When my 1-year-old son began vomiting recently, I was very concerned, so I called the advice nurse at my health plan. We received a prescription for two doses of Ondansetron for which we paid a $10 co-payment. Two days later, however, I had to take my son to the emergency room because he began vomiting again. For that trip I had to pay a $75 co-payment. If the advice nurse had originally provided us with a reasonable number of doses of Ondansetron, the trip to the emergency room would not have been necessary. As a result, I think my health plan should refund the co-payments we paid.
– Heidi Correa, Sacramento
Your request for a refund was refused by your health plan for a number of reasons. Your co-payments for things like prescription medications, office visits, and emergency room visits all are defined in your evidence of coverage, which is your contract with your health plan. It defines what services the health plan will cover and your co-payment obligation. You are contractually required to pay these pre-established amounts regardless of the reason you receive the services or your level of satisfaction with the outcome. Occasionally, a health plan will issue a refund as a gesture of goodwill, but it is not contractually obligated to do so.
In your case, there was a clinical reason for prescribing only two doses of Ondansetron. The Department of Managed Health Care's review of your complaint file found that the advice nurse you spoke with had consulted with one of the call center physicians, who agreed that it was safe to offer your son telephone treatment for vomiting. However, your health plan's pediatric protocol is to require an evaluation by a doctor if symptoms persist and more medication is needed.
Based on a review of your file, the DMHC is unable to conclude that the services you received were inconsistent with good medical practice or that the services you received from your health plan violated any laws. Therefore, the plan's denial to refund your co-payments was upheld.
Californians with questions or concerns about the services they receive from their health plans can call the DMHC's help center toll-free at (888) 466-2219, or log onto www.healthhelp.ca.gov.
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