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.
Last November, I went to the emergency room because I had a severe migraine. At the time of the visit, I had a primary and a secondary health insurance company. I went to the closest facility that happened to be part of my primary insurance company's network, and they paid a large portion of the bill. But my secondary plan, an HMO, refused to pay the remaining portion because the emergency room that I went to was not part of the HMO's network, and they didn't agree that the situation required emergency care. Any assistance you could provide in resolving this matter would be greatly appreciated.
– Laurel Schamber, Galt
If your health plan disputes the need for emergency-room services or refuses to reimburse the cost of emergency services, a consumer can submit the dispute, at no cost, to the Department of Managed Health Care's independent medical review (IMR) program to determine whether a reasonable person would have believed that the medical condition or symptoms justified seeking emergency services.
If a reasonable person would have concluded that a potential emergency medical condition existed, your health plan is obligated to cover the emergency services, no matter where the services were received. A health plan cannot require its members to get emergency services and care at in-network hospitals.
After receiving your complaint, the department notified your secondary health plan that an IMR was being scheduled. After the health plan received this notification, it made an administrative decision to overturn its previous denial and pay for your emergency-room visit.
Working out problems with a single health plan can be complicated enough, but when you have secondary insurance or a supplemental health care policy, payment issues can get twice as complicated. When you do have more than one health plan or health insurance policy, both plans need to coordinate your benefits to avoid payment delays. If you are scheduling routine services, you should always contact both plans before you receive services and let each plan know about your multiple health coverages.
If you find that you can't make sense of who should be paying for what, we encourage you to contact an agent at the department's Help Center by calling (888) 466-2219 so we can help you sort through it all.
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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