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If
you joined an HMO because your doctor was in the network, only to find
out she's left, you have no rights in many states for continued
coverage for that doctor.
According to Families USA, only about one-fourth of states have enacted laws requiring health plans
to continue paying for treatment provided by primary care doctors or
specialists whose contracts with the health plan aren't renewed (for
reasons other than quality-of-care problems, such as incompetence).
Most of these state laws specify a minimum number of days that the
health plan must provide transitional care.
Minnesota
became the first state to require HMOs to let patients continue to see
doctors who are dropped from the network, and it was later followed by
Florida, Kansas, Maryland, New Jersey, New York, Texas and Virginia,
among others.
In Florida, if a contract between an HMO and a
provider is terminated (for any reason other than for cause), they must
allow HMO members for whom treatment is active to continue coverage
through the completion of medically necessary treatment, until the
patient picks another provider, or until the next open enrollment
period offered by the HMO (not to exceed six months or through
postpartum care if pregnant).
In 1998,
California enacted a continuity-of-care law for high-risk patients
(those with certain chronic or life-threatening illnesses) that allows
them to continue seeing their doctor for up to 90 days if their doctor
is dropped from their health plan.
Under
the Patient Bill of Rights in Illinois, signed into law in August 1999,
certain patients in managed care plans must be allowed transitional
care. To qualify, patients must be in an ongoing course of treatment,
which is rather murkily defined as "a condition or disease that
requires repeated health care services pursuant to a plan of treatment
by a physician because of the potential changes in the therapeutic
regimen." Unfortunately, the laws do not always require the health plan
to maintain payment at the same level. If you have to pay
"out-of-network" costs, you may find yourself with a hefty medical
bill.
| All HMO customers in Illinois must be given information about their rights to transitional care. |
If
you think you're one of those patients, you are allowed to continue
visiting your doctor for 90 days after the doctor leaves the plan. The
doctor, of course, must agree to the plan's rules and fees first. (If
you aren't sure if you're one of those patients, ask your health plan.)
In
addition, women in Illinois in their third trimester of pregnancy must
be given the option of continuing to see their doctor through
postpartum care, just as in New York. Patients also must be given a
60-day notice that their primary care doctor is leaving the plan and
all customers must be given information about their rights to
transitional care.
Under Wisconsin law,
if you were told at the time you joined a health plan that your doctor
was in the plan's network, you must be allowed to see your doctor at no
additional cost for the entire plan year if your doctor is then dropped
from the plan. In addition, patients must be allowed to continue to see
their specialist who is dropped for the course of their treatment or 90
days, whichever is less. And if you're in your second trimester of
pregnancy, you can continue to see your doctor through postpartum care.
The
exception to these Wisconsin laws is when your doctor is no longer
practicing at all in your health plan's service area or if your doctor
was terminated from the plan for "cause," such as malpractice, fraud or
other wrongdoing.
Interestingly, Wisconsin
law requires your HMO to give you a 30-day notice if it terminates its
contract with your primary care doctor, but it does not have to notify
you at all if it terminates its contract with your specialist. (There's
a lesson here: Before you visit your specialist, double-check that he or she is still in your network.)
If you're facing the problem of having your doctor
dropped from your network, contact your state department of insurance
to find out what your rights are for continued coverage for that
provider.
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