🔖 Archived Resource (2001): This guide was published in 2001 and is not current. It is preserved here for historical and general reference by
Consumer Watchdog.
Laws may have changed — consult a qualified attorney for current legal advice.
Table of Contents
Introduction
- Your Rights to Continuous Care, Second Opinions, Referrals and Information
- WHAT DUTIES DO MY DOCTOR AND HMO HAVE TO ENSURE THAT I WILL RECEIVE CONTINUED CARE?
- HOW CAN I END THE PATIENT/PHYSICIAN RELATIONSHIP?
- CAN MY DOCTOR END THE PATIENT/PHYSICIAN RELATIONSHIP?
- WHAT ARE MY RIGHTS TO CONTINUE TREATMENT WITH A DOCTOR WHOSE CONTRACT WITH MY HEALTH CARE PLAN IS TERMINATED?
- WHAT ARE MY RIGHTS TO CONTINUED COVERAGE BY MY CURRENT DOCTOR WHEN I JOIN A NEW HEALTH PLAN?
- WHAT ARE MY RIGHTS TO OBTAIN A SECOND OPINION?
- WHO CAN PROVIDE A SECOND OPINION?
- IN WHAT SITUATIONS WILL MY PLAN AUTHORIZE A SECOND OPINION?
- WHAT IS THE TIMELINE FOR MY PLAN AUTHORIZING A SECOND OPINION?
- WHAT HAPPENS IF MY PLAN DENIES MY REQUEST FOR A SECOND OPINION?
- HOW LONG CAN MY PLAN TAKE TO AUTHORIZE MY REFERRAL TO A SPECIALIST?
- CAN MY HMO RESTRICT WHAT MY DOCTOR TELLS ME ABOUT MY CONDITION OR TREATMENT OPTIONS?
- I'VE HEARD THAT HMOs SOMETIMES PROVIDE FINANCIAL INCENTIVES TO DOCTORS TO NOT PROVIDE CERTAIN TREATMENT OR CARE TO THEIR PATIENTS. IS THIS LEGAL?
- WHAT DUTIES DO MY DOCTOR AND HMO HAVE TO ENSURE THAT I WILL RECEIVE CONTINUED CARE?
- Your Right to Informed Consent
- WHAT IS INFORMED CONSENT?
- WHY IS INFORMED CONSENT IMPORTANT TO ME?
- IS MY INFORMED CONSENT ALWAYS REQUIRED FOR ALL MEDICAL TESTS OR PROCEDURES?
- IS THE DOCTOR REQUIRED TO TAKE THE TIME TO TALK TO ME ABOUT INFORMED CONSENT?
- HOW DO I GIVE THE DOCTOR INFORMED CONSENT?
- WHEN SHOULD MY DOCTOR DISCUSS THE RISKS AND BENEFITS OF A PROPOSED COURSE OF TREATMENT AND ANY TREATMENT ALTERNATIVES WITH ME?
- WHAT KINDS OF QUESTIONS SHOULD I ASK SO I CAN GIVE "INFORMED CONSENT?"
- IS THE DOCTOR LIMITED BY MY INFORMED CONSENT?
- WHAT ARE MY RIGHTS IF THE DOCTOR DOESN'T GET MY CONSENT, OR PERFORMS SERVICES BEYOND THE SCOPE OF MY INFORMED CONSENT?
- WHERE ELSE CAN I GO FOR HELP?
- WHAT IS INFORMED CONSENT?
- Your Rights to Medical Records and Confidentiality
- HOW CAN I OBTAIN MY OWN MEDICAL RECORDS?
- WHAT INFORMATION IS SUBJECT TO PROTECTIONS CONCERNING MEDICAL RECORD CONFIDENTIALITY?
- DO DOCTORS AND HMOs NEED TO OBTAIN MY CONSENT BEFORE RELEASING MY MEDICAL RECORDS?
- WHAT DOES AN AUTHORIZATION FORM FOR RELEASE OF MY MEDICAL RECORDS HAVE TO INCLUDE TO BE VALID?
- CAN MY DOCTOR OR HMO RELEASE MY MEDICAL RECORDS WITHOUT MY CONSENT?
- WHEN CAN MY EMPLOYER OBTAIN AND USE OR DISCLOSE MY MEDICAL RECORDS WITHOUT MY CONSENT?
- WHEN CAN AN INSURANCE COMPANY OBTAIN ACCESS TO MY MEDICAL RECORDS WITHOUT MY CONSENT?
- WHAT CAN I DO TO PROTECT MY MEDICAL RECORD INFORMATION FROM BEING DISCLOSED WITHOUT MY CONSENT?
- WHAT IS THE MEDICAL INFORMATION BUREAU?
- WHAT REMEDIES DO I HAVE IF SOMEONE ILLEGALLY OBTAINS OR DISCLOSES MY MEDICAL RECORDS?
- OTHER RESOURCES
- HOW CAN I OBTAIN MY OWN MEDICAL RECORDS?
- Your Right to Emergency Medical Care
- WHAT IS CONSIDERED AN "EMERGENCY MEDICAL CONDITION" THAT REQUIRES EMERGENCY MEDICAL CARE?
- DOES A WOMAN IN LABOR HAVE AN EMERGENCY MEDICAL CONDITION?
- WHAT ARE MY RIGHTS TO EMERGENCY CARE?
- WHAT DOES IT MEAN TO HAVE MY MEDICAL CONDITION SCREENED?
- WHAT DOES IT MEAN TO HAVE MY CONDITION STABILIZED?
- WHEN CAN I BE TRANSFERRED TO ANOTHER HOSPITAL?
- WHAT ARE MY LEGAL RIGHTS IF I AM HARMED WHILE RECEIVING EMERGENCY CARE?
- WHAT ARE MY HEALTH CARE PLAN'S OBLIGATIONS WITH REGARD TO PAYING FOR EMERGENCY SERVICES I RECEIVE?
- WHERE CAN I GO FOR HELP WITH QUESTIONS OR COMPLAINTS REGARDING A HOSPITAL'S EMERGENCEY SERVICES?
- WHAT IS CONSIDERED AN "EMERGENCY MEDICAL CONDITION" THAT REQUIRES EMERGENCY MEDICAL CARE?
- Your Rights to Coverage of Pre-Existing Conditions
- WHAT IS A "PRE-EXISTING CONDITION"?
- CAN MY HEALTH PLAN DENY COVERAGE FOR TREATMENT OF MY PRE-EXISTING CONDITION?
- WHAT CAN I DO IF I AM DENIED COVERAGE?
- WHERE ELSE CAN I GO FOR HELP?
- WHAT IS A "PRE-EXISTING CONDITION"?
- Your Rights to File Grievances with your Health Plan and the Department of Managed Health Care
- WHEN SHOULD I FILE A GRIEVANCE WITH MY PLAN?
- WHAT ARE MY RIGHTS TO FILE A GRIEVANCE AGAINST MY HEALTH PLAN?
- WHAT STEPS SHOULD I TAKE BEFORE I FILE A GRIEVANCE?
- WHAT IS MY HEALTH PLAN'S TIMELINE FOR RESOLVING MY GRIEVANCE?
- WHAT IS THE TIMELINE FOR RESOLVING MY GRIEVANCE IN AN EMERGENCY CASE OR WHERE A SERIOUS THREAT TO MY HEALTH IS INVOLVED?
- WHEN MAY I SUBMIT A GRIEVANCE TO THE DEPARTMENT OF MANAGED CARE (DMHC)?
- WHAT IS THE DEPARTMENT OF MANAGED HEALTH CARE'S TIMELINE FOR RESOLVING MY GRIEVANCE?
- CAN THE DEPARTMENT OF MANAGED HEALTH CARE PENALIZE MY HEALTH PLAN FOR NOT COMPLYING WITH THE GRIEVANCE STANDARDS?
- WHEN SHOULD I FILE A GRIEVANCE WITH MY PLAN?
- Your Rights to Have your HMO's Decisions Independently Reviewed and to Sue Your HMO
- WHAT ARE MY RIGHTS TO AN INDEPENDENT REVIEW OF AN HMO DENIAL?
- IS THERE A DIFFERENCE BETWEEN FILING A GENERAL GRIEVANCE WITH THE DEPARTMENT OF MANAGED CARE AND SEEKING AN INDEPENDENT REVIEW?
- WHAT HMO DECISIONS ARE SUBJECT TO INDEPENDENT REVIEW?
- IS THERE AN "EMERGENCY REVIEW"?
- IS THERE A SPECIAL REVIEW PROCESS FOR EXPERIMENTAL TREATMENTS?
- HOW DOES THE INDEPENDENT REVIEW PROCESS WORK?
- WHAT IS THE RELATIONSHIP BETWEEN SUING AN HMO & APPEALING DENIALS OF CARE THROUGH MY PLAN'S INTERNAL GRIEVANCE PROCESS OR THROUGH THE INDEPENDENT REVIEW PROCESS?
- TIMELINE FOR BASIC REVIEW
- TIMELINE FOR EXPEDITED REVIEW
- ARE THERE ANY EXCEPTIONS TO THE REQUIREMENT THAT I USE THE INDEPENDENT REVIEW PROCESS BEFORE FILING A LAWSUIT??
- WHAT ARE THE LIMITS ON MY ABILITY TO SUE AN HMO?
- WHO IS NOT LIMITED BY ERISA IN THEIR RIGHT TO RECOVER DAMAGES?
- HOW DOES ERISA LIMIT THE ABILITY OF PRIVATE SECTOR EMPLOYEES TO RECOVER DAMAGES IN A LAWSUIT?
- WHAT ARE MY RIGHTS UNDER CALIFORNIA LAW TO SUE MY HMO?
- WHAT ARE MY RIGHTS UNDER CALIFORNIA LAW TO SUE MY HMO?
- UNDER WHAT CIRCUMSTANCES CAN I SUE MY HMO?
- WHERE CAN I SUE?
- WHAT ARE MY RIGHTS TO AN INDEPENDENT REVIEW OF AN HMO DENIAL?
- Your Rights to Appeal and Litigate Benefit Denials Under ERISA
- DOES ERISA APPLY TO MY HEALTH PLAN?
- HOW LONG DOES MY HEALTH PLAN HAVE TO MAKE A DECISION ON MY INITIAL CLAIM FOR BENEFITS?
- WHAT ARE MY RIGHTS UNDER ERISA PERTAINING TO REVIEW OF BENEFIT DENIALS?
- WHAT CAN I DO IF MY APPEAL IS DENIED?
- WHAT STEPS SHOULD I TAKE TO PREPARE TO BRING A LAWSUIT?
- DOES ERISA APPLY TO MY HEALTH PLAN?
- Health Care Coverage Options
- Medicare
- Medi-Cal
- Healthy Families Program
- Child Health And Disability Prevention Program (CHDP) And California Children Services (CCS)
- Medicare
Appendix B: Vital Steps to Receiving the Health Care You Need-A Checklist
Appendix C: Sample Letter
Appendix D: Strategic Advice For Patients: Tactics to Use and Understand
Appendix E: Useful Code Sections of the California Knox-Keene Health Care Service Plan Act of 1975 and Regulations
Glossary
Acknowledgements