You have legal rights and protections as a member of a managed care plan. Knowing your rights means you could have a greater chance of getting the treatment or medicine you need. You can find your rights in the plan contract and in state and federal laws.

Plan Contract

The contract may be between you and the health plan or between your employer and the health plan. Ask your employer or the plan's member services department if you want a copy of this contract.

State or Federal Laws

People who pay for their own health insurance or who are insured through their employer have rights under federal and state laws. If you pay for your own health insurance, usually the state laws that apply to your managed care plan are those of the state you live in. If you get health care through your work, the state laws that apply are those of the state in which you work.

Some types of plans are exempt from state laws on health insurance, but federal laws might apply. Talk to your employer's benefits manager to see if any state laws affect your health insurance.

Find out which state agency oversees managed care plans. In some states, the state insurance commissioner oversees managed care plans, while in other states the health departments do. If you have a serious problem with your health plan, call your state insurance or health department.

Appeals

You don't have to accept your plan's decision to stop or deny treatment you think you need. You can ask the plan to reconsider its decision. This is called an appeal and it is your right to appeal a decision you feel is unfair. Many plans first say "No" to certain kinds of care but later change the decision if you appeal or complain about it.

Here are some examples of the kind of plan decisions you might want to appeal:

• Your plan is not giving you the care you think you need.
• Your plan won't pay for treatment you believe is necessary.
• Your plan won't pay for treatment because you did not first get an okay from the plan.
• Your plan won't pay for your visit to the emergency room.

How to file an appeal

There is no single appeals process; it varies by state. Read your plan information or call the plan's member services department to find out how your plan's appeals process works. The appeals process can take a lot of time and work on your part, but it can be worth the effort.

No matter how your plan's appeal process works, there are some steps you can take that will help. The first and most important step to take when appealing a decision is to ask your plan to put into writing why they are denying or ending your treatment. Ask your plan to include:

• the specific provisions of the policy or contract used for its decision. That's important because it requires the plan to give the legal and medical reasons care was denied. This tells you the specific points to use if you need to challenge them further.
• If they can't cite a section of the policy, they may back down.
• the medical background of the person who made the decision.

When you have this information, put your request for an appeal in writing. Include information about the treatment you wanted, when the treatment was denied or stopped, the plan's reason for denying treatment, and why you think the plan should pay for the care you want. Your doctor might be able to help you. A letter from your doctor explaining why the treatment is necessary carries a lot of weight.

Send your appeals request to your plan. You can send your request by fax, mail, or take it in person to your plan. Also, be sure to send a copy to the medical director of your plan. The director has the power to change the decision.

Keep accurate and detailed records so that you can document your claim through the appeal.

• Write down the times, dates and names of people you speak to and what was said.
• Follow up every phone call and meeting with a letter reviewing what was discussed.
• Keep copies of all the letters you have written and all the letters and notices the health plan sends you.
• Make sure your health plan has all of the necessary medical records.

Get Help

Ask your doctor to support your appeal of the plan's decision. If your doctor won't support you, think about getting a second opinion. You might want to see another doctor in the same network or go to a doctor outside your network. Many plans will pay for a second opinion if you see a doctor in its network.

Ask your employer for help if you get your insurance through your job. Tell your benefits manager about your problem and ask if he or she will support your appeal. Managed care plans might be more likely to listen to an employer who can move its business to another plan, then to one individual's complaint.

Check with your state insurance commissioner, health department, or other agency that regulates managed care plans in your state. Let them know you are appealing your plan's decision.

Call or search the Web sites of national health groups such as the American Cancer Society or the American Heart Association for information on treatments that can help support your appeal.

Appeals Beyond the Plan

If the plan denies your appeal, you may be able to appeal outside the plan. Check with your state insurance or health department. They may be able to lend support to your appeal. Most states require an independent group to review plan decisions that are appealed.

The next step would be to take legal action. Although it might not be your easiest or least expensive option, sometimes this is the only way to resolve a problem with a health plan.

Filing a Complaint

If you have problems -- such as delays getting through on the phone to your plan or waiting too long to get an appointment to see your doctor -- you might want to register a complaint with the member services department. Often they appreciate hearing from members so they can improve their service.

AARP Resources

Managed Care Enrollees Gain Ground
How state laws are protecting people in managed care plans.

Additional Resources

A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan
A guide from the Kaiser Family Foundation to help you with the appeal process.

National Association of Insurance Commissioners (NAIC)
Contact information for your state insurance department.

Healthinsuranceinfo.net
Reviews the health insurance protections in each state. Read "A Consumer Guide for Getting and Keeping Health Insurance" for your state.