Consumer Guide to Health Insurance
Your health-care rights
An insurance company cannot deny, limit, charge more for, or refuse to renew your coverage because of your race, color, religion, or national origin. Individuals with similar levels of risk (of the
same rate class) cannot be offered different rates, policy terms, or benefits, nor can they be discriminated against in any other manner unless the insurer bases the refusal, limitation, or higher
rate on sound actuarial principles.
Access to your health information
The Health Insurance Portability and Accountability Act of 1996, which took effect in April of 2003 (April 2004 for small companies that earn less than $5 million), provides right-of-access to your
health information. This means that your medical records must be released to you upon written request. HIPAA also restricts health insurers and providers' release of your personal information, including
your name and your medical history.
Complaints about lack of access or possible violations of privacy related to your personal health information should be sent by e-mail to OCRcomplaint@hhs.gov. Letters can be sent to Region X Office
for Civil Rights, U.S. Dept. of Health and Human Services, 2201 Sixth Ave., Suite 900, Seattle WA 98121-1831. They may be faxed to (206) 615-2297.
Be sure to include the name of the party about whom you have a complaint and a description of how your privacy was violated.
Information your insurer must provide to you
Your insurance company is required to provide the following written guidelines to you:
- Covered benefits, services, copays and co-insurance amounts.
- Participating providers, network and service-area restrictions.
- Referrals to specialists.
- Where to go for emergency care.
- Preauthorization requirements.
- Hospital, doctor and clinic network guide
- How to choose and change primary-care providers (PCPs).
- Provider risk-sharing arrangements
- General prescription-drug 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.
- Language services available to non-English speakers.
The following information is available upon request:
Medically necessary services
Within the coverage limitations of your insurance policy, you have a right to have your medical needs met. If a treatment plan does not meet your medical needs, you have a right to receive a different
treatment if your physician agrees that it is medically necessary and the treatment meets current medical standards for medically necessary treatment.
Emergency services
Your insurance company must provide a written disclosure to you, clearly explaining the following:
- How the company defines "emergency."
- Coverage for emergency services.
- How and where to get emergency services.
- Appropriate use of 9-1-1 services.
Although many insurance plans require preauthorization (permission from the insurance company before services are rendered by a provider) for certain medical treatments, you are not required to obtain
it for emergency medical services.
Oregon law defines emergency 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 that 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 medical conditions, emergency medical screening exams, items and services furnished in the emergency room, and related services, including ambulance transportation
from participating and nonparticipating providers.
Special health-care needs for women
Women 40 and older can get a routine preventive mammogram every year without a referral from their primary-care physician. Your insurance company may require you to select from among participating
providers for the mammogram.
Mammograms must be covered as often as needed for women at high risk for breast cancer or who are experiencing symptoms; they must be referred by a women's health-care provider.
If your primary-care physician is not a women's health-care provider, you may get care from a participating women's health-care provider for pregnancies and for at least one health examination a year
without obtaining a referral from your primary-care physician. This means that a managed-health-care plan cannot require you to get a referral from your primary-care physician for these services. You
can continue treatment without a referral for any medically necessary follow-up to the initial condition for which you sought care. However, you or your women's health-care provider should notify and
consult with your primary-care provider.
Pregnancy and childbirth
You have the right to see an in-network women's health-care specialist for your pregnancy. You must be allowed a minimum hospital stay of 48 hours for a normal vaginal delivery and 96 hours for a
Cesarean section. Your insurance company must begin calculating the hospital stay from the time of birth. For a home delivery that results in a hospital admission, the hospital stay begins at the time
of admission. The attending physician and mother may decide that a shorter hospital stay is appropriate. Your insurance company cannot require you to leave the hospital after a stay that is shorter
than these minimums.
Newborn and adopted children
Individual and employer-sponsored group health policies must provide benefits for newborn and adopted children if the policy provides coverage for dependents. Insurance policies may give you as little
as one month to enroll new members of the family, so notify your insurance company promptly. If there is an additional premium due because of the new family member on the policy, it needs to be paid
within 31 days after the birth or placement of the adopted child in your home.
A child is eligible for dependent coverage if a legal obligation exists for you to provide total or partial support, including when you are anticipating adopting the child. If the adoption is not finalized,
the child may not be eligible for coverage on your policy.
Diabetes education
Many group and employer-sponsored health plans cover an initial diabetes self-management education program taught by a health-care professional. You must complete the program to be eligible for benefits.
Be sure to review your benefit booklet to see if limitations apply to this coverage.
Mental health and treatment for chemical dependency
Individual plans and policies issued by labor unions may exclude mental health and chemical-dependency treatment or may provide very limited benefits.
Most group and employer health plans issued in Oregon must include minimal coverage for mental health and chemical-dependency services.
Most policies that cover these services require you and your therapist to develop a treatment plan. Some companies may review this treatment plan to determine if it is medically necessary.
Review your benefits booklet or contact your insurance company to be certain you understand your mental-health and chemical-dependency coverage.
Get answers to the following questions:
- From which providers can I choose?
- Do I need a referral from my PCP?
- How often are treatment plans reviewed and what are the guidelines?
- How much will my insurance pay?
- Do I have to pay any deductibles or copays?
Your copay and deductible for mental health and chemical-dependency services must be the same as for any other medical condition. For example, if your copay is $10 for a doctor visit, it should be
the same for outpatient mental health and chemical-dependency visits. Copay and benefit limitations for inpatient mental health and chemical-dependency care are different than those for outpatient
care.
Genetic Information
If you are asked to take a genetic test in connection with applying for insurance, the use of that test must be explained to you and you must complete a from giving your authorization to do the testing.
An insurer may not use genetic information about you or a blood relative to reject, deny, limit, cancel, refuse to renew or affect the terms and conditions of any insurance policy.
Managed-care rights
Standing referrals to specialists
Health-insurance plans that require a patient referral from a primary care physician to a specialist must have a procedure for granting standing referrals so that a patient is not required to get
approval from the PCP for each specialist appointment beyond the first one. The plan must allow a standing referral if the patient's doctor determines that the patient needs continuing care from a
specialist. If the patient and his or her PCP disagree about the need for a referral, the patient has a right to see another plan physician for a second opinion.
Continuity of care
Should a provider leave a health plan's network, a patient receiving treatment is entitled to continue in that provider's care for up to 120 days after the provider leaves the network. Pregnant women
past their third month of pregnancy may also get continuity of care for up to 120 days or until they give birth. Patients must request continuity of care from their health plans.
Insurers must give patients written notice when ending a contract with their provider. The written notice must explain the right to continuity of care and how to request it.
Grievances, complaints, and appeals
You have the right to file formal grievances and written complaints with your health-care providers and your insurance company. Grievances and complaints may express your dissatisfaction with services
you have received or appeal denied claims.
Every health insurer has grievance and appeal procedures. When you appeal a decision, you have the following rights:
- To receive an explanation of grievance procedures.
- To get help writing and filing a grievance.
- To receive an easy-to-understand written decision at each appeal level.
- To appear before review committees or select a representative to appear.
- To file a complaint with the Oregon Insurance Division.
Your insurance company must acknowledge non-emergency complaints and grievances within seven days of receiving them, make a decision, and respond within 30 days. If an extension is needed by the
insurance company, the company must notify you of the reason for delay and send a response within 15 additional days. Further extensions are not allowed in the grievance process. Your insurance company
must have procedures for responding more quickly in emergencies.
Filing an insurance complaint
You have the right to be your own advocate and to ask for help from the Oregon Insurance Division at any time. To request help, file
an insurance complaint, or call to request a complaint form, (888) 877-4894 (toll-free in Oregon). Our consumer advocates will investigate and try to solve your insurance-related problem.
External review
External review can help resolve disputes between patients and insurers. An external review
is a review of your medical records by an independent review organization
(IRO) that is contracted by the Oregon Insurance Division. IROs have doctors in every medical specialty to evaluate treatments of illness and injury.
When a private health insurer in Oregon has denied a claim at every level of its appeals process, Oregon law requires the insurer to inform the enrollee of his or her right to an external review. Upon
the enrollee's written request, the insurer must refer a dispute about whether a treatment plan is medically necessary, whether a treatment plan is experimental or investigational, and whether a treatment
plan that an enrollee is undergoing is eligible for continuity of care.
The patient must request external review from his or her insurance company.
Some health insurers use external review as part of their internal appeals process. External reviews are paid for by the insurer, regardless of whether the final decision is in favor of the patient
or the insurer.
Consumers must request external review from their health insurer no later than 180 days after receiving the insurer's final written denial. Within two business days, the insurer must inform the Oregon
Insurance Division of the request, and OID must assign an IRO (through a random-selection process) to review the medical record. The patient and insurer should receive the IRO's decision no more than
30 days after the date that the patient requested the external review. Most insurers comply promptly with a ruling from an IRO.
You have the right to an expedited external review (three days) if your physician or other provider states that a 30-day wait could seriously jeopardize your life, health, or your ability to regain
maximum function.
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