US HealthcareSystem

&CONSUMER RIGHTS

HLTH 33

P. Elzie

Affordable Care Act

• New way individuals, families, and small businesses to get health coverage (Health Insurance Marketplace)

• Helps you understand the coverage you’re getting.

• Holds insurance companies accountable for rate increases.

• Requires insurance companies to cover people with pre- existing health conditions.

• Provides free preventive care

• It’s illegal for health insurance companies to arbitrarily cancel your health insurance just because you get sick.

• Right to choose the doctor you want from your health plan’s provider network.

• Use an out-of-network emergency room without penalty.

• No referrals needed for OB-GYN services

• Children up to age 26 can stay on or be added to their parents’ family health plan. (healthcare.gov)

Private Health Insurance

Limit potential losses:

• cost sharing (deductibles, co-payments, and coinsurance)• Exclusions• waiting periods• upper limits on payments

Managed Care Plan

• Type of health insurance• Contracts w/providers and medical facilities• Provide care for members at reduced rates• Costs depend on network rules• Providers are plans network

• Plans that restrict your choices cost less• Flexibility increases cost• Managed Care Plans:

HMOPPOPOS

Health Maintenance Organizations HMO

• Usually the least expensive• Most restrictive prepaid • Pay for care within the network.• Partial/no payments on out-of-network. • You choose a primary care doctor who coordinates most of your

care

Preferred Provider Organizations PPO

• Networks of independent doctors and hospitals that contract to provide care at discounted rates

• Pay more if you get care within the network. • Pay part of the cost if you go outside the network.

Point of Service POS

• Plans let you choose between HMO or PPO each time you need care.

• In-network PCP• no referral for out of network providers

High Deductible Health Plan HDHP

• Consumer pays higher deductible• Lower monthly premium• Deductible paid before service begins

Exclusive Provider Organizations EPO

• Services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).

• Treatment or care received outside of approved network must be paid by patient.

Government Funded Programs

Medicare• Federal health insurance program for people who are 65 or older,

certain younger people with disabilities• Permanently disabled people.

Medicaid• Federal/state program covers low-income people

Medi-Cal• free or low-cost health coverage for children and adults with

limited income and resources.

• families w/ children, seniors, persons with disabilities, foster youth, former foster youth to age 26, and pregnant women.

Healthy Kids• Medical, dental, and vision care for a very low cost

Patient’s Rights

Information Disclosure • You have the right to receive accurate and easily understood information about your

health, plan, health care professionals, and health care facilities.

Choice of Providers and Plans • You have the right to choose health care providers to provide you with access to

appropriate high-quality health care; seek opinions. • Free preventive care.

Standard or Experimental • The right to know if treatment is standard or experimental. If drugs being used are

part of a research project for purpose not approved by FDA.

Access to Emergency Services • If you have severe pain, injury, or sudden illness that leads you to believe your health is

in serious jeopardy, you have the right to receive screening and stabilization emergency services whenever and wherever needed, without prior authorization or financial penalty.

Informed Consent • Before care you should be informed of treatment plans, options, risks and potential

benefits, and “no treatment” options. Consent is voluntary.

Respect and Nondiscrimination • The right to courtesy, considerate, respect, dignity, responsiveness, nondiscriminatory

care and timely attention to health needs.

Confidentiality of Health Information • The right to talk in confidence with health care providers. • Have your health care information protected. • The right to access and copy your medical record. • Request physician to amend your record if it is not accurate,

relevant, or complete.

Complaints and Appeals • The right to a fair, fast and objective review of any complaint you

have against your health plan, doctors, hospitals or other health care personnel.

Choosing a Health Professional

Consider the following questions:

• What professional education and training have they had?

• Are they affiliated with an accredited medical facility or institution?

• Are they open to complementary or alternative strategies?

• Do they indicate clearly how long a given treatment may last, what side effects you might expect, and what problems you should watch for?

• Are their diagnoses, treatments, and general statements consistent with established scientific theory and practice?

• Do they make alternative arrangements for your care when on vacation or off call?

• Do they listen, respect you as an individual, and give you time to ask questions?

• Do they return your calls, and are they available to answer questions?

Being Involved…

Speak up if you have questions or concerns.• You have a right to question anyone who is involved with your care.

Someone, such as your primary care doctor, coordinates your care.• This is especially important if you have many health problems or are in

the hospital.

Your doctors should have your important health information. • Do not assume that everyone has all the information they need.

Ask a family member or friend to go to appointments with you. • Even if you do not need help now, you might need it later.

Know that "more" is not always better.• It’s a good idea to find out why a test or treatment is needed and how it

can help you. You could be better off without it.

If you have a test, do not assume that no news is good news. • Ask how and when you will get the results.

Learn about your condition and treatments i.e. asking your doctor/nurse, using other reliable sources. • Is the proposed treatment based on the latest scientific evidence.

USDHHS/Agency for Healthcare Research and Quality