The California Patient's Guide
  Your Health Care Rights and Remedies
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acute condition or illness - a condition or illness that only lasts for a short period of time and usually is stopped with the appropriate care without requiring ongoing treatment. A common cold is an acute illness, as is a heart attack, because these conditions are short-lived and do not necessarily require continued care.

administrative record - all the papers, documents and recorded testimony in a proceeding before an HMO's administrative body.

appeal - review of a health plan decision regarding a patient's health care with which the patient and/or his or her doctor disagrees. An "appeal" can refer to both review through the plan's own grievance process and a review by other outside decision-makers, such as the Department of Managed Health Care and independent medical review organizations.

arbitrary or capricious - depending on individual discretion and not fixed by standards or rules; lacking a rational basis.

arbitration - a process of resolving disputes out of court through the use of a neutral decision-maker that is usually agreed to by contract.

authorization - approval by a health care plan required in order for a patient to receive health care, including specific treatments, procedures or tests.

bad faith - willful failure to carry out legal obligations.

battery - an unlawful act of applying force to the person of another without consent.

capitation payment - a fixed, lump-sum paid to doctors by health care plans, typically on a monthly basis, to care for all patients belonging to that health care plan.

chronic condition or illness - a condition or illness that requires ongoing treatment for a long period of time that may extend over a person's entire lifetime.

COBRA - Consolidated Omnibus Budget Reconciliation Act of 1986. COBRA is a law that gives certain employees, retirees, spouses, former spouses, and dependent children the right to temporary continuation of health coverage at group rates. COBRA applies to group health plans with 20 or more employees in the private sector and those sponsored by state and local governments.

copayment - a fixed sum of money paid by a patient each time he or she receives certain health care services. For example, plans may charge a copayment of $10 for a visit to a doctor's office, above and beyond what the health plan pays the doctor.

conservatorship - a legal relationship created when a person, official, or institution is designated to take over and protect the interests of someone who is incompetent.

continuity of care - medical treatment received without interruption.

contract - an agreement between a health plan and a patient or his or her employer that describes what health care services are covered by the plan, how much the plan will pay for those services, and what premiums must be paid by the patient or his or her employer. A plan usually also has a contract with certain doctors who will provide health care services to members of the plan.

contracted provider - a hospital, doctor, or other health care provider who has an agreement with a health care plan to provide health care services to members of the plan.

coverage - a process by which a health plan determines what health care services or products will be paid for by the plan.

damages - monetary compensation in a legal action awarded to someone who has been injured by another.

Declaration Under The Natural Death Act - A legal document that any person of sound mind over the age of 18 can execute that will govern the withholding or withdrawal of life-sustaining treatment. (California Health and Safety Code section 7186.5)

denial of care - a decision made by a health care plan not to pay for (or provide coverage for) a particular health care service or product.

Department Of Managed Health Care (DMHC) - the state agency in California with the authority to regulate all health care plans. (888) HMO-2219 or (800) 400-0815.

Durable Power Of Attorney For Health Care - a legal document that designates a person to make certain health care decisions, as directed in the document, on a person's behalf when that person is unconscious or otherwise unable to communicate with a treating doctor. (see California Probate Code section 4606, et. seq.)

duty of ordinary care - an obligation owed by one person to another to avoid injury to him or her.

emergency care - medical care provided to patients with severe, life-threatening conditions that require urgent attention.

emergency medical condition - a medical condition that in the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

emotional distress - a highly unpleasant emotional reaction (as anguish, humiliation, or fury) that results from another's conduct and for which damages may be sought.

employer group health plan - a package of medical benefits provided to all employees by their employer, usually through an HMO or network of approved doctors.

ERISA, "Employee Retirement Income Security Act of 1974" - a federal law that regulated pension, health and welfare benefits offered by employers to their employees. Under ERISA, some employer group health plans are exempt from state laws and regulations that govern insurance.

Evidence of Coverage - a detailed summary of health care services that is available to patients under a certain health care plan, usually provided upon enrollment in the plan.

exhaustion - using all available means of review before proceeding to the next level of review.

experimental or investigational treatments - a treatment that a doctor recommends for a particular illness that may not be the standard method of treatment; health care plans may often refuse to cover costs for treatments that they consider experimental or investigational.

fiduciary relationship - a relationship created when one person owes a legal duty to act for the benefit of another; the physician/patient relationship is considered a "fiduciary relationship."

fraud - intentional deception or concealing of facts that results in an injury to another.

gag rules - any provision in a health care plan contract that may limit a doctor's ability to communicate freely with his or her patients regarding patients' health care options. California law prohibits health plans from putting gag rules in their contracts.

grievance - a complaint by a patient to the administration of a health care plan; such complaints may relate to quality of care, a denial or delay of coverage for a treatment or product, or disputes over the amount that a plan has paid towards health services received.

grievance review process - process that all health plans are required to establish internally in order to review complaints by patients about any decisions by the plan that negatively impact a patient's ability to receive quality health care. The Department of Managed Care also has a grievance review process in place that will review patients' grievances if they receive no satisfactory resolution through their health plan.

group health plan or group coverage - a health plan which is offered through a specified group of people, such as employees of a particular employer or members of an association.

guardianship - a relationship created for one to take over the care of the person or property of another, often a minor.

health care "contractors" - various entities under contract with your health care plan that may include medical groups, independent practice associations, pharmaceutical benefits managers, and medical service organizations that are not themselves a health care service plan or health care provider

Health Care Financing Administration (HCFA) - federal agency that runs the Medicare and Medicaid programs

health care provider - a qualified licensed professional such as a doctor, dentist, optometrist, etc. or an institution such as a hospital, clinic, nursing facility, etc., that provides health care services to patients under a contract with a health care plan.

health care service plan - Used in California law to refer to any person or entity that arranges for health care services to be provided to subscribers or enrollees, or to pay for or reimburse any part of the cost for those services, in exchange for a prepaid or periodic charge paid by or on behalf of the subscribers or enrollees. HMOs and PPOs are examples of health care service plans. All health care service plans are subject to regulation by the Department of Managed Health Care.

Health Insurance Portability And Accountability Act or HIPAA (also known as the Kassebaum-Kennedy Act) - the federal law designed to allow employees to move freely from one job to another without the risk of becoming uninsured for their most serious health problems. This law sets limits on the ability of health care plans to exclude coverage for "pre-existing conditions."

health maintenance organization (HMO) - An HMO is the most common form of a managed health care plan under which health services are delivered and paid for through one organization, often under one roof. An HMO requires its participants to use only certain health providers and hospitals, usually those within its own network.

independent medical review organizations - organizations that will contract with the Department of Managed Health Care to conduct reviews of certain denials of treatment by health care plans. These organizations are subject to qualifications set by the Department of Managed Health Care and must be entirely independent of any health plan.

independent practice associations (IPA) - an association of physicians and other health care providers, including hospitals, who contract with an HMO to provide services to enrollees, but usually still see non-HMO patients and patients from other HMOs.

independent review process - a process administered by the Department of Managed Health Care to review health plans' denials of care decisions based on medical necessity. The process is "independent" of your health care plan.

individual health plan - health care insurance that you purchase in the private market that is not a part of any "group health plan" provided through an employer or other organization.

informed consent - consent to medical treatment by a patient, or to participation in a medical experiment by a subject, after achieving an understanding of the risks and benefits.

injunction - a legal remedy to stop a party from continuing to perform a particular action.

judgment - a final decision by a court as to the rights of parties to a lawsuit.

liable - to be responsible for; to be obligated by law.

liaison - person that establishes and maintains communication between two parties in order to achieve mutual understanding and cooperation.

Major Risk Medical Insurance Program (MRMIP) - a state-operated program that provides health care to qualifying Californians unable to obtain health insurance in the private market due to serious health conditions. The program is provided through contracts with various health plans. Participants in the program are responsible for the cost of program premiums, and the program supplements those premiums to cover the cost of care from the state's tobacco tax funds.

managed care - a method of financing and delivering health care for a set fee using a network of physicians and other health care providers. The network coordinates and refers patients to its health providers and hospitals, and monitors the amount and patterns of care delivered. Managed care plans usually limit what services patients may receive by using "gatekeepers" to make sure services considered unnecessary or referrals outside the network are kept to a minimum.

Medicaid - a joint federal and state program that provides health insurance to low income people who meet specific eligibility requirements.

Medical Information Bureau (MIB) - MIB is a company that keeps a database of medical record information on individuals as provided to them by insurance companies who subscribe to their services. Insurance companies use information obtained from MIB to make decisions regarding your eligibility for coverage at the time of application for insurance benefits.

medical malpractice - negligent care provided to a patient by a doctor or managed care plan that results in harm to the patient.

medical records - Any information about you, in electronic or physical form, regarding your medical history, mental or physical condition, or treatment in the possession of or derived from an HMO, health insurer, or any health care provider are subject to California laws protecting your medical record confidentiality.

medically necessary - health care products and services that are considered to be appropriate and would assist in the diagnosis or treatment of a disease.

Medicare - a federal health insurance program that provides medical benefits to all persons over age 65 who receive Social Security benefits or are disabled and meet specific eligibility requirements.

morbidity - a diseased state.

negligence - failure to exercise the degree of care that a reasonable person would exercise in the same circumstances.

networks of health care providers - groups of hospitals, physicians, and other providers that offer health care plans and patients an organized, comprehensive system of care.

ombudsman - a problem solver who assists patients with complaints, either working directly for a health care plan or an outside agency.

pain and suffering - a type of damages awarded in a lawsuit for physical and mental injury that result from a wrong done or suffered.

participating provider - a hospital or doctor who has a contract with a health care plan to provide health care services to the patients of that plan for a specified rate. Patients will usually be charged lower or no out-of-pocket fees when they use participating providers.

patient/physician relationship - the relationship established between you and your doctor when he or she begins treating you that gives rise to a number of legal obligations on the part of your doctor to ensure that you receive continued health care.

plan contract - an agreement between a health care plan and its subscribers or enrollees pursuant to what health care services are provided.

plan medical director or administrator - an employee of a managed health care plan that has the authority to approve or deny coverage for patients in accordance with the terms of the plan.

pre-existing condition - a condition that was diagnosed or treated within a certain period (six months under CA and federal law) prior to the patient's joining a particular health care plan. Plans may only limit coverage for pre-existing conditions for up to six months, in most cases.

Preferred Provider Organization (PPO) - a large group of hospitals and doctors under contract to a managed care plan who deliver services for set fees. In a PPO, patients must choose their primary health provider from an approved list and must pay extra for specialty services received outside the PPO group.

punitive damages - a monetary award for the injured party who prevails in a lawsuit that serves to punish the wrongdoer, usually where there has been malicious or willful misconduct.

referral - authorization by a doctor or health care plan to receive other health care services under the plan such as diagnostic tests or care from a specialist.

specialist - a doctor who has received extensive training in a specific area of medicine.

specialty care center - a center that is accredited or designated by an agency of the state or federal government, or by a voluntary national health organization, as having special expertise in treating the life-threatening, or degenerative and disabling, disease or condition for which it is accredited or designated.

stabilized - state reached when one's physical condition is considered within normal ranges of function.

standard of review - the term used to describe on what basis a court will review a lower court's decision.

status-based discrimination - being treated differently on the basis of one's sex, race, class, medical condition or other distinguishing characteristic.

statute of limitations - the time within a person may file a particular type of lawsuit, after which such actions will not be allowed.

substance abuse - using drugs or medications in manner that is harmful to one's health.

transfer - to move or transport to another facility.

utilization review - process in a health care plan to determine whether a particular health care treatment is medically necessary and appropriate for a patient's needs.