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To a full, honest and confidential discussion with their physician about their medical needs.
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Receive a "standing referral" to a specialist if ongoing care is required.
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Receive care for any emergency condition at an emergency room without getting prior approval from their HMO.
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A second medical opinion for the diagnosis of cancer.
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See an out-of-network provider without additional cost if their HMO does not have an in-network provider for their condition.
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If a person switches to a new HMO, the person can continue to see their current provider for 60 days if they have
a life-threatening, degenerative or disabling condition or disease and their provider agrees to the new HMO's terms.
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File a grievance if they disagree with any HMO determination other than those involving medical necessity or experimental or investigational treatment.
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Have any grievance decided within 48 hours when a delay would increase the risk to their health.
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Appeal through the HMO's own internal appeal process any determination that a procedure, service or treatment is not covered because it is considered experimental, investigational or not medically necessary.
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An expedited appeal through the HMO's utilization review process if they are undergoing a course of treatment or if their doctor believes an immediate appeal is warranted.
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An external review by an external review organization for any final adverse determination denying coverage because a procedure, service or treatment is considered experimental, investigational or not medically necessary.
Women are entitled to:
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Direct access to primary and preventative OB/GYN services at least twice a year,
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Coverage for bone mineral density measurements and testing,
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Coverage for contraception under most group health insurance contracts.
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Remain in the hospital for 48 hours after a natural delivery of a child and at least 96 hours after a Cesarean section delivery.
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Continue to see their current provider for the duration of postpartum care related to delivery if they switch to a new HMO during their second or third trimester of pregnancy. The provider must agree to the new HMO's terms.
