Every health plan must disclose specific information to consumers—members of a health plan and those people considering joining a plan.
This consumer information will be provided in the plan’s member handbook, subscriber contract and member newsletters. Other information must also be provided at the request of a consumer. A partial list of the information that must be provided to all health plan members or those people thinking of joining a plan includes descriptions of:
- Plan benefits and coverage—the services the health plan will pay for and any limitations, such as dollar amounts, number of visits allowed, or any other limits.
- How the plan defines “medical necessity.”
- Prior authorization requirements. The plan will probably have provisions relating to when you must get approval for some services before receiving those services.
- How the health plan pays health care providers for the services given to patients that are members of the plan.
- Member’s financial responsibilities—or what your costs are—including co-payments or deductibles, payments for charges that are above what the plan considers “usual and customary” and paying for services not covered by the plan or services received from a provider outside the plan’s network.
- Grievance procedures and appeals rights, including the plan’s toll-free number, the process for filing a complaint and how long it will take to receive an answer. (See the section on “grievances and appeals” for more details.)
- Procedures to select and change your primary care physician (PCP).
- List of providers in network, listed by specialty.
- Coverage for emergency services (see the section on Specialty and Emergency Care Needs for more information).
Upon request, a plan must provide members or those people thinking of joining a plan with the following (partial list):
- Information on consumer complaints.
- Confidentiality procedures.
- The ability to inspect the health plan’s prescription drug formulary.
- Description of procedures used to evaluate requests for experimental and investigational treatments.
- Hospital affiliations of individual physicians.
- Specific written treatment protocols for a particular disease or condition.