A: Information on the Affordable Care Act (ACA) is widely available on the internet, but for the most accurate, up-to-date information, you can go straight to the source -- www.healthcare.gov.

This website is run by the federal government and is managed by the U.S. Department of Health and Human Services. The website provides important information for a wide range of people, including small business owners, families with children looking for insurance, seniors, and people with disabilities.

According to the website, small businesses may be entitled to a premium rebate when their health plan’s medical loss ratio exceeds certain thresholds. A medical loss ratio (also called an “MLR”) is the percentage of premium dollars a plan spends on claims for medical services as opposed to administrative costs. For health plans in the individual and small group markets, the health plan has to spend at least 80 percent of the premium dollars it collects on health care services. For health plans offering large group products, the ratio is set at 85 percent of the premium dollars collected. If a health plan fails to meet these ratios, it must reimburse the difference to its enrollees.

The ACA also provides small businesses with a premium tax credit when they insure up to 25 employees, pay average annual wages less than $50,000, and provide health insurance. For now, small businesses that meet the criteria can qualify for up to a 35 percent tax credit to offset the cost of providing health insurance. In 2014, the tax credit will increase to 50 percent for businesses that qualify.

In addition to information on tax credits, www.healthcare.gov has tools to help business owners choose the most affordable plans for their employees by comparing benefits and premium rates in one convenient location.

The Department of Managed Health Care can also help answer your questions about the Affordable Care Act. You can call (888) 466-2219 or log onto www.healthhelp.ca.gov for more information.

A: Your situation is truly regrettable. It is indeed possible that you do not owe anything for the services you received due to your accident. In your case, to expedite the situation, you should contact your health plan and file a formal appeal (include all issues) and simultaneously contact the Help Center with the Department of Managed Health Care. You may call the Help Center at 1-888-466-2219 or send in an application which you can find on the Department’s website (www.dmhc.gov). The Department’s website also contains other information you may find helpful. It would be best to include as much information as possible in your application such as, but not limited to, a written explanation, including dates of events, and any correspondences you’ve had with your health plan, Meridian, and/or the facility where you were treated.

A: Due to the nature of your condition and the fact that you have attempted to access care unsuccessfully, we recommend that you contact the Help Center at the DMHC as quickly as possible so that we can better assist you with getting an expedited referral. Please contact us at (888) 466-2219 at your earliest convenience.

A:
Based on the limited information you provided, our first recommendation is to check with your son's insurance provider to find out if there is a reason that more of the bill was not paid.

For example, does your son have a high-deductible health plan? Was the surgery performed by non-participating providers? Could there have been any mistakes made in the coding or billing of these procedures that could have led to unexpected costs?

When a consumer encounters unexpected costs related to health care coverage, it is always a good idea to read the Evidence of Coverage booklet that's given at enrollment. This booklet will provide the outline for the costs which can be expected to share when receiving services. A consumer should also make sure that the bills received match up with the coverage listed in the EOC.

Assuming that the charges owed in this case are valid, the best way for your son to negotiate with the doctor and the hospital is simply to let them know that he does not have the money to pay all at once, and to request a structured repayment schedule.

Although there is no guarantee, it is likely that the providers of the services would rather be paid over time than not at all.

Even if your son's application for Medi-Cal is accepted, it is not likely to affect the cost of services he received prior to enrollment.

For more information on how Medi-Cal may or may not affect this situation, contact the Department of Health Care Services at (800) 541-5555 or the Medi-Cal office in your son's county.

A: In most cases, pharmacies are completely separate businesses from health plans. If the pharmacy does not contract with your health plan, it would not be required to sell products for less than its costs. If the pharmacy does contract with your health plan, it should have an agreed-upon price for each prescription medication.

If your local pharmacy will not fill your prescription, you should contact your health plan’s member services department and ask if there is a contracted pharmacy close to you that will fill your prescription. Another option would be to use your health plan’s mail order pharmacy provider – often this is a less expensive alternative if you expect to use the drug for an extended period of time. If the prescription medication is a covered benefit and is medically necessary for your medical condition, you should not be required to pay more than the co-payment or deductible amounts stated in your Evidence of Coverage (EOC).

Many medications also have a more cost-effective generic version, and you may want to consult your doctor about this possibility. If these options do not resolve your problem, you could file an official complaint with your health plan and, if that fails to address your access to this prescription drug, you can contact the insurance commissioner of your state or if your plan is based in California you can call the DMHC to ask if you can file a complaint with us.

Consumers with questions about obtaining the right care at the right time are encouraged to contact the DMHC by calling (888) 466-2219 or by logging onto www.healthhelp.ca.gov.

A: Unfortunately, many uninsured people are facing similar problems today. A recent study conducted by UCLA found that as many as 85,000 people in the Sacramento area have lost their health insurance coverage in the last two years. And there are no silver bullet answers.

Without insurance, your parents’ options are limited. They can continue trying to receive care through the county hospital system. There may be more than one local facility that offers reduced prices for people with no insurance. You can check for available facilities nearby on the US Department of Health and Human Services web site.

A more expensive option is to pay out-of-pocket to choose another provider for a second opinion. If your parents decide to pay out-of-pocket, they should shop around first and try to negotiate a lower price for necessary services.

Once all of the provisions of the federal health care reform package are enacted in 2014, those with pre-existing conditions, like your father, will no longer be excluded from obtaining coverage. In the meantime, your parents may want to consider applying for a Pre-Existing Condition Insurance Plan, sometimes referred to as a High-Risk Pool. In California, applications for these plans became available on August 31, and coverage will begin as early as September for those who are accepted. Such a plan will help bridge the gap between now and the time when your parents qualify for Medicare. To inquire about eligibility, you can contact the Managed Risk Medical Insurance Board at (916) 324-4695 or look at the web site at www.mrmib.ca.gov.

For more information on these options and other health coverage issues, other consumers can contact the Help Center at the Department of Managed Health Care by calling 1-888-466-2219 or by logging onto www.healthhelp.ca.gov.

A: When an employer provides health coverage through a group plan, all its participating employees are covered, regardless of their health status.

Because it is a large pool of health plan members, some of whom use a lot of services and some of whom use a little, the health plan is able to cover all those employees for a lower price.

However, when an individual purchases insurance, he does not have the benefit of being part of a large pool where the risk averages out. The health plan then performs "medical underwriting" to determine whether that individual has any pre-existing conditions that could be expensive to treat.

If so, that person will either have to pay more for health care coverage or deal with denial of coverage.

In California, a health plan can deny individual coverage for someone due to a pre-existing condition, even to someone who was previously a member.

In your son's case, he can now enroll in group health coverage offered by his new employer, and because it is a group policy, the health plan cannot deny coverage based on a pre-existing condition.

However, there may be a certain waiting period before the health plan will begin to provide coverage for care related to that pre-existing condition, so he needs to discuss his options with his employer before deciding which health plan will best meet his needs.

If he decides to switch to a different health plan, he can request that his medical records be transferred.

A: A formulary is a list of prescription drugs that are covered by a health plan or health insurance company. Health plans' formularies are different from one another and often include different medications that are used to treat similar conditions. For instance, a health plan's formulary could offer a 30-day supply of a generic allergy medication with a $10 co-payment in Tier 1 (a lower cost category) and a brand- name allergy medication with a $30 co-payment in Tier 2 (a higher cost category). Other plans will have a similar structure, but they might use terminology such as "preferred" and "non-preferred" medications.

Because you say that your mother-in-law received an authorization for Lyrica, it sounds like either the medication is part of the formulary, but in one of the higher-cost tiers, or the plan covers non-formulary drugs at a higher cost. Either way, as a first step, we recommend that she talk to her doctor about the availability of other medications that have proved helpful for others with fibromyalgia and that are covered by her health plan. If she can show that no other drugs are effective, some health plans have a process that may allow her to receive Lyrica at a lower cost.

Most health plans do have a board or panel that meets on a quarterly basis to evaluate the formulary and decide to add or withdraw medications. You can ask to have a specific medication considered for addition to the formulary.

However, if the medication is needed urgently, it may be better to seek coverage for it through the plan's complaint process, especially if you have already tried and failed a treatment program with the medications covered by the formulary.

If the health plan continues to refuse coverage of a specific medication, you can submit your complaint to the state department or federal agency that regulates the health plan.

A: You are not alone in your confusion. In California, there are many health plans, and each health plan has different types of coverage designed to meet the needs of a diverse consumer base. Although we would need more information from you to be certain, it sounds like the health plan product you have selected is not going to meet your ongoing needs.

Most health plans require some kind of qualifying event, such as the loss of a job or a change in marital status, before you can switch products outside the open enrollment period. However, that shouldn't stop you from contacting your health plan's member services department and asking it about other types of plans that are available to you. Explain your situation and your concerns, and there's a good chance that they'll have a plan better suited to meet your specific needs. Ask questions now so that when open enrollment does arrive, you'll be ready to switch plans if you need to.

There are $4 prescription programs out there in some retail-store pharmacies, but not all medications or dosages are included in these programs. In fact, most of the prescriptions included are the most common and least expensive medications. While these programs are a great benefit to a lot of consumers, the types of medication are limited. Contact your local pharmacies directly and ask if any of your medications are included in the program.

Another option you should explore is whether your health plan's mail-order prescription service offers 90-day supplies of any medications that you will be taking for an extended period. The co-pay obligations are generally lower when you order a 90-day supply through the mail.

One other option is to check with an online prescription drug assistance site. There are several sites on the Internet that can show you how to receive medications at steep discounts, but with most of these sites, you have to fall below certain income levels to qualify.

Consumers needing assistance with their health plans can call the Department of Managed Health Care toll- free at (888) 466-2219 or log on to www.healthhelp.ca.gov.

A: You indicate that your health plan is under the jurisdiction of the California Department of Insurance. If that is the case, there are no formal avenues that the Department of Managed Health Care can take to help you with this issue. However, we can offer some suggestions on how you could approach this problem.

Health plans can deny coverage for treatment, even treatment that is medically necessary, when that treatment is specifically excluded in the evidence of coverage (EOC) or summary plan description. The EOC represents the health plan's agreement to pay the cost of health services included in the benefit section. Although you say that reimbursement for your surgery is specifically excluded, double check to determine whether the language in the summary plan description or EOC suggests that the surgery could be a covered benefit. For example, although dental procedures are excluded from medical policies, a case might arise in which it was necessary for a specific dental procedure to be done as a part of a medical procedure, which might possibly make the dental work be considered medical in nature.

Because your health plan excludes coverage for this surgery, you only have a few options. First, you may want to ask your doctor if there are any alternative treatments for your condition that your health plan does cover. If not, you will have to pay for the surgery yourself. If you go that route, you could try negotiating a lower cost directly with the doctor and hospital where the surgery is scheduled. Many hospitals will discount their charges up to 30 percent for advance payment; other hospitals will agree to a payment plan.

You might also consider investigating whether your county hospital can perform this surgery, as county hospitals are often less expensive. Finally, check the Internet to see whether there is an association or support group for your condition that could lend you some assistance or point you toward other resources.

A: Based on this information, it appears that your situation would qualify for an Independent Medical Review (IMR) because the plan said the anesthesia was not medically necessary. You can download an IMR form from our web site http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_imrapp.aspx or you can call our Help Center at (888) 466-2219 to arrange for a complaint form to be mailed to you.

A: Because Medicare is a federal program, it is regulated by the Centers for Medicare and Medicaid Services (CMS) which is an agency within the U.S. Department of Health and Human Services. The DMHC does not directly have jurisdiction to intervene on Medicare issues.

But to answer your question, in general, not everything that a doctor prescribes will be covered by your health plan. In fact, depending upon your plan, many “necessary” things may be specifically excluded from your covered benefits. For example, foot orthotics are almost always excluded from coverage, but they are still commonly prescribed because of the advantages they provide for those that need them. Ultimately, the decision to receive specific treatments must be made by the patient and their doctor and it is the patient’s responsibility to know what will and won’t be covered. Usually, your doctor can tell you if a treatment is covered or not. If you still need help determining your exact coverage, call your health plan’s member services department or call the Department of Managed Health Care for assistance. If you have Medicare, you can call CMS at their office in San Francisco at (415) 744-3501 or you can contact the Health Insurance Counseling and Advocacy Program, also known as HICAP. HICAP counseling is confidential and free of charge. Call them at (800) 434-0222.