If you have questions about the practices of your managed-care coverage, ask the experts at the state Department of Managed Health Care. They take up issues ranging from difficulties getting an appointment to the denial of a doctor's recommendation for treatment.
I believe that a customer sales agent misrepresented my financial responsibility when I signed up with my PPO.
I was told that there would be no out-of-pocket expenses once my $2,500 deductible had been met. After I met my deductible this year, I received additional bills totaling $5,000.
If I had known that I would have to pay this much out of pocket, I would never have chosen this product. I think my health plan should pay all my claims above the $2,500 deductible as I had been led to believe it would.
– Norma Reagan, Sacramento
Health plans are required to provide a document called an Evidence of Coverage, explaining all rules, procedures, processes, exclusions and limitations for each health care policy.
Consumers are responsible for reading and understanding this information before deciding to purchase a policy.
If, after reading the Evidence of Coverage, you have questions or concerns, you may ask the agent to explain further, or you may either decline to purchase that policy or cancel it (in your case, within 10 days).
Consumers do have protections under the law, but they also bear the responsibility of reviewing the policy in detail before signing a contract. The health plan is not responsible for any misunderstanding.
According to your health plan, you purchased an Individual PPO Share $2,500 Plan. This particular plan requires that you pay the first $2,500 of your medical costs each year before your health plan will start to pay any medical benefits.
Even after you have paid your annual deductible, your plan requires co-payments or co-insurance for any services you receive, up to an out-of-pocket maximum of $5,000 a year.
Such high-deductible policies are becoming more common. Although it may sound expensive, the deductible and out-of-pocket limits help to lower monthly premiums.
These plans are generally marketed to those who are healthy and do not expect to need a lot of medical care. They may not be a good deal if you require a lot of care.
If you want help choosing the health plan that is right for you, consult the Office of the Patient Advocate's Web site to see how health plans measure up.
The office's 2009 Health Care Quality Report Card has just been released. View it at www.opa.ca.gov or call the DMHC, toll-free, at (888) 466-2219 for assistance.
To ask a question, go to www.sacbee.com/ask or write Second Opinion; Features Department; The Sacramento Bee, P.O. Box 15779, Sacramento, CA 95852.
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