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Your Health Care Rights

You have the right to:

  • Voice grievances.
  • Receive information about your insurance company's services and providers.
  • Participate in health care decisions.
  • Be treated with respect, dignity, and with privacy.
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Bullet How to file a grievance with your insurance company
Bullet Your rights against unfair discrimination
Bullet How to seek assistance from the Insurance Division
Bullet Your right to information
Bullet Obtaining emergency services
Bullet Special health care needs of women
Bullet Maternity and newborn care
Bullet Newly born and adopted children
Bullet Pharmacy services: prescriptions
Bullet Diabetes education
Bullet Mental health and chemical dependency services
Bullet Pre-existing conditions
Bullet Exclusion periods for specified servies
Bullet Obtaining credit for prior coverage
Bullet How to obtain prior authorization
Bullet Obtaining medical treatment and referrals
Bullet How your doctor is paid
Bullet Settling your health insurance claims
Bullet Utilization review

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How to file a grievance with your insurance company

You have the right to file a formal grievance (written complaint) with your insurance company. The grievance can be related to a denied claim or can be an expression of dissatisfaction and request for an insurance company to respond. You may appeal an initial grievance decision two times. The grievance is required to be reviewed by people that were not previously involved in the dispute at one of the appeal levels.

When you appeal a decision, you have the right to:

  • receive an explanation of the grievance process
  • obtain assistance in filing and writing a grievance
  • receive an easy to understand written decision at each appeal level
  • appear or select a representative to appear before review committee
  • file a complaint with the Insurance Division

Your insurance company must acknowledge grievances that are not an emergency within seven days of receipt. A decision must be made within 30 days of receipt of the grievance. If an extension is needed, the insurance company must notify you of the specific reason for a delay. A response must be sent within 15 additional days. An extension is allowed only for the initial grievance. Your insurance company must have procedures for ensuring a timely response for urgent situations. You also have the right to seek assistance from the Insurance Division at any time.

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Your right to information

Your insurance company must provide you with written guidelines on:

  • covered benefits, services, and any co-insurance amounts
  • network and service area restrictions
  • specialty referrals
  • how to obtain emergency care
  • prior authorization requirements
  • utilization review procedures
  • hospital, doctor and clinic network guide
  • how to choose and change primary care providers
  • provider risk-sharing arrangements
  • general prescription formulary guidelines
  • how enrollees will be notified of changes in benefits
  • how enrollees will be notified of changes in physician availability and how to obtain assistance
  • assistance available to non-English speaking members

The following information is available upon request:

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Obtaining emergency Services

Your insurance company must provide you with a written disclosure clearly stating:

  • what they determine is an emergency
  • coverage that is provided for emergency services
  • how and where to obtain emergency services
  • the appropriate use of 911 services

You are not required to obtain prior-authorization for emergency medical services. Emergency services are defined by law as "a medical condition that manifests itself by symptoms of sufficient severity that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect failure to receive immediate medical attention would place the health of a person, or a fetus in the case of a pregnant woman, in serious jeopardy." Emergency services include stabilization of emergency medical conditions, treatment for emergency medical conditions, treatment for emergency medical screening exams, items and services furnished in the emergency room and ancillary services including ambulance transports from participating and nonparticipating providers.

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Your rights against unfair discrimination

An insurance company cannot deny, refuse to renew, limit, or charge more for coverage because of your race, color, religion, or national origin. A company also cannot deny, refuse to renew, limit, or charge more for coverage because of your gender, marital status, disability, or partial disability unless the refusal, limitation, or higher rate is based on sound underwriting or actuarial principals.

In addition, a company cannot unfairly discriminate between individuals of the same (rate) class and essentially the same hazard (risk) in its rates, policy terms, benefits, or in any other manner unless the refusal, limitation or higher rate is based on sound actuarial principles.

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Special health care needs of women

Women age 40 or older may have a preventive routine annual mammogram without a referral from your primary care provider. Your insurance company may still require you to see a participating provider for the mammogram. Mammograms are covered for symptomatic or high risk women at any time upon referral from a women's health care provider.

If your primary care provider (PCP) is not a woman's health care provider you may also obtain care from a participating women's health care provider for at least one annual preventive women's health examination or pregnancy care without obtaining a referral from a primary care provider (PCP). This means that a managed health care plan cannot require you to obtain a referral for these preventative services. In addition, you can continue treatment without a referral for any medically necessary follow-up care. However, you and your woman's health care provider should notify and consult with your primary care provider.

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Maternity and newborn care

You have the right to a minimum hospital stay of 48 hours for a normal vaginal delivery and 96 hours for a caesarean section. Your insurance company must begin calculating the hospital stay from the time of delivery. In the event of a home delivery that results in a hospital admission, the time will be determined from the time of admission. The attending physician and mother may decide that a shorter hospital say is appropriate. However, your insurance company cannot restrict your hospital stay to a shorter period than these limits.

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Newly born and adopted children

Individual and employer sponsored group health policies must provide benefits for newly born children and adopted children if that policy provides coverage for a family member of the insured. It is important that you notify your insurance company right away in order to add your new dependent on your policy. The additional premium needs to be paid within the first 31 days of the date of birth or the placement of the adopted child in your home. An adopted child is eligible if their is a legal obligation to provide total or partial support of a child in anticipation of the adoption. This means that the child will not be eligible for coverage on your policy if the adoption is not finalized.

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Pharmacy services: prescriptions

Insurance companies usually offer pharmacy benefits based on prescription formularies. A formulary determines which prescriptions or brands are covered or not covered under an insurance plan. There are three types of formularies available.

  1. Open Formulary: No limitations on prescriptions
  2. Closed Formulary: Medical exceptions allowed
  3. Mandatory Closed Formulary: No medical exceptions allowed

Upon request, your insurance company must tell you if a medication is included as a covered benefit in a formulary as well as how it can be included in the formulary when exceptions are allowed. The company must provide you with a summary of prescription formulary policies, cost sharing, and restrictions that may apply to your coverage.

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Diabetes education

Most group or employer sponsored health plans must provide coverage for an initial self management diabetes education program that is offered by a health care professional. You must complete the program to be eligible for the benefits. You will need to review your benefit booklet to determine the limitations that apply to this coverage.

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Mental health and chemical dependency services

Most group or employer health plans issued in Oregon must include minimum benefit coverage for mental health and chemical dependency services. Individual policies, out of state contracts, and employer or union trusts may have different or no benefits.

Most insurance companies require you and your therapist to develop a treatment plan based on your needs. Some companies may review this treatment plan to determine if it is medically indicated.

It is important that you review your benefit booklet or contact your insurance company to find out any restrictions that might affect your coverage. You will want to find out the answers to the following questions.

  • What providers can I choose from?
  • Do I need a referral from my primary care provider?
  • How often are treatment plans review, what are the guidelines, and are my records handled in a confidential manner?
  • What are the dollar limitations on my coverage?
  • Do I have to pay any deductibles or copayments?

Your copayment and deductible for mental health or chemical dependency services should be the same as for any other medical condition. For example, if your medical office copayment is $10 then you will also have a $10 copayment for mental health or chemical dependency services.

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Pre-existing conditions

A pre-existing condition provision on an insurance contract may apply for six months, twelve months, or eighteen months depending on the policy and the time that you enrolled for coverage. This provision applies to medical conditions that you have sought medical advice, diagnosis, care or which treatment was recommended or received during the six months prior to the time that you enrolled in the insurance contract. Insurance contracts may not cover these pre-existing medical conditions or may offer a reduced benefit.

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Exclusion periods for specified services

An exclusion period is a period during which specified treatment or services are excluded from coverage for all new enrollees. For example, some policies contain a 24 month exclusion period for transplant services. That means that covered transplants would not be covered the firest 24 months of eligibility. Creditable coverage must be applied against an exclusion period on the basis of lapsed time covered in the prior coverage.

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Credit for prior coverage

Creditable coverage means prior health care coverage and includes coverage remaining in force at the time the enrollee obtains new coverage. If you were covered under another health plan without a break in coverage of no more than 63 days and obtain a new health plan or you obtain a second health plan, you have the right to receive a credit towards any new pre-existing condition provisions and exclusion periods. You will need to obtain a certificate of coverage from the prior insurance company to present to your new insurance company as proof of coverage.

Most health coverage is creditable coverage, such as coverage under a group health benefit plan (including COBRA continuation coverage), state continuation, HMO, individual health insurance policies, Medicaid, and Medicare. Creditable coverage does not include coverage consisting solely of "excepted benefits," such as coverage solely for dental or vision benefits.

Example 1: You were covered under Plan A for 12 months. You enroll in Plan B within 63 days of Plan A's termination date. The 12 month pre-existing condition contract provision under Plan B would not apply due to the credit of coverage from Plan A.

Example 2: You were covered under Plan A for 12 months. You enroll in Plan B within 63 days of Plan A's termination date. You need a transplant which is covered under Plan B but has a 24 month exclusion period. If Plan A included transplant benefits then you would receive a 12 month credit towards the 24 month transplant exclusion period. you would have to wait for 12 months rather than 24 months to have the transplant.

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How to obtain prior authorization

Insurance companies may require prior authorization for some medical procedures. This is often referred to as prior approval of services because it means you must get approval before you have the service performed. It does not include referral approval for evaluation and management services between providers. Your insurance company must complete a prior authorization review for non-emergency services within 2 days.

Your insurance company should provide a general written summary on how prior authorization decisions are made. Determinations of coverage and medical necessity are binding if obtained within 30 days of the date services are rendered. Prior authorizations affected by cancellation of eligibility are binding for five days unless the insurance company knows coverage will end prior to the date of service and a termination date is specified.

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Obtaining medical treatment and referrals

The contractual arrangement between your physician and your insurance company is generally not regulated. However, your physician cannot be restricted from:

  • Discussing any aspect of your medical condition
  • Proposing any treatment including alternative care options
  • Referring you to another participating or nonparticipating provider
  • Disclosing general financial contract arrangements

Your physician must:

  • Follow any written policies that your insurance company has in place
  • Inform you that the service may or may not be covered by your health plan

You may obtain care from a participating women's health care provider for at least one annual preventative women's health examination or pregnancy care without obtaining a referral from a primary care provider (PCP). This means that a managed health care plan can not require you to obtain a referral for these preventative services. Your insurance company may require a referral for medical treatment.

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How your doctor is paid

Physicians generally contract with insurance companies to provide medical services to their members. A physician that contracts with an insurance company is generally referred to as a participating provider. A participating physician may be reimbursed for providing medical care in many different ways. The most common contract arrangements include a capitated arrangement or a fee for services provider agreement.

A capitated agreement is when the physician receives a guaranteed set dollar amount by an insurance company based on a projected number of members per month that will receive services from the provider. The physician receives the compensation regardless of whether or not the patient receives medical services.

A fee for service agreement is when the physician receives reimbursement from the insurance company. The payment is based on the usual customary and reasonable amounts of the actual services provided. The physician only receives payment if the patient is treated.

You have the right to find out how your physician is reimbursed, receives incentives, or penalized for medical services that you receive.

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Settling your health insurance claims

Your insurance company must make a reasonable investigation prior to denying a claim. Claims must be acknowledged within 30 days and investigations must be completed within 45 days. An extension is allowed if a notice is sent to you stating the reason for the delay and the additional information that is necessary to complete the review. Insurance companies must comply with the Unfair Claims Settlement Act.

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Unfair claims settlement act does not allow an insurance company to misrepresent facts or policy provisions in settling claims. An insurer must:

  • not fail to acknowledge or act promptly with claims communications
  • not fail to adopt and implement reasonable standards for a prompt investigation
  • not refuse to pay claims without a reasonable investigation of available information
  • not fail to affirm or deny coverage of claims within a reasonable time
  • attempt, in good faith, to promptly and equitably settle claims
  • not attempt to settle claims at a lower benefit than what a reasonable person would believe they were entitled to based on written or printed advertising material
  • not attempt to settle a claim on the basis of an altered application without notifying and obtaining your consent
  • not delay investigation or payment of claims by requiring duplicate information
  • not fail to inform you, upon request, of the benefit a claim was paid
  • not fail to settle claims under one coverage of the policy in order to pay claims under a different benefit of the policy
  • not fail to promptly provide the proper explanation for a denial of a claim

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Utilization review

Your insurance company must provide you with a general summary stating how utilization review decisions are made. Utilization review is a set of formal techniques used by your insurance company that are designed to monitor the use of or evaluate the medical necessity, appropriateness, efficacy or efficiency of health care services, procedures or settings.

You may request specific information pertaining to utilization review procedures for a specific condition or disease. Your insurance company must provide available information to you. Some information might be considered proprietary or confidential and will only be shared verbally.

All medical necessity and appropriateness of service decisions made by your plan will be determined by a licensed medical doctor (M.D.) or a doctor of osteopathic medicine (D.O.). You have the right to a timely review with a peer review committee or medical consultant at your insurance company for denials of medical necessity or experimental procedures.

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File a complaint with the Insurance Division

 

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This document was last revised on April 12, 2002 .