T HE
PG
ing a health plan is whether pre-exist-
ing conditions are excluded. Many
HMOs will not cover care for pre-exist-
ing conditions at any time, while others
require a waiting period of up to three
months before paying for care for a
pre-existing condition.
Here are some other important
questions to explore prior to signing up
for any health plan: What is the pre-
mium each month? Are there co-pays?
What is the deductible? What exclu-
sions are there that might affect you or
your family? Are preventive services
covered? What do you have to do to
see a specialist? If you have a chronic
condition, will your plan cover it?
What is the lifetime expenditure cap?
How and when can you change doc-
tors? What is the appeals process?
If you want to check on the quality
of your health plan, you can contact
your state health or insurance depart-
ment to find out if they have reports
on medical loss ratios, disenrollment
figures, complaints, financial stability
and doctor turnover. Additionally,
many HMOs conduct satisfaction sur-
veys of their members which they pub-
lish in a "report card." Ask if you can
obtain a copy before joining a plan.
You may also want to find out if your
HMO is accredited by the National
Committee for Quality Assurance or
the Joint Commission on the
Accreditation of Healthcare
Organizations. These organizations
review HMOs based on a set of prede-
termined standards and grant accredita-
tion accordingly.
Although you hope and expect to
receive a certain standard of care from
your HMO and your primary care
physician, there is no guarantee that
you won't encounter a problem some-
time down the road, either in service or
coverage. Fortunately, there are steps
you can take to try to remedy the situa-
tion.
The first step is to talk with a service
representative. If that fails, you can file
a formal complaint with the member
services department or grievance office
of your HMO. If your complaint is
denied, you may be able to file an
appeal, which will be reviewed by a
higher-level committee. If you are still
not satisfied with the outcome, you can
contact your state insurance depart-
ment.
As with any bureaucracy, it's impor-
tant to keep accurate written records
when dealing with a managed-care
organization, noting when you first
made a complaint, the date and to
whom you spoke.
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