information about what managed care is, see Defining Managed Care in this handbook.

I hear a lot of different names mentioned with regard to managed care plans. Aren't they all just HMOs?

No. The term "HMO," or "health maintenance organization" refers to a certain type of managed care plan. There are many different types of managed care plans. Some plans offer more health services as part of their benefit package than others. Some plans offer more doctors and hospitals than others. Some plans let you choose between network providers or out-of-network providers. Generally, a plan with a greater number of health services covered and more doctors is more expensive than a basic plan.

For more information about the different types of managed care plans, see the Types of Managed Care section of this handbook.

How do I know what my managed care plan covers?

In the member handbook provided by your managed care plan, you should find a list of "covered health services." These are the treatments and procedures that are covered by your particular managed care plan, as long as they are "medically necessary" for your particular health care needs.

In order for you to exercise your consumer right to appeal decisions of your managed care plan for health services that have been denied, limited, or restricted, the health service in question must be a "covered health service" or "covered benefit" of the managed care plan.

For more information about covered health services, see the Types of Managed Care section of this handbook.

I've heard that managed care plans don't cover emergency care. Does this mean my family can't use the emergency room?

Managed care plans cover health care provided through an emergency room, but only for what is called a "true emergency." These are emergency health situations that are sudden, serious, and/or life threatening. Examples include broken bones, seizures, serious medical conditions affecting a pregnant woman, severe bleeding, severe pain, etc. If you have an emergency, go to the nearest emergency room. In New Jersey, if you believe you are experiencing a potentially life-threatening situation, you can call 9-1-1 or go to an emergency room without prior approval from your health plan.

For more information about emergency care, see the Making Managed Care work for You section of this handbook.

What if I or a family member is sick, but not sick enough to go to the emergency room?

Managed care plans must provide access to urgent care. You can call your primary care physician, or if that is not possible, the managed care plan must have a 24-hour toll-free number to call to get access to medical care. You should find the telephone number on your plan's member card and/or in the member handbook. For routine care, schedule an appointment with your primary care physician.

For more information about routine and urgent health care, see "How to Get General Health Care from Your Managed Care Plan in this handbook.

What about going to see a specialist?

It is important to check your plan's member handbook for the rules related to specialist care. In many instances, you must have a referral from your primary care physician in order to see a specialist for care. Also, you are generally required to see specialists within the managed care plan's network, unless you get approval from the managed care plan.

For more information on specialist care, see your health plan's member handbook.

Do I have some way to complain if I'm unhappy with my managed care plan?

Yes. No matter what type of managed care plan you have, you can call the plan's member services department and complain about issues such as long waiting times for appointments, a poor attitude by the doctor treating you, or other quality issues. This process is sometimes called a 'grievance.' It is up to the managed care plan to get back to you within a certain period of time and respond to your complaint. If you are unhappy with the managed care plan's response, you can file a complaint with the State Department of Health and Senior Services and/or the State Department of Banking and Insurance.

For more information about making complaints related to quality issues, see "How to Deal with Quality of Care Issues-Filing a Grievance" for commercial insurance, "For Medicaid Managed Care Enrollees: Your Complaint, Grievance and Appeal Rights" for Medicaid, and "How to File an Appeal Under Medicare Managed Care" for Medicare.

What if the managed care organization denies a health service that is covered under the plan?

Depending on the type of health insurance you have, you may have a legal right to appeal decisions of your health plan that deny, limit or reduce health benefits covered by your plan. Different appeal procedures apply depending on the type of health coverage you have. For example, there is a specific appeal process which applies to Medicare, and a different process for Medicaid. Yet another process applies to commercial insurance. In all appeal processes, there are different time frames for emergency appeals and more routine appeals.

For more information, including the steps to follow in each appeal, see the following:

For Commercial Insurance, see "How to Deal with a Denial, Termination or Limitation of Covered Health Services-Filing an Appeal" in this handbook.

For Medicaid, see "Filing a Grievance/Appeal with Your Plan" in this handbook.

For Medicare, see "Medicare Grievance and Appeal Rights" in this handbook.

Is going through the appeal process worth it? Isn't the managed care plan just going to say no?

The appeals process can work to your benefit. You need to stand up for your rights, because it is your health at stake. You can follow some suggestions to help increase the chances of a successful appeal.

First, work with your doctor. Your primary care physician is responsible for managing the delivery of your health care. He or she can help find ways to make your appeal to the health plan stronger.

Get as much information as possible to back up your appeal. Look to organizations that have information about your particular health concern, do research at the local library, and become as informed as possible about why you should get the treatment you are seeking.

Keep a record of all information you gather, and every person you spoke to and how to contact them again. You are your own best advocate, but if you are overwhelmed by the appeal process, consider getting legal help.

For more information on preparing a successful appeal, see the Appeal Tips section of this handbook.

For more information about resources you can use, see the Resource Guide section of this handbook.

For more information about record keeping, see "A Record-Keeping Checklist" in this handbook.

What does it mean when I hear about something called a "Patient Bill of Rights"?

The phrase "Patient Bill of Rights" refers to laws that would ensure certain rights to members of managed care plans. The federal government has proposed laws centered around patient rights, and these are under debate as this handbook goes to press. In New Jersey, there are state laws and regulations that give persons covered by certain types of managed care plans important consumer rights. New Jersey has one of the strongest consumer protection laws in the country. For more details on the rights provided by New Jersey law, see "Your Legal Rights in New Jersey" in this handbook.

For Medicare Beneficiaries

I am on Medicare and belong to a managed care plan. Does the information in this handbook apply to me?

Yes. This handbook can be very helpful to you. The general information about managed care plans applies to Medicare beneficiaries, as does the information about appeal tips. Your rights as a member of a managed care plan are found later in this handbook.

If you have a problem with your Medicare managed care plan, you should follow the guidelines for Medicare grievances and found later in this handbook. There is also a list of organizations you can turn to for help with your Medicare questions, found in the Resources section of the handbook.

I am on Medicare, but I am not a member of a managed care plan. Is this handbook useful to me?

It depends. The information in this handbook concerns managed care plans. However, the organizations that address Medicare-related issues found in the Resources section can help answer questions about your traditional Medicare plan.

For Medicaid Beneficiaries

I receive Medicaid benefits. Am I required to join a managed care plan?

During 2000, New Jersey is continuing to move the majority of Medicaid recipients into managed health care. All beneficiaries who qualify for Medicaid by virtue of income are required to be in a managed care plan. Those Medicaid recipients who receive benefits in conjunction with Supplemental Security Income (SSI) are also required to enroll in managed health care, with a few exceptions. There are a small number of Medicaid recipients in New Jersey who are not required to enroll in managed care, including those dually eligible for Medicare and Medicaid, and those persons receiving Medicaid benefits in connection with the Division of Youth and Family Services (DYFS). These exceptions to mandatory Medicaid managed care enrollment are subject to change.

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Managed Care is:

• A way that medical care is paid for and provided
• A way of offering health care while controlling the cost of care

Know Your Responsibilities When Joining a Managed Care Plan:

• Only certain doctors and hospitals are part of your managed care plan's network, and you must use doctors and hospitals that are part of the network.
• You must choose a Primary Care Physician (PCP) for each family member covered by the plan.
• You must get a written referral from your primary care physician before you see a specialist. If you do not have a referral, you will be responsible for paying for the specialist visit.

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Health insurance in the United States is changing. Not long ago, if you had health insurance offered by an employer or through a government program such as Medicare or Medicaid, or you paid for your insurance yourself, the costs of your care were covered by a method called fee-for-service medicine. This traditional health insurance paid the physician, health center or hospital, or reimbursed the patient, after health services were delivered. Under this system, you or the doctor, hospital, or health center submitted a claim to the insurance company and the company paid the claim. Under some plans, you might have paid out of your own pocket for deductibles and/or coinsurance, or for certain things not covered by this type of insurance (for example, physicals and prescription medicines).

Managed care is different. It is a method of both providing and paying for medical care. The purpose of managed care is to provide health care that is effective in keeping persons healthy while controlling the cost of care. There are many kinds of health insurance plans that are part of managed health care. Managed Care Organizations (MCOs) generally control costs by a method called capitation, where providers (doctors, nurse practitioners, etc.) are paid a set amount of money each month for each member they have as a patient, whether or not that patient uses health services, or how frequently the patient uses health services. If a person uses fewer services than expected in a month, the managed care plan makes money. If a person uses more services in a month than predicted, the managed care plan loses money.

Persons who join managed care plans are known as members or enrollees. Depending on the type of managed care plan you have, you are required to follow certain rules, and these rules can be strict or relaxed. For example, a health maintenance organization selects doctors, hospitals and other providers to be part of its network, and members must use the providers that are part of the network. In many cases, the providers are selected for their high quality service. Each member chooses one doctor, known as a primary care physician (PCP), whose responsibility it is to serve as a gatekeeper for the coordinated care of that member. A gatekeeper is someone who manages all medical care for a patient and determines whether services such as tests or referrals to specialists are necessary.

The HMO will give you a list of doctors from which to choose your PCP. If family members are covered under the same insurance plan, each family member can choose his or her own primary care physician. Besides providing all general medical care, the primary care physician decides if your health condition needs specialist care. You must have the primary care physician's written permission, usually called a referral, before making an appointment with a specialist. The primary care physician will usually make referrals to specialists that are part of the managed care network.

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Not all managed care plans are the same. There are different types of plans and different benefits offered. Be sure to:

• Find out what type of managed care plan you have. The type of plan you have determines your choice of doctors, hospitals and health care facilities. Some types of managed care plans are HMOs, POSs, and PPOs.
• Learn what health benefits are offered by your plan. These are called 'covered health services' and should be found in your health plan's member handbook.
• Understand which doctors and hospitals are part of your plan's network. In many managed care plans, you must use the providers in the network in order for health services to be covered.

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There are a wide variety of managed health care plans. Plans with more covered health services and greater numbers of primary care physicians, specialists and hospitals generally cost more. The health services a member receives, the cost of premiums, and amount of co-payment vary with each type of plan.

In order to get the most out of the plan you have, you must take responsibility for learning the specific covered health services of your plan. This is particularly important because in order to exercise your rights to appeal a denial, termination or limitation of health services, you need to be aware of the plan's covered services. Look in your plan's member handbook for a list of covered health services.

In the private market, sometimes called commercial insurance, managed care companies are selling insurance coverage to employers for their employees, or to individuals directly. An employer selects a plan or plans that suits the needs of its' employees as well as the budget available for benefits. The level of benefits offered depends on the type of plan the employer selects and how much that plan costs. It is also possible for individuals to purchase commercial insurance, depending on the managed care plan.

In the public market, the government funds the Medicare and Medicaid programs. The Medicare program operates on funds from the federal government supplemented by member premiums, while Medicaid operates on funds from both the federal and state government. The types of health services offered are determined by what the government decides must be covered. Medicare and Medicaid plans can also offer other covered health benefits in addition to those required by the government. Plans can change these additional benefits on an annual basis.

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You may hear people refer to their managed health care plans as health maintenance organizations, or HMOs. Actually the term HMO is used to describe certain types of managed care plans. Other types of managed care plans include preferred provider organizations (PPOs) and Point of Service plans (POSs), as well as others. See the chart "Overview of Private or Employer-Provided Insurance" in this handbook for a comparison of the various types of managed care plans.

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HMOs are prepaid health plans with no deductibles and minimal co-payments. The HMO contracts with or employs a network of hospitals, doctors and other health care providers. For health care to be paid for or reimbursed, members must choose doctors and providers who are part of the HMO network. Every member must choose a primary care physician (PCP) to manage the member's care as a gatekeeper. PCPs are generally family doctors, internists or pediatricians.* The primary care physician coordinates the member's health care and ensures that specialists are being consulted only for services which cannot be provided by the PCP. You must use specialists within that HMO's network. Generally, if you are treated by a doctor or hospital outside of your HMO network, the cost of that care will not be covered unless there is an emergency or the care is pre-approved by the HMO. There are generally small co-payments for each visit, usually between $5 and $25.

* In certain cases, a specialist can serve as a PCP.

There are several types of HMOs, including:

Staff Model

The HMO employs the primary care physicians and specialists to provide medical care only for its members. The HMO provides the facilities, equipment and supplies and the physicians are paid a salary, and practice together in the HMO's facility.

Group Model

The HMO contracts with one or more individual physicians and/or group physician practices. The groups provide or arrange for all services under a fixed budget.

Independent Practice Association (IPA)

A group of physicians generally contracts with an independent practice association, who in turn contracts with an HMO to provide services. Physicians agree to provide health care to HMO members, but they continue to work out of their own private offices. The physicians may be part of more than one HMO network.

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A Point of Service (POS) plan is the same as an HMO, but includes the option of seeing medical providers outside the network without a prior referral by your primary care physician. A POS plan will cover both services within the network and outside the plan's HMO network, but going outside the network will cost you more in the form of deductibles and co-payments. Also, when you get care outside the network, generally you must pay the bill and then submit claims to your plan. These plans are called Point of Service plans because you decide which doctor (in- or out-of-network) you want to see when you need the care, in other words - at the point of service. All plans in New Jersey must offer this option for a higher premium cost. If you are a Medicaid recipient, the POS plans do not apply to you.

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Preferred Provider Organizations (PPO) include a network of doctors and physicians, but there are no primary care physicians acting as gatekeepers to specialist care. You save money by going to a doctor and/or specialist who is a preferred provider. However, if you choose to go to a non-preferred provider, you will pay more money out of your own pocket. This may include higher deductibles and co-payments.

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If you are a Medicare beneficiary (other than beneficiaries with end-stage renal disease) you may voluntarily decide to enroll in a Medicare HMO. Should you do so, you continue to pay your monthly Part B premium. Usually there are lower deductibles and no or low co-payments in Medicare HMOs, and therefore fewer out-of-pocket expenses than under original Medicare. Medicare HMO members must have a primary care physician, get written referrals for all specialist services, and use only network providers to avoid out-of-pocket costs.

A new program, Medicare+Choice, is designed to expand the choice of managed care plans available to Medicare beneficiaries. As of early 2000, the Medicare+Choice program in New Jersey included the option of original Medicare or a Medicare HMO. Additional health plan choices may be available in the future.

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New Jersey Care 2000+ is the name of the state's Medicaid managed care program. It is mandatory for the Aid to Families with Dependent Children (AFDC)/Temporary Aid to Needy Families (TANF) and AFDC-TANF-related Medicaid populations to enroll in Medicaid managed care. Beginning in mid-2000, managed care will be phased in over the course of a year as a mandatory program for those Aged, Blind, and Disabled (ABD) persons who are Medicaid-only recipients.

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New Jersey KidCare is a program designed to enroll uninsured children 18 years old and under in health care coverage through HMOs. In order to be eligible for KidCare, your family must meet certain income guidelines, which are higher than the income level to be eligible for Medicaid. For example, a maximum annual income of $58,450 for a four-person family allows the uninsured children in that family to qualify for KidCare. Generally, in order for your child to be eligible, he or she must have been uninsured for the previous six months or more. There are differing KidCare plans, known as New Jersey KidCare Plan A, B, C, or D, depending on your family's income. These different plans have various associated premiums, co-payments, and benefits. Also, the type of appeal you can file depends on the level of KidCare plan for which you are eligible. Only KidCare Plan A participants have the option of filing for a Medicaid Fair Hearing, further described in "You Have a Due Process Right to a Fair Hearing" in this handbook. KidCare Plans B, C, D participants should follow the three-stage appeal process outlined in "How to Deal with a Denial, Termination or Limitation of Covered Health Services-Filing an Appeal" in this handbook.

For more information on KidCare, or to apply, call 1-800-701-0710. Also see the Resource Guide in this handbook.

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You may be eligible for charity care hospital services in New Jersey if you do not qualify for Medicare or Medicaid, or do not have private insurance. However, you MUST NOT have too much income or too many assets. New Jersey recently started a new program to have charity care services provided through managed care organizations. This will eventually allow hospitals providing charity care to set up programs similar to an HMO. The state is taking this step because many uninsured patients rely on hospital emergency rooms for all health care needs, and this is not a cost efficient way for the community to provide health services to the uninsured.

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If you have health insurance through your employer, whether it is traditional health insurance or coverage through a managed care plan, you are probably concerned about what would happen should you lose your job, or want to change jobs.

There are two federal laws which may offer you protection. They are:

COBRA: (Consolidated Omnibus Budget Reconciliation Act) - This law states that if you separate from an employer who provided your health coverage (except if the employer normally employed fewer than 20 persons), you must be offered the opportunity to purchase continuing coverage for yourself and your family for a period of 18 months, or up to 29 months if you were disabled at the time of separation. Premium charges can be up to 102 percent of the full cost to the employer. The advantage of this law is that you can continue insurance coverage when you leave your job. The disadvantage is that the coverage can be very expensive.

HIPAA: (Health Insurance Portability and Accountability Act) - This federal law went into effect in 1997, and in part protects persons who have pre-existing conditions when joining a new employer's health plan. The law stipulates that if you leave a job that provided you with health care coverage, and you go to a new job which offers health insurance, you cannot be excluded from new coverage based on a pre-existing condition for a period longer than 12 months. This 12-month waiting period can be reduced by the amount of creditable coverage you have under prior plans. For example, if you were not covered for a pre-existing condition for six months by your last employer, those six months count toward the amount of time you would have to wait for coverage of a pre-existing condition by a new employer. In effect, the new employer could restrict you from coverage for a pre-existing condition for a maximum period of six months. In order for the HIPAA law to apply to you, you must have had health insurance coverage during the previous 12 months, and not have had a break in coverage greater than 63 days.

HIPAA also contains an anti-discrimination provision that states a plan or insurer cannot charge a different premium for similarly situated individuals on the basis of health status. However, this does not mean an insurance plan cannot charge a higher rate to an entire group based on the health of the individuals in the group. For a complete explanation of HIPAA, consult your employee benefits advisor or personnel/human resources department.

Important Guidance on Making COBRA and HIPAA Work for You:

• If the person who carries the health insurance for your family is about to change jobs, and one of your family members has a pre-existing health condition, you may need to use COBRA combined with HIPAA in order to cover the person with the pre-existing condition. The person with the employer-provided health coverage would purchase COBRA coverage from his or her old employer to cover the person with the pre-existing condition, and also elect health coverage from the new employer to cover the whole family. He or she would carry COBRA until the pre-existing condition exclusion waiting time expired, a maximum of 12 months.
• As an example, if your spouse has been treated for rheumatoid arthritis in the past 12 months, you would need to pay for COBRA coverage for your spouse, and start health coverage for the entire family with the new employer. Purchasing COBRA coverage will protect your spouse for any health care needs until the pre-existing condition clause of the new coverage expires under HIPAA. Once the pre-existing condition exclusion expires, your spouse's arthritis should be covered under the health policy of the new employer, and you can discontinue COBRA benefits.

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Tips for Working with Your Managed Care Plan

• Make an appointment with the primary care physician you chose for your regular health care needs.
• Coordinate all your needs for specialist care through your primary care doctor, if required by your health plan.
• If you are sick and need urgent care, call your primary care doctor and tell him or her you need to be seen. If it is after office hours or on the weekend, call your health plan's member services 24-hour hotline and tell them you or your family member need urgent care.
• Obtain pre-authorization before all specialist treatment and testing.
• Use the hospital emergency room only for true emergencies.

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Managed care is the way the majority of health care is delivered in the United States today. Because your health care is now controlled by managed care, you need to learn how your plan works, how you can be more responsible for your own health care, and how you can get the most out of being a member of your managed care plan. A starting point is to read your plan's member handbook, and keep it in a safe place where you can easily find it.

The two most important persons in obtaining quality health care are you and your primary care physician. It is to your advantage to work with your primary care doctor to coordinate all of your medical care, including routine physicals, preventive health services, referrals to specialist doctors and hospital visits. In most managed care organizations, all medical care must be approved by your primary care doctor, except for true emergencies.

How do you determine when you or a family member has a true emergency?

A true emergency is an illness or injury that is sudden, serious, and/or life threatening. Examples are if you or a family member are bleeding severely from an injury, in severe pain, have difficulty breathing, have a broken bone, or are experiencing active labor or a seizure. Emergencies need immediate attention because delays could mean serious damage to your health. If there is an emergency, go to the nearest emergency room. Let your managed care plan know within 24 hours that you had to use emergency services.

What if I am sick, but not sick enough to go to an emergency room?

This is when you or a family member need immediate medical attention, but not on an emergency basis. When this happens, call your primary care physician's office and tell the person answering the phone that you need to be seen right away. If you cannot reach your doctor's office, every managed care plan must have a toll-free number for you to call to get immediate care. You should find this phone number in your managed care plan's member handbook.

What if I am traveling away from home or work?

An important thing to remember about managed care is that, in most instances, the network you joined delivers care in the area where you live or work. This means that when you are traveling, the costs of any care you receive will not be covered by your health plan unless it is an emergency or a situation requiring urgent care. For more information, see your managed care plan's member handbook.

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After you have enrolled in a managed care plan, call to make an appointment with the primary doctor you have selected. If you are scheduling a regular physical exam visit for yourself or your family member, you may have to wait up to four months for an appointment. Routine appointments must be scheduled within two weeks. However, if you become sick while waiting for your appointment and need urgent care, you can call back to be seen within 24 hours. You must tell the person taking appointments that you are sick and need urgent attention.

You should call your primary care provider when you or your family:

• Are sick or hurt
• Need a check-up
• Need shots
• Need prescription drugs
• Need a referral to see another doctor
• Need advice about health problems

Also, be sure to ask your doctor how often you and your family need check ups, shots and health screenings, and check your member handbook for how frequently these services are paid for by your plan.

(Source: Community Service Society's Health Plan Handbook)

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If you have a question or concern about your health care, ALWAYS check your health plan's member handbook to find the toll-free phone number of the patient services department or representative, who is sometimes referred to as a case manager. Call and speak to this representative about your problems or concerns, and ALWAYS write down the name and phone number of the person with whom you have spoken. Ask how soon you can expect to get an answer regarding your problem. If you don't hear back in that time, call again and remind the representative that you are waiting for a response. If you think the patient services representative cannot help you for some reason, you may request to speak with a supervisor.

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Your Legal Rights…

New Jersey is a leader in laws enacted to protect consumers in managed care. However, the state can only exercise its authority over certain health care plans. To learn whether these state law rights apply to your plan, find the type of health coverage you have below.

For Commercial Insurance: If your employer purchases health insurance for its employees, or you purchase your health insurance through a group or on an individual basis, the rights listed in "Your Legal Rights in New Jersey" apply to your health plan. However, if your health care plan is 'self-funded' by your employer, meaning that the employer is responsible for paying the claims submitted by its plan members, these protections do not apply. You must follow a different process for appealing a health plan decision on filing a complaint (see your member handbook). For this reason, it is important to find out how your plan is funded. Ask your employer or group benefits department what kind of insurance you have. Your employer has an obligation to inform you on an annual basis if your health insurance benefit is self-funded, and therefore not subject to regulation by the State of New Jersey. You can also request this information from your employer at any time. Even if vou have a health plan card that has a health insurer's name on it, this does not mean vour plan is not a self-funded insurance program. That company may only be acting as administrator for health claims processing.

For Medicaid Recipients: If you are a Medicaid beneficiary, the rights listed in "Your Legal Rights in New Jersey" apply to you, and you also have additional federal and state law protections. See "Your Rights Under Medicaid Managed Care" of this handbook for a description of your rights, particularly your fair hearing rights.

For Medicare Recipients: If you are a Medicare beneficiary, the rights listed in "Your Legal Rights in New Jersey" apply to you, and you are also protected by federal law. See "Medicare Grievance and Appeal Rights" of this handbook for a description of your federal rights, particularly your grievance and appeal rights.

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As a member of a managed care plan in New Jersey, you have the RIGHT TO:

• Obtain a current directory of doctors within the network.
• Choose a primary care provider for each enrolled member of your family.
• A choice of specialists following a referral, if a referral is required by the health plan.
• Assistance and referral to providers with experience in treating patients with chronic disabilities.
• Have a doctor - not an administrator - make the decision to deny or limit coverage.
• Access a primary care provider or a back-up doctor 24 hours a day, every day of the year for urgent care.
• Call 9-1-1 or go to the nearest emergency room in a potentially life-threatening situation without prior approval from your managed care organization.
• Have the managed care organization pay for a medical screening exam in the emergency room to determine whether an emergency medical condition exists.
• Receive up to 120 days of continued coverage - if medically necessary - from a doctor that has been terminated by a managed care organization.
• Have a doctor discuss, in terms that you can understand, all testing and treatment options even if they are not covered health services.
• Know how your managed care plan pays its doctors, so you know if financial incentives or disincentives are tied to medical decisions.
• Courteous and considerate treatment, with respect for your dignity and need for privacy.
• Know which treatments or services are covered under your plan, and when changes are made in covered services or benefits.
• Know your financial responsibility, including co-payments and deductibles.
• Prompt notification if your doctor is no longer part of your plan's network.
• Coverage of any treatment or service which was authorized (a managed care plan cannot deny coverage after it has approved the service).
• Notification in writing from your managed care plan about your grievance and appeal rights and procedures.
• Appeal a decision to deny or limit coverage, first within the managed care plan, then through an independent organization for a $25 fee (which can be reduced to $2 if hardship is shown). See the Medicaid Fair Hearing process in "You Have a Due Process Right to a Fair Hearing" in this handbook for Medicaid appeals, and see the Medicare appeals process in "Medicare Grievance and Appeal Rights" in this handbook.
• No retaliation against you or your doctor for filing appeals.

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The Grievance and Appeals Process for Commercial Insurance

If you have a managed care plan purchased by your employer, or through a group or individual purchase, you have the right to:

1. File a grievance with your health plan for complaints about quality of care issues; and
2. File an appeal if you or a family member has had a health benefit
3. which is covered under your plan either denied, reduced, or terminated.

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Under New Jersey law,* you have the right to complain to the managed care organization about such issues as the quality of care you are receiving, the choice of providers, and the adequacy of the health network.

• Start by speaking with your primary care doctor as soon as the problem arises. This may be the quickest and most effective solution to your concern.
  
  
• If your doctor cannot provide a satisfactory answer, or it is inappropriate to speak to your doctor, call your managed care plan's member services department. In some instances, a representative can help you get the service you need, or inform you of why your grievance cannot be resolved in your favor. As always, remember to write down the name of the person you spoke to, the date, and the information he or she gave you. If you do not get an immediate answer, ask when someone will get back to you. The MCO must get back to you within 30 days with a response to your complaint. It is always a good idea to send a follow-up letter to your phone call. Make sure you send the letter certified mail, return receipt requested.

*Not applicable to self-funded insurance plans. See your employer for information on the complaint process applicable to your health plan.

• If you are not satisfied with the managed care plan's response, you can contact the New Jersey Department of Health and Senior Services for complaints about quality of care, choice of providers, or getting access to providers in the plan's network. Contact the Department of Banking and Insurance for complaints about a health plan's business practices such as payment of claims, member enrollment, or termination of coverage. For complaints regarding Medicaid, contact the New Jersey Department of Human Services, Division of Medical Assistance and Health Services. See the Resource Guide section of this handbook.

See Samples Section of this handbook for examples of how to begin a grievance process via phone.

Some Common Problems You Can File a Grievance About

• not being able to get an appointment
• not being able to schedule a physical check-up
• not being able to see a specialist
• not being able to see a doctor who speaks your language
• unhappiness with your doctor's attitude
• not being able to get medication
• receiving a bill you are not supposed to pay
• receiving poor medical care
• not getting help when you call the plan's toll-free number

(Source: Community Service Society's Health Plan Handbook)

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If your managed care plan denies, reduces, terminates, or limits health services, or denies payment for any health care services covered under the plan, under New Jersey law you have the right to appeal that decision.* Either you, or your doctor with your consent, can file an appeal.

*Disclaimer: It is important to note that this appeal process applies only to commercial insurance plans licensed by the state, and purchased by an employer or privately. If your employer has a plan that is 'self-funded,' this appeal process does not apply. Before you take steps to file an appeal, ask your employer what type of insurance plan you have, because self-funded plans can appear to be a commercial plan (you may even have an insurance card from a managed care plan and it can still be a self-funded plan). If you have a 'self-funded' plan, follow the appeal process in your member handbook, or contact your employee benefits department. For grievances and appeals under Medicare and Medicaid, see "For Medicaid Managed Care Enrollees: Your Complaint, Grievance and Appeal Rights" and "Medicare Grievance and Appeal Rights" in this handbook.

The appeals process can involve three stages:

Stage I: The Informal Internal Appeal - Call your managed care plan and ask to speak to the medical director or the physician who denied or restricted coverage. (Ask your doctor for the name of the physician who made the decision regarding your case.) You can also file your Stage 1 appeal by writing a letter, or by having your doctor file the appeal with your permission. Tell the medical director or physician you want to appeal the decision to deny, terminate or restrict coverage, and inform that person that you want a reconsideration of the decision. It is a good idea to give information as to why the decision should be reconsidered (see the Tips section of this handbook for ideas). This is called an informal internal appeal. (See the sample phone conversation later in this handbook for a Stage 1 appeal.) Keep notes about the details of your conversation with the health plan.

The managed care organization must get back to you within five business days (Monday through Friday), or within 72 hours (three days) if it is an emergency. Be sure to request an immediate review in an emergency situation.

If the managed care plan continues to deny or restrict coverage, they must inform you in writing how to proceed to Stage 2, the formal internal appeal.

Stage 2: The Formal Internal Appeal - Every managed care organization is required by law to provide you with clear directions on how to file a Stage 2 appeal if the Stage 1 appeal is not decided in your favor. Your appeal must be reviewed by physicians who are trained or practice in the same specialty and would typically manage the case you are appealing, but who were not involved in the Stage 1 appeal process. Promptly file your Stage 2 appeal in writing. Make sure you include in your written appeal what you want and why. Make copies of every document you send, and send all written correspondence by certified mail, return receipt requested. Once your Stage 2 appeal is received by the managed care plan, you are entitled to a decision on the appeal within 20 business days, or if emergency or urgent care is involved, within 72 hours. For urgent situations, be sure to mark the envelope "Emergency Decision Required." If the managed care organization wants more than 20 days to complete the appeal, it must obtain permission from the state.

If a Stage 2 appeal is denied, the managed care plan must give you written notice detailing the reasons for denial, as well as an explanation of your right to proceed to the Stage 3 level of appeal, the formal external appeal. Any forms required to start a Stage 3 appeal must be included. Also, if the managed care plan does not comply with the deadlines for completion of the Stage 2 appeal, you have the right to proceed directly to a Stage 3 appeal.

See the Samples section, of this handbook for an example of a Stage 2 appeal.

Stage 3: The External Appeal - This level of appeal is made to the New Jersey Department of Health and Senior Services, which in turn refers your appeal to an independent utilization review organization (IURO). You must file this third level of appeal within 60 days of the time the Stage 2 decision was finalized by the managed care organization.

In order to file an appeal, mail your request for an appeal, along with the completed form supplied to you by your managed care plan to:

N.J. Department of Health and Senior Services
Office of Managed Care
P.O Box 360
Trenton, N.J. 08625-0360

You must include the following information:

1. The name and business address of the managed care organization,
2. A brief description of the medical condition for which benefits were denied, reduced or terminated;
3. Copies of Stage 1 and Stage 2 written denial decisions from the managed care organization;
4. A written consent to obtain any necessary medical records from the managed care plan or physician (all records remain confidential);
5. An application fee of $25, which may be reduced or waived in cases of financial hardship*; and
6. A copy of the "summary of insurance coverage" from your managed care member handbook.

The IURO will review your appeal application, and inform you within five business days of its decision to further review your case. If the independent review organization accepts your appeal, it will issue a decision within 30 days, both to your managed care plan and you or your doctor/care provider. The decision reached is a non-binding recommendation, which means the managed care organization decides whether to follow the recommendation made by the external review organization. The decision of the managed care organization must be reported to the state within 10 days. The state can take action on managed care plans when it finds there has been a pattern or practice of abuse with regard to following the recommendations of the IURO .

See the Samples section of this handbook for an example of the Stage 3 appeal.

*If you are eligible for either PAAD (Pharmaceutical Assistance to the Aged and Disabled), Medicaid, General Assistance, SSI, or New Jersey Unemployment Assistance, you qualify for the reduction in fee to $2.

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New Jersey's Medicaid managed care program is called "New Jersey Care 2000+." Under this program, the state contracts with health maintenance organizations to provide a comprehensive package of Medicaid health care services. You must join a managed care plan to receive Medicaid if you receive benefits as part of the Aid to Families with Dependent Children (AFDC)/Temporary Aid to Needy Families (TANF) and AFDC/TANF-related Medicaid programs. During 2000, the state will expand its mandatory Medicaid managed care program to the Aged, Blind, and Disabled (ABD) Medicaid-only population. This group includes elderly Medicaid beneficiaries, the disability community, Division of Developmental Disabilities clients, and children with special needs. Persons who are dually eligible for Medicare and Medicaid may enroll in managed care on a voluntary basis.

Those individuals covered by Medicaid managed care in New Jersey are protected by the same rights outlined in "Your Legal Rights in New Jersey" in this handbook, including the right to use the grievance and appeal processes for denials or reductions in health care services. You also have additional legal protections under federal law, in particular the right to a fair hearing if you are denied Medicaid benefits.

Your Rights Under Medicaid Managed Care

As a Medicaid managed care enrollee, in addition to the rights outlined in "Your Legal Rights in New Jersey" in this handbook, you have the RIGHT under Medicaid managed care to:

• Choose your own doctor for yourself and each member of your family from within your HMO's network of health care providers. You may want to choose a pediatrician as the primary care provider for your children, and you may want to choose an internist for your care. You must choose all primary care physicians from the HMO's network, and you can only choose one HMO to provide your family's care.
• The same types of health services you received under traditional Medicaid, including doctor and hospital care, prescriptions and dental care. But, you first must get a referral from your primary care physician in order to access some of these services.
• Access to care when you need it, 24 hours a day, every day of the year. When someone needs urgent medical care and it is 'after hours' or a holiday, the HMO must have a toll-free number to call to get medical help.
• Written notice of a decision to deny or terminate health benefits, generally with at least 10 days notice before an action affecting benefits can be taken.
• File for a fair hearing if you are denied, limited or terminated for a covered health service. You have a right to stay in the plan while you appeal.
• Change HMOs. If you have a good reason to be unhappy with your HMO, you can transfer to another HMO with the assistance of a health benefits coordinator. The transfer process usually takes between 30 to 45 days.
• Choose between at least two primary care providers in your area. You must have access to a primary care provider who offers services within 30 minutes average drive time/public transit time from your home.
• Obtain family planning services from the HMO or from any Medicaid family planning provider.
• Have a health benefits coordinator answer your questions and help you choose an HMO that is right for you and your family. You can call 1-800-701-0710 to speak with a health benefits coordinator. The TTY number is 1-800-701-0720.
• Enroll in an HMO through the health benefits coordinator. No HMO plan can sign you up directly.

Your Responsibilities Under Medicaid Managed Care

As a member of a HMO, you also have certain RESPONSIBILITIES that go along with your rights:

• You must talk to your primary care physician first when you need medical care from a specialist. He or she needs to give you a 'referral' in order for you to see a specialist.
• You must use the emergency room only for true emergencies. You must contact your doctor or HMO as soon as possible after using emergency room services, and within 24 hours. See "How to Use Your Health Care Plan" in this handbook for examples of true emergencies.
• You must make an appointment when you or any family member needs to see a primary care physician or any doctor. Unless your doctor is part of a walk-in clinic, it is important that you call for an appointment. Remember that if you cannot keep an appointment you have made, you MUST call the doctor's office and cancel. Do this as soon as you know you cannot make the appointment.

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As a Medicaid or New Jersey KidCare Plan A beneficiary enrolled in managed health care, you have grievance rights found in both state and federal law. Since these rights overlap at times, it can be confusing to know which steps or procedures to follow first. We suggest you contact the health benefits coordinator or a legal services organization for information about your options. A list of legal aid societies is found in the Resource Guide of this handbook.

As a Medicaid beneficiary in a managed care plan, you have the right to:

• Complain to your managed care plan and/or the State of New Jersey about quality of care issues.
• File a grievance with your managed care plan for denials, terminations or limitations on health care services, or payment for health services.
• Follow the steps for the New Jersey three-stage appeal process.
• File for a fair hearing at any point in the grievance process to resolve your issue.

Filing a Complaint with Your Health Plan

Some Common Problems you Should Complain About:

• Not being able to get an appointment
• Not being able to schedule a physical check-up
• Unhappiness with your doctor's attitude
• Receiving medical care with which you are unhappy
• Not getting help when you call the plan's toll-free number
• Not being able to reach your health plan 24 hours per day, every day of the year
• Not being able to see a doctor who speaks your language

(Source: Community Service Society's Health Plan Handbook)

As a Medicaid managed care enrollee, you have the right to complain to your managed care plan about the quality of care you and your family receive. The problems listed above are some types of problems you may encounter, but there are many others. Call the health plan with your complaint. If you are unsatisfied with your health plan's response to your complaint, you can write to the Department of Health and Senior Services at the address listed in the Resource Guide in this handbook.

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Under Medicaid law, you have the right to challenge the denial of coverage or of payment for Medicaid benefits. If a Medicaid covered health service is denied, terminated, reduced or delayed, you can take action to challenge that decision. Your managed care plan must provide you with written instructions on how to file a grievance. However. the grievance procedure does not substitute for vour right to a fair hearing: You can file for a fair hearing at any point in the grievance procedure. or at the same time vou file a grievance.

Also, any time your health plan makes a decision that denies, delays or reduces your Medicaid benefits, you have the right to written notice explaining the action, and that notice must be received at least 10 days before any such action is taken. This written notice is often the first alert that you should take action, whether by filing a grievance, requesting a fair hearing, or both.

Types of Issues for Grievances and Fair Hearings:

• Denial of health care
• Denial of access to specialists
• Denial of a choice of health care provider
• Denial of access to needed drugs
• A limitation or reduction in necessary health services
• Denial of payment for a health service you received

These and other types of grievances are also sometimes called appeals. You should find information on the grievance and/or appeal process in your health plan's member handbook, or by calling your plan's member services department.

For Urgent Grievances: In situations where the health status of the Medicaid beneficiary could be jeopardized, you or your doctor can request an urgent grievance decision, an answer to which must be given within 48 hours.

See the Samples section of this handbook for an example of a grievance filing.

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If a covered service is denied, terminated, reduced or delayed by your Medicaid managed care plan, you can file for a fair hearing as well as using the plan's grievance process. By law, you must receive written notice that your covered health service is being denied, limited, terminated or delayed, and that you have the right to a fair hearing.

THE NOTICE MUST:

• Be timely (generally at least 10 days before the date if a proposed termination or reduction of services).
• Explain how to obtain a fair hearing.
• Explain how and which benefits will continue pending the outcome of the fair hearing.

Explain that you can be represented by legal counsel, or have another person at the fair hearing serve as a spokesperson.

If you receive such a notice, you can file for a fair hearing, and you should do so promptly - not more than 10 days after the date of the notice. If you are already getting health services and the plan states it wants to reduce/discontinue those services, filing promptly may mean these benefits will continue pending the outcome of the fair hearing. To file, write a letter to the address given in the notice requesting a fair hearing and the reasons why you want the hearing. In case of an emergency where a delay in treatment could affect your health status, you should request an emergency fair hearing.

At the fair hearing, you are entitled to have an impartial hearing officer listen to your position, as well as to present witnesses on your behalf and cross-examine witnesses the HMO may present. You are entitled to a written decision on the outcome of the fair hearing within 90 days from the date the initial grievance is filed. If you are considering filing for a fair hearing, you may want legal help. See the Resource Guide in this handbook.

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Medicare managed care is an available option for most Medicare beneficiaries (except for those persons enrolled in Medicare due to end-stage renal disease). Remember that enrolling in a Medicare managed care plan is your choice. If you are satisfied with the original Medicare program and its associated coverage and costs, you do not have to change to a managed care plan.

Medicare managed care plans are offered by private companies. If you decide to join a managed care plan, you must continue to pay your monthly Part B premium. Additionally, the plan can charge you a monthly premium, as well as co-payments. The managed care plan must cover all the health services the original Medicare program does, and the plan can choose to offer services not available under original Medicare. Some popular additional services managed care plans offer are prescription drug, vision and dental coverage.

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Things to remember:

• Generally, managed care plans are limited by geographic area. You are not covered (except for emergencies and necessary urgent care) for health services received outside of your area. If you spend part of the year away from New Jersey (such as wintering in the South), or travel frequently, managed care may not be your best choice.
• Doctors can join or leave managed care plans. This means that if you sign up for managed care because your doctor is in a plan, you may be disappointed if he or she leaves the plan. You will then need to select a new doctor from the plan's network.
• You can switch managed care plans, or leave managed care and go back to the original Medicare plan at any time during 2000. This policy will change in 2002, and you will be limited as to when you can switch or disenroll from managed care plans.
• You cannot be turned down for a managed care plan based on your health status (except if you have end-stage renal disease). However, some plans have enrollment limits, and therefore you may not be able to join a particular plan when you want. Generally, managed care organizations are required to hold "open enrollment" during the month of November, and accept new members up to their capacity. If a plan does not accept your enrollment, it must provide you with a written denial.
• Every year, managed care plans can decide whether or not to continue offering Medicare managed care plans in your geographic area, and can change the premiums they charge and the additional benefits they cover. For example, a plan could decide to drop prescription drug benefits, or it could decide to stop doing business in your area altogether. By law, you are entitled to receive advance notice of the changes your plan intends to make.

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There are three different processes to voice complaints under Medicare managed care, and which one you use depends on the type of complaint you have. The three processes are called: a grievance; an appeal; and, a peer review organization (PRO) complaint process for inpatient hospital stays.

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Grievances are complaints. Under Medicare managed care you can file a grievance with your managed care plan when you have a complaint that relates to issues that are not about payment or service requests. For example, physician attitude, adequacy of facilities, or time spent waiting for appointments are some types of issues for which you may want to file a grievance. Your managed care plan must provide written information about filing grievances, and respond to your complaint in a timely manner. See the Samples section of this handbook for an example of a phone grievance. Always remember to write down the name of the person you spoke to, what he or she said regarding how long an answer would take, the information you gave the plan in your grievance, and anything else discussed. You will find a checklist of information to use in the Samples section of this handbook.

If you want to complain about the quality of care you received from the managed care plan or any of its member providers, including hospitals, skilled nursing facilities or home health agencies, you can file a complaint with an entity called a peer review organization, or PRO. PROs include doctors and other health care professionals who monitor quality of care for Medicare beneficiaries. To find out further information, call the New Jersey PRO's tollfree information number at 1-800-624-4557. You can also file a quality of care grievance with your managed care plan.

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You can file an appeal under Medicare Managed Care anytime the managed care organization makes a decision that is adverse to you and that decision relates to whether you are entitled to receive a health service (either provided by the managed care organization or outside the plan), or what you are expected to pay for that health service. This means that if the plan denies, reduces, or terminates services or payment for health services, you can file an appeal.

The appeal process can be a one-step process or involve as many as five steps, depending on whether or not the initial steps are resolved in your favor. Here is a summary of the appeal process:

Step I: If a health service or payment for a health service is denied, reduced or terminated by your managed care plan, you must be informed of that decision in writing within 14 days of the managed care plan receiving the request for the service or payment. You can file for a "reconsideration" of the decision as the first step in the appeal process. The request for reconsideration must be in writing, and generally must be made within 60 calendar days of the date of the managed care plan's written notice denying, reducing or limiting the health service, or payment for the health service.

You can file the written reconsideration request either with the managed care plan, or your local Social Security Administration office, or if you are a qualified railroad retirement beneficiary, a Railroad Retirement Board office. The most efficient choice is to file with the managed care plan. The plan will review the reconsideration, and must get back to you within 30 days for decisions related to health services, and 60 days for decisions related to payment. You have the right to submit evidence in writing and in person to support the reconsideration.

See the sample reconsideration in the Samples section of this handbook.

Appeals on an Emergency Basis:

If the reconsideration you are requesting is for a denial or discontinuation of health services, you can request an "expedited" review either orally or in writing. You or your physician would do this when a delay in health services may impact your health status. You cannot get an expedited review of decisions related to payment for health services. The managed care plan must respond to an expedited reconsideration within 72 hours (three days).* The managed care organization must give you the process to follow to file an expedited reconsideration. See your Member handbook or call the MCO to get this information.

*Note: The expedited reconsideration review can be extended under certain circumstances, including request by the enrollee.

When the reconsideration by the managed care plan is complete, you must be notified of the decision, and the reasons for the decision in easily understood language. If the decision is not completely favorable to you, the managed care organization must inform you of that in writing, and then AUTOMATICALLY proceed to Step 2, which is an independent review outside of the managed care plan of your case file and your original request for reconsideration by a qualified organization with whom Medicare contracts.

Step 2: In Step 2, the independent organization will review the reconsideration. Once the independent organization makes a determination, the organization must mail you a notice stating the decision and the reason(s) for the decision. If the decision is not completely in your favor, you can proceed to Step 3 if the dispute involves $100 or more. In the case of a denial of health services, the amount of money in controversy is determined by the value of the services.

Step 3: This step is a hearing in front of an administrative law judge (ALJ). In most circumstances, you must file your request for a hearing within 60 days of the date of the decision from the independent review organization in Step 2. At the hearing, you are entitled to present your case, to call witnesses, and to cross-examine witnesses. You can represent yourself, or be represented by an attorney or anyone else. If your claim reaches this level, you may want to consult an attorney. (See the Resource Guide in this handbook). If the ALJ reaches a decision unfavorable to you, you can then go to Step 4.

Step 4: This is called the Departmental Appeals Board (DAB) review, and is a review before an Appeals Board. Following this level of administrative review (or if you are denied review by the DAB), you can file for judicial review of the decision regarding health services if the amount in dispute is $1,000 or more.

Step 5: This is the final level of review, and is the filing of a civil action in Federal District Court.

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Another Medicare protection is an appeal process for inpatient hospital discharges. If you believe you are being discharged from the hospital prematurely, you have the right to file an appeal. As a hospital inpatient, you should receive a written notice of noncoverage explaining why inpatient care is no longer needed and the effective date. If you think you are being prematurely discharged, you can immediately request a review of the decision. You must act immediately, and submit your request in writing or by telephone by noon of the first working day after you receive notice that you are being discharged. Your request must be submitted to the PRO that works with the hospital in which you are a patient. You can find out who the PRO organization is by contacting the patient services department of the hospital. The PRO decision must be made by the close of the business day on which it receives all necessary information from the hospital and the managed care organization. You may stay in the hospital until noon after the day that the PRO makes its final decision at no cost to you.

If you have questions about how to file a grievance, appeal, or PRO review, contact your Social Security Office, the Senior Health Insurance Counseling and Assistance Program, or a legal representative. See the Resource Guide in this handbook.

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Tips to Increase Your Chances of a Successful Appeal

This tips list can be used for all types of appeals under all health care plans, whether you are covered by Medicare, Medicaid, or commercial insurance. Being well prepared and backing up your appeal with quality information may help your chances of success.

• Do not be afraid to ask your physician to contact the HMO on your behalf.
• Do research on your health condition, and the treatment you seek. Good research sources are health magazines, the Internet, national health organizations, locally based patient advocacy groups, and of course, your doctor. Your local library is a good place to go for research and help with the Internet.
• Get a second opinion on your health condition from another doctor. Try to see a specialist who provides the services you are seeking. You can call your local medical society for information on specialists, or talk to other patients you know with a health condition similar to yours. You may have to pay for the second opinion on your own.
• Contact the consumer reporters at your local or regional newspaper to see if they have information on your health condition.
• Show the managed care company that it is more cost effective to provide the care you seek now than to wait until your condition has worsened and/or you need additional care.
• Offer evidence of other patients' successful outcomes with similar treatment. You may be able to find out this information from local support groups run through your local hospital or by contacting an organization which specializes in your problem (for example, your local chapter of the American Heart Association). Be very careful not to identify any person by name, address, etc. who you are using in your request.

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• If you have a choice of health care plans, consider changing to another managed care plan which offers the health services you need covered. But be sure to check the pre-existing condition exclusions clause for new coverage.
• Consider paying for the treatment yourself.
• If your appeal is denied and you want to go outside the managed care plan's network for treatment, try to convince the out-of-network provider and the managed care plan to accept the in-network provider rate.

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Admission Certification: A method of assuring that only those patients who need hospital care are admitted. Certification can be given before admission (pre-admission) or shortly after (concurrent).

Advocate: A person who pleads the cause of another.

Ambulatory Care: Health services provided without the patient being admitted to a hospital. Also called outpatient care.

Ancillary Services: Supplemental services, including laboratory, radiology, physical therapy, and inhalation therapy, that are provided in conjunction with medical or hospital care.

Beneficiary: An individual who receives benefits from or is covered by an insurance policy or health care financing program including Medicare and Medicaid.

Capitation: A method of payment for health care services whereby providers are paid a fixed monthly rate for each plan member he or she has as a patient regardless of the amount of care the member receives.

Case Management: A method designed to accommodate the specific health services needed by an individual through a coordinated effort to achieve the desired health outcome in a cost effective manner. Includes the monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high cost or extensive services. Also called care management.

Coinsurance: The portion of a medical bill you are required to pay under a traditional insurance or a mixed plan after the deductible is paid. It is usually a percentage (e.g., if the health plan pays 80 percent, you are responsible to pay the remaining 20 percent).

Copayment: A fixed amount you pay when you receive covered services under your health plan.

Covered Health Services: The health services your health plan covers for the premium charged.

Deductible: The fixed annual amount you must pay for health care services before your insurance plan will begin to pay for the cost of your care. This is a common feature of fee-for-service insurance plans.

Emergency: Term used by health plans to distinguish those conditions which are life threatening and require immediate attention in a hospital emergency room from serious illnesses or injuries that require prompt attention but are not life threatening. Managed care plans will generally cover care delivered in emergency rooms only if the condition is a true emergency. Conditions the plan considers true emergencies can be found in the plan's member handbook. Examples include loss of consciousness, severe bleeding or pain, and seizures.

Experimental Procedures/Services: Health services that are generally not recognized under accepted medical standards as safe and effective for treating a particular condition. These services will generally not be included in the covered services of a managed care plan. If you want to challenge a denial of coverage for an experimental treatment/procedure, you should offer proof that this treatment is recognized as part of the standard of care (do research through support groups, specialty physicians, or other resources such as the National Institute of Health).

External Appeal: An appeal of a decision denying, limiting, or terminating covered health services made to an external independent utilization review organization with whom the state contracts.

Fee-for-Service: A traditional method of paying for medical services, where doctors and hospitals are paid for each service provided. Bills are either paid by the patient, who then submits the bill to the insurance company, or submitted by the medical services provider to the patient's insurance carrier for reimbursement. See also indemnity insurance.

Formulary: A list of approved drugs under a health plan's prescription drug benefit. Only drugs on the formulary are covered unless approval is obtained by the doctor or pharmacist for a drug not on the list. Drugs are selected for inclusion in the formulary based on their effectiveness, safety, and price.

Gatekeeper: A primary care physician who coordinates all medical care for a patient and determines whether services such as tests or referral to a specialist are necessary. See also primary care physician.

Grievance: The process by which an insured person can air complaints and seek remedies.

Health Benefit: See 'covered health service.'

Home Health Care: Full range of medical and other health-related services such as physical therapy, nursing, counseling, and social services that are delivered in the home of a patient by a provider.

Indemnity Insurance (also known as fee-for-service): A traditional insurance plan that reimburses for medical service provided to patients based on bills submitted after the services are rendered.

Internal Appeal: An appeal of a decision denying, limiting or terminating covered health services made to the managed care organization, and reviewed by the managed care organization. (See also external appeal).

Managed Care: Systems and techniques used to control the cost of health care services. Used as a general term for the activity of organizing doctors, hospitals and other providers into groups in order to enhance the cost-effectiveness and quality of health care.

Medicaid: Federal and state government health insurance program for those families of low-income, the aged, blind and disabled population, and other specific groups. Each state has its own standards for qualification. Subject to federal guidelines, states determine the benefits covered, program eligibility, rates of payment for providers, and methods of administering the program.

Medically Necessary: Term used by insurance plans to describe care that is appropriate and provided according to general standards of medical practice. A physician's proposed course of treatment may be reviewed by health plan clinical personnel to determine if it is medically necessary.

Medicare: Federal health insurance program for the elderly and disabled, regardless of financial status. Medicare consists of two separate but coordinated programs: hospital insurance (Part A) and supplementary medical insurance (Part B).

Medical Savings Account (MSA): An account in which individuals can accumulate contributions to pay for medical care or insurance.

Medigap: Private health insurance plans that supplement Medicare benefits by covering some costs not paid for by Medicare.

Member: Any person eligible as either a subscriber or a dependent for a managed care service by contract.

Network: The doctors, hospitals, and other medical providers that a health plan contracts with to provide health coverage to its members. Members are generally limited to receiving services from the network providers for full coverage of their health costs.

NJ KidCare: A state program to provide affordable health insurance to uninsured children in low-to-moderate income families. There are four plan levels, and uninsured children from birth through age 18 can qualify based on total family income as related to family size. Plan A offers health benefits at no charge for families with limited income. Plans B, C, and D offer health benefits for children in families with a higher income level. There is a small monthly premium and copayment amount for certain KidCare members.

Out-of-Network: Use of health providers who have not contracted with the health plan to provide services. HMO members are generally not allowed to go out-of-network except in emergency situations. Members of preferred provider organizations (PPOs) and HMOs with point of service (POS) options can go out-of-network but must pay additional costs including deductibles and coinsurance.

Out-of-Pocket Costs: Portion of health services or health costs that must be paid for by the plan member including deductibles, copayments and coinsurance. Can also refer to the payment of services not covered by or approved for reimbursement by the health plan.

Point of Service (POS): An option provided by some managed care organizations which allows members to go outside the plan's provider network for care, but requires that they pay a higher cost amount than they would for network providers.

Pre-Existing Condition: A health condition or medical problem diagnosed or treated before a member's enrollment in a new health plan or insurance policy. In the past, a pre-existing condition might not be covered under a member's new plan, or was covered only after a lengthy waiting period. The federal law, Health Insurance Portability and Accountability Act (HIPAA), changes this for those persons with employer-provided or private coverage. See "Laws to Keep Employer-Sponsored Health Care Coverage" in this handbook.

Preferred Provider Organization (PPO): A health plan that combines managed care and traditional insurance. If you use the plan's network providers, you pay low, cost-sharing amounts similar to that in an HMO. If you go out of network, you are subject to higher out-of-pocket costs including deductibles and co-insurance.

Preventive Care: Health care which emphasizes prevention, early detection and early treatment.

Primary Care Physician/Primary Care Provider (PCP): The doctor you select to provide your basic medical care and to coordinate your other medical needs including referrals to specialists. Also known as a gatekeeper.

Pre-Approval or Prior Authorization: The process by which a provider receives permission from the health plan to proceed with a course of treatment.

Premium: The amount paid to an insurance carrier or managed care plan for providing health care coverage under a contract.

Quality of Care: Refers to issues related to the quality of health care delivery, including such things as physician attitude, accessibility of non-English speaking health care providers, amount of waiting time for appointments, ease of scheduling, etc.

Referral: Authorization for a patient of a managed care plan to receive care from a specialist or hospital. The patient's primary care physician must generally provide the referral.

Self-Insurance or Self-Insured: Generally used to describe a type of insurance which an employer provides. When an employer is self-insured, this means that the payer or managed care company manages the employer's funds rather than requiring the employer to pay premiums. Many employers choose to self-insure because they are then exempted from certain insurance laws and in order to save money. Employers assume the risks involved and have the right to all insurance claim information. The employees and their dependents will not be able to discern if their employer is self-insured easily since all paperwork or benefits cards often contain the name of an insurance company, which is acting as an administrator for the plan.

Service Area: The geographic region the managed care plan serves. Since HMOs limit service to a geographically-determined provider network, plan members should live near their doctors and hospitals.

Specialist: A physician with training or expertise in a particular area of medicine.

TANF (Temporary Aid for Needy Families): A Medicaid program for families with dependent children (formerly AFDC).

True Emergency: See "emergency."

Utilization Review (also known as utilization management): Evaluation of the necessity, appropriateness, and efficiency of the use of health services, procedures, and facilities. Used as a method of tracking, reviewing, and rendering opinions regarding care provided to patients. Managed care organizations will sometimes refuse to reimburse or pay for services which do not meet their utilization review standards.

Source: Select definitions drawn from the following sources:
1. Kaiser Foundation - Understanding Managed Care
2. P. Pohly's Net Guide: Glossary of Terms in Managed Health Care (http://www.pohly.com)

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Our attempt in this Samples section is to provide examples of grievances and appeals in managed care. The situations described are examples only; you should be able to change the facts to fit your personal situation. If you have questions about how to make these samples fit your problem, use the Resource Guide in this handbook to locate organizations who may be able to help you.

To use these samples, look for the notes on the top of each page for when to use the sample, and who should use the sample.

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When dealing with any managed care organization, it is important that you have excellent records of all written correspondence and telephone conversations.

You should keep originals and records of:

• Your health plan handbook (member handbook)
• Notes of all phone conversations (see "A Record-Keeping Checklist" for important information)
• Every letter you receive from your managed care plan about the claim you have (see below for what to keep and your records)
• Bills, explanations, or notices of covered and non-covered services for any claim
• Letters from your doctors or other providers (for example: the hospital, lab, social worker) which support your claim
• Letters or articles from health or support organizations about care and treatment of your illness or condition
• All magazine, newspaper or computer articles about your diagnosis or illness (your local public library can help you find these), or notes about where and when you saw and heard TV or radio pieces about your illness or condition
• This handbook for reference

Use a single sheet of paper to keep records about all telephone conversations with the MCO. On this telephone log sheet, always note:

• the date and number you called
• the name of the person with whom you spoke
• a note about the subject of the call
• when you can expect to get a response and from whom, or the name
• and number of another person for you to contact.

You can use the sample log sheet in the Samples section of this handbook for a guide to recording information. We suggest you make a copy of this page so that you can use the form over again.

Keep all written correspondence about the same subject together. Use a large envelope for each issue in dispute, and keep a record on the outside of the envelope including:

• the date letters were received
• who wrote the letter
• something about the subject of the letter
• copies of all correspondence you send

If you file an appeal, you will be asked for all written correspondence you received, it is much easier to prove your case if you have everything together. Do not depend on the managed care plan to provide you with copies.

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For Use By:  Persons covered by commercial insurance
When:  To voice a grievance about a quality of care issue via telephone

WHAT TO DO:

• First, try to solve the problem with your primary care physician. If that is not possible, call your managed care organization.
• Use the sample conversation in the Samples section of this handbook, tailored to your concerns, to complain to your plan's patient or member services department (toll-free phone number should appear on your membership card).
• Have a blank sheet of paper ready when making the call. This is your log sheet. Write the date, phone number and subject of your call before you start. You can also make a copy of the log sheet in this handbook and use it as your checklist to get information.
• Ask to speak to a patient services representative or case manager.
• Be sure you write down:
  1. the date and number you called
  2. the name of the person with whom you spoke
  3. a note about the subject of the call
  4. when you will get a response and from whom, or the name and number of another person for you to contact

Sample Phone Call

PATIENT: I am having a problem. My child has spina bifida. We heard at our support meeting about a specialist in Vineland who we would like to see. Our primary care pediatrician says this doctor is not in your network. How can I get the referral to see this specialist?

MCO: I will check into this. You may have to have your in-network PCP request the out-of-network referral or you may have to submit your request to the medical director of our plan. I will find out and call you back.

PATIENT: The best time to reach me is from 1 to 4 on Tuesday, Wednesday or Thursday afternoon. When will you get back to me? How can I reach you directly if I do not hear from you? How do I submit the request to the medical director? Should I write a letter or can I call? What is the address and phone number? What is the next step if I am turned down by the medical director?

If you do not get satisfaction after this phone call BE PERSISTENT - do not give up. Do your homework; get as much information as possible to support why your position is the best solution for the problem. Keep records of what you find out and the source of the information. Be sure to always ask what is the next step in the managed care plan's process and keep track of deadlines to go to the next step. (See three-stage appeal process in this handbook for more information).

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For Use By:  Persons covered by commercial insurance
When:  Stage 1 informal appeal (phone call)

Get name and phone number of the Managed Care Plan's Medical Director or the physician who denied, limited, or terminated a health service covered under your plan. Have a telephone log sheet ready before you call.

Be sure you write down:

1. the date and number you called
2. the name of the person with whom you spoke
3. a note about the subject of the call
4. when you will get a response and from whom, or the name and number of another person for you to contact

Sample Phone Call

You should be speaking with the medical director of the managed care plan, or with the physician who denied, restricted or terminated your covered health benefit.

PATIENT: My doctor received a denial of her request for me to get reconstructive surgery, following my treatment for cancer. She says you made the determination that this is cosmetic surgery and not covered by my health plan. I want to appeal your decision and want the plan to conduct a reconsideration of your decision. My doctor recommended this as a necessary follow-up to my treatment for the cancer. I was trying to schedule this surgery in the next month as my surgeon suggested. When will I hear from you? (Record answers on log sheet)

MCO DOCTOR: I'11 look into this Stage 1 appeal. Since it is not an emergency, I will get back to you by the end of next week (by law, within five working days, counted Monday through Friday).

You can be informed of the outcome of the Stage 1 by phone. If you are told "the initial decision is being upheld," this is another denial. If the outcome of this first level of appeal is to continue denying the health benefit, you must be informed in writing of the steps to proceed to Stage 2, the formal internal appeal.

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For Use By:  Persons covered by commercial insurance
When:  Stage 2 formal internal appeal

The directions for filing a Stage 2 appeal should come from the managed care organization. Follow the directions precisely and be sure to provide all the information requested so as not to slow down the process.

Letter Sample

Your address
Your phone number
Date (be sure to respond within
stated time period, usually
60 days from denial)

(Inside Address)
Name of a representative you've spoken to or been given
Managed Care Organization
Customer Service Department
PO Box 00000
City, State ZIP

RE: (this information will come from any denial letter you've received)
Your name
Contract #
Claim #
Inquiry #

Dear Ms. Frances:

I wish to file a Stage 2 appeal for your denial of reimbursement to my gynecologist because I was seen before one year from my last examination. I receive my health insurance coverage through (my employer/a group plan/etc.) On April 21,1998, I requested reimbursement which you denied in the letter dated, June 2, 1998. I am attaching additional information for your review (attach letter from your doctor stating that in her medical opinion, you have conditions which require more than yearly diagnostic tests and examination) outlining the reason for my request.

In your denial letter of May 2 1, 1998, written by (name of managed care plan) customer service representative, Ms. Frances, you stated that this was not a covered benefit.

As I stated in my phone conversation with the customer service representative on June 10,1998, and as supported by this new information, I request that you reevaluate your previous denials.

Please contact me at your convenience or take the necessary steps to process a reconsideration. Thank you for your assistance.

If you do not find in favor of this request, please send written procedures for me to file an external appeal of this decision.

Sincerely,
(sign your name)

ENC. (list any supporting materials you are including in the packet)

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For Use By:  Persons covered by commercial insurance
When:  Stage 3 external appeal

Special Note: You should file a letter along with a completed form requesting a Stage 3 appeal. The form must be supplied to you by the managed care plan if your Stage 2 appeal is denied. There are certain documents which also must accompany the Stage 3 appeal request. See "How to Deal with a Denial, Termination or Limitation of Covered Health Services-Filing an Appeal" in this handbook for that document list.

Letter Sample

Your Address
Your Phone Number

Date (request within 60 days
of Stage 2 denial decision)

Office of Managed Care
PO Box 360
Trenton, NJ 08625-0360

I received denials at the Stage 1 on (give date) and Stage 2 on (give date) level of appeal for my request for continuing rehabilitative services for my chronic back problems following surgery on June 1, 1997. Copies of those denial letters are attached. I request a Stage 3 external appeal by the New Jersey Department of Health and Senior Services. Please refer my claim for review by the Independent Utilization Review Organization. My health coverage is provided by:

Healthy Health of the United States
123 Acme Boulevard
Hometown, NJ 00010

I have also enclosed a release for you to obtain my medical records concerning this appeal and a check for $25. (Usually a form for "release of medical information" will be sent to you with the Stage 2 appeal denial).

You will also find letters from Dr. X, a rehabilitation specialist in Trenton and Ms. L of MidState Rehab services in Princeton who have examined me and believe the discontinuation of my treatment would negatively affect my health. I have also submitted the transcript of the Healthy Decisions segment of the WNS television documentary aired on August 14, 1998 describing the need for long-term rehabilitation following trauma. You will also find the "Summary of Insurance Coverage" from the Healthy Health Managed Care Organization.

I understand that the IURO will inform me of its decision whether to review my case. Please contact me if you require any additional information. Thank you.

Sincerely,
(your signature)
Your Name

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For Use By:  Medicare Managed Care Enrollees
When:  To file a grievance via phone

Get the toll free phone number from your member handbook. Ask to speak to the customer/patient services/case worker.

Sample Phone Call

PATIENT: My name is Ms. Williams. I use a wheelchair, and the cardiologist who my primary care doctor referred me to is 45 minutes from my house and I cannot get transportation to visit her. I used to go to a cardiologist in my neighborhood. Can I still see her? Her name is Dr. Merit.

PLAN: Your former cardiologist is not on our list of participating physicians. What is your primary care doctor's name and phone number?

PATIENT: Dr. Small, his phone number is 555-4664.

PLAN: I will speak to your doctor and see if we can help to find a participating cardiologist closer to home for you.

PATIENT: What is your name and when will you get back to me? How can I reach you directly if I do not hear back from you?

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For Use By:  Medicare HMO enrollees
When:  Step 1 appeal, request for reconsideration

When a managed care organization makes a decision to deny, reduce or terminate Medicare-covered services, it must inform you of that decision in writing. You then have 60 days from the date of that written notice to file an appeal, known as a reconsideration. You should file a written request for reconsideration.

Letter Sample

Your Address
Your Phone Number
Date

Name of representative denying the health benefit Managed Care Plan Name Address

RE: (this information will come from any denial letter you've received)

Your Name
Contract Number
Claim Number
Inquiry Number

Dear Mr./Ms. (Name):

I wish to file a request for reconsideration for your denial of rehabilitation services necessary to restore maximum physical movement after my recent stroke. On November 28, 1999, my primary care physician, Dr. Harold Smith, requested pre-authorization for rehabilitation services, which you denied in the letter dated December 8, 1999.

Please take the necessary steps to facilitate the process of reconsideration. You will find a letter from Dr. Smith attached which supports the medical necessity of rehabilitation services for my health condition.

If the reconsideration does not result in a wholly favorable decision to me, please forward for a second level of reconsideration by an independent entity as required by law.

Sincerely,
(Your Name)

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For Use By:  Medicaid managed care enrollees
When:  Filing a grievance related to a quality of care issue

• Use the sample conversation in the Samples section of this handbook to help you make a complaint about your problem to your plan's patient or member services department (toll-free phone number should appear on your membership card).
• Have a blank sheet of paper ready when making the call. This is your log sheet.
• Write the date, phone number and subject of your call before you start.
• Ask to speak to a patient services representative or case manager.
• Be sure you write down:
  1. the date and number you called
  2. the name of the person with whom you spoke
  3. a note about what the call was about
  4. when you will get a response and from whom, or the name and number of another person for you to contact

Sample Phone Call

PATIENT: Hello. I would like to speak to the patient services or member