Answer to Question 1
- What percentage of the plan's doctors are board-certified. How many leave each year?
- Has the plan been evaluated by the National Committee for Quality Assurance or another organization. Can you read the report?
- What is in the sample benefits contract?
- How many of the complaints against the plan filed with the state insurance department have been upheld?
- Must primary care physicians request permission from the HMO before they can refer patients to specialists? Does that rule extend to gynecologists?
- Is it easy or difficult to file an appeal when treatment is denied?
- Do doctors receive financial incentives for holding down medical costs? Are they willing to disclose them?
- What type of preventative care, such as immunizations and annual physicals, does the plan offer?
- Is preauthorization needed for hospitalization? What kind?
- Is a prescription drug you use on the plan's list of approved medications?
Answer to Question 2
- The health care provider is required to place the patient's interests first.
- The health care provider is required to push for care that will benefit the patient's health.
- The health care provider is required to discuss all treatment options, even options not covered by the plan. The patient can then decide whether or not to appeal for coverage of an uncovered option or go outside the plan.
- There should be established adequate means for appealing disputes.
- Plans should disclose limitations of restrictions in coverage to prospective members deciding whether or not to join.
- Plans should not encourage or permit substandard care.
- Plans should disclose incentives to health care providers that limit care.
- Plans should limit the incentives health care providers receive for limiting care.
