Your Rights and Your Health Plan
You have the right to:
- Ask questions regarding your covered benefits
- Compare plans when looking for the coverage that is right for you (The California Office of the Patient Advocate provides a “report card” on California’s HMO’s/PPO’s) www.opa.ca.gov
- Review your Evidence of Coverage (EOC) and know what is covered by your health plan, before you need care.
- Are my medications covered? Brand names or only generic drugs?
- Will I have co-pays? What will they be? What are step therapies?
- What type of preventive healthcare and alternative care is included?
- Am I limited to certain doctors and hospitals? Can I see a specialist if I need to?
- Is there a lifetime or yearly maximum of benefits?
- What benefits are limited and/or NOT covered?
- If you are denied services or experience long delays in obtaining prior-authorization, you have the right to ask for a member services coordinator.
- You have the right to ‘disenroll’ from a healthplan (each plan has specific guidelines on disenrolling).
Under California law, health plans must have a system in place for addressing a grievance filed by a member patient. Your plan must inform you in writing at the time of enrollment and each year afterward on how and where to file a grievance.