Last Updated: August 2005

SOLVING PROBLEMS WITH A COMMERCIAL PLAN

When tackling a problem with a client’s managed care plan, it is always a good idea to try calling the plan first. If that doesn’t work, clients have several other ways to get the results needed.

But first if the client gets health insurance through his/her employer or union, find out if the employer or union is “self-insured”. This means that when the client needs health care, the employer or union rather than an insurance company, is responsible for the cost.

A client can find out by asking his/her employer or union, or by looking at the back of his/her health benefits booklet to see if an insurance policy backs up the plan. If there is no insurance policy, the client’s plan is self-insured. For more information on client rights, go to page 9B-26, because only rights under a Federal law called ERISA will apply to the client.

If the client’s employer or union is NOT self-insured, the client not only has rights under ERISA but he/she also has rights under State law, which the following sections describe. The law requires every managed care plan (except self-insured plans) to follow formal procedures, with strict time limits, to solve the client’s problem. These are called Grievance Procedures and Utilization Review Appeal Procedures. The client may be able to get his/her problem solved through an External Review process described in Section 9B.4 later in this chapter.

Whether the client’s plan is insured or self-insured. If his/her employer or union provides the client with the coverage it is subject to ERISA and the client should read the section starting on page 9B-26 because ERISA can increase the client’s rights.

Q. How a client solve a problem with his/her managed care plan?

A. First, call the plan’s Member Services Department. All managed care plans are required to have a toll-free “800 number” to help clients. The number should be on the managed care plan card and/or in the Member Handbook. Tell Member Services about the problem.

Take notes whenever the client calls his/her managed care plan. Write down what was said, who the client talked to, and the date and time the client talked to the plan. That way the client will have a record of how the plan said it would solve the problem. If the plan representative does not answer the client’s question or deal with his/her problem, ask to speak to his or her supervisor.

A managed care plan must have someone who speaks Spanish and other languages to help the client. They must also have a TTD/TTY for people who are deaf or hard of hearing.

Q. What if the managed care plan’s member services department doesn’t fix the client’s problem?

A. If the plan’s Member Services Department does not fix the problem, the client can try to solve the problem through one of several formal procedures, described below.

They include the plan’s internal Grievance or Utilization Appeal Review Procedures and—in special cases—the State’s External Review system.