Order your free copy now and learn all you need to know about living the good life in San Francisco!
| Insurance |
HMOs may not prohibit doctors from talking to you about your medical condition, treatment options and terms and requirements of your health-care plan, including how to appeal an HMO’s decision. An HMO also may not provide financial rewards to doctors for withholding necessary care.
California HMOs are required to cover medically necessary emergency services even when outside of their coverage area. All HMOs in California are regulated by the Department of Managed Health Care (DMHC). If you have a complaint with an HMO, contact the member services department of your HMO. HMOs are required to have an internal complaint or grievance process in place. If you file a grievance and it has not been resolved within 30 days or there is some question as to the HMO’s decision, you may contact the DMHC for assistance.
— Federally Mandated Benefits
In addition to benefits required by state law, health plans must abide by federal law and offer maternity and newborn coverage and mastectomy benefits.
Maternity and Newborn Coverage
If maternity benefits are covered, a group health plan with more than 15 employees must provide for a minimum hospital stay of 48 hours after an uncomplicated vaginal delivery and a minimum stay of 96 hours after an uncomplicated cesarean birth. A carrier may not deny benefits on the grounds that a pregnancy is a “pre-existing condition.”
Plans that have maternity benefits automatically must extend coverage to the newborn for 31 days. To continue coverage beyond 31 days, you must notify your plan administrator during this period and pay any additional required premiums to add the child to your insurance.
A carrier may not exclude or limit initial coverage of a newborn child because of premature birth, accident, illness or congenital medical conditions. This includes providing reconstructive surgery for craniofacial abnormalities for a child younger than 18 who has been covered continually by a health plan.
A benefit covering “complications of pregnancy” may help if your plan does not include a maternity benefit. Miscarriages or nonelective cesarean births are considered complications. In most cases, management of a difficult birth is not considered a complication and only is covered by plans with maternity benefits.
Mastectomy Coverage
Plans that offer mastectomy coverage also must provide for reconstructive surgery of the breast on which the operation was performed as well as the other breast if needed for a symmetrical appearance. This coverage may be subject to deductibles, copayments and coinsurance that are consistent with other benefits under the plan. The benefit also must cover prosthesis and treatment of complications at all stages of mastectomy, including lymphedemas.
— Health Savings Account
As of January 1, 2004, health-care consumers had a new way to help manage their own health care. Health Savings Accounts (HSAs) provide consumers with added insurance coverage and control. Flexibility is the key component of an HSA. Anyone with a high-deductible health plan can set up a health savings account to save money on medical care now or save for future medical expenses. You may use HSA funds to pay for expenses that must be met before your deductible, to pay for services not covered by your health care plan (such as alternative therapies or out-of-network providers) or to pay for insurance coverage during periods of unemployment.
California HMOs are required to cover medically necessary emergency services even when outside of their coverage area. All HMOs in California are regulated by the Department of Managed Health Care (DMHC). If you have a complaint with an HMO, contact the member services department of your HMO. HMOs are required to have an internal complaint or grievance process in place. If you file a grievance and it has not been resolved within 30 days or there is some question as to the HMO’s decision, you may contact the DMHC for assistance.
— Federally Mandated Benefits
In addition to benefits required by state law, health plans must abide by federal law and offer maternity and newborn coverage and mastectomy benefits.
Maternity and Newborn Coverage
If maternity benefits are covered, a group health plan with more than 15 employees must provide for a minimum hospital stay of 48 hours after an uncomplicated vaginal delivery and a minimum stay of 96 hours after an uncomplicated cesarean birth. A carrier may not deny benefits on the grounds that a pregnancy is a “pre-existing condition.”
Plans that have maternity benefits automatically must extend coverage to the newborn for 31 days. To continue coverage beyond 31 days, you must notify your plan administrator during this period and pay any additional required premiums to add the child to your insurance.
A carrier may not exclude or limit initial coverage of a newborn child because of premature birth, accident, illness or congenital medical conditions. This includes providing reconstructive surgery for craniofacial abnormalities for a child younger than 18 who has been covered continually by a health plan.
A benefit covering “complications of pregnancy” may help if your plan does not include a maternity benefit. Miscarriages or nonelective cesarean births are considered complications. In most cases, management of a difficult birth is not considered a complication and only is covered by plans with maternity benefits.
Mastectomy Coverage
Plans that offer mastectomy coverage also must provide for reconstructive surgery of the breast on which the operation was performed as well as the other breast if needed for a symmetrical appearance. This coverage may be subject to deductibles, copayments and coinsurance that are consistent with other benefits under the plan. The benefit also must cover prosthesis and treatment of complications at all stages of mastectomy, including lymphedemas.
— Health Savings Account
As of January 1, 2004, health-care consumers had a new way to help manage their own health care. Health Savings Accounts (HSAs) provide consumers with added insurance coverage and control. Flexibility is the key component of an HSA. Anyone with a high-deductible health plan can set up a health savings account to save money on medical care now or save for future medical expenses. You may use HSA funds to pay for expenses that must be met before your deductible, to pay for services not covered by your health care plan (such as alternative therapies or out-of-network providers) or to pay for insurance coverage during periods of unemployment.
1
2
3
4
5
6
7
