Ways to Optimize Your Care This Year

The New Year brings more weapons to the arsenal of consumers as they fight to make their way successfully through the increasingly complicated world of health insurance.

Medicine gets better every year in its ability to help people overcome disease. The real challenge is making the system work for you, delivering the care you need with a minimum of delay and obstruction.

Consumers will get vital help in 2001 in areas ranging from Medicare coverage, to HMO appeals, to insurance to defray the costs of delivering a baby.

Here is a compendium of the ways you can make the most of health care coverage this year.

When Your HMO Says No

A new California law gives consumers the right to an independent appeal when an HMO says that a treatment, procedure or referral to a specialist is not medically necessary. First, you appeal within the HMO, or health maintenance organization, itself. If your appeal is denied, you have the right to an outside review by independent doctors who do not work for the health plan.

The new California Patients Guide, prepared by a consumer advocacy group with help from doctors and nurses, is a useful document for anyone trying to make sense of the complex health care system. It discusses topics such as treatment in the emergency room, getting a second opinion, maintaining medical privacy and taking legal action. It offers these examples:

“You can use the independent review process, for example, when your doctor is recommending a hysterectomy for treatment of recurrent cervical cancer, but the HMO will only approve cervical cryosurgery. Similarly, when the doctor recommends proton beam radiation for treatment of prostate cancer, but the HMO only approves surgery, you can also use the independent review process.”

The California Department of Managed Health Care, the state agency that regulates HMOs, will handle the appeals process.

The guide was prepared by the Foundation for Taxpayer and Consumer Rights, a Santa Monica lobbying group active in consumer health access issues. It was developed with funding from the California Wellness Foundation, a nonprofit health care philanthropy based in Woodland Hills. The state Department of Consumer Affairs, as well as medical organizations, also worked on the guide. It has specific citations to state laws to help consumers know the law when they appeal HMO decisions and rulings.

The Web site location for the document is https://www.calpatientguide.org. Printed copies are available from the foundation at: FTCR, 1750 Ocean Park Blvd., Suite 200, Santa Monica, CA 90405. Copies can be requested by e-mail at: calpatientguide@consumerwatchdog.org. The phone is (310) 392-0522, Ext. 308. A Spanish-language version will be available in March.

When Your Medicare HMO Leaves the Market

You can go back to the regular Medicare program, which allows free choice of any participating doctor or hospital. But you have to make the co-payments and deductibles, and regular Medicare doesn’t cover prescription drugs, which may be why you joined the HMO in the first place.

The best advice usually is to continue seeing the doctors you use and trust, especially if you have a chronic ailment that requires regular examinations and treatments. The HMO may have withdrawn from the market, but your doctor might be a member of other health plans in the area. Call your doctor’s office and find out what other Medicare HMOs he or she belongs to.

If you decide not to join another HMO, you should consider buying Medi-gap insurance, which covers such things as the part A deductible ($796 for the first day in the hospital) and co-payments of 20% of doctor charges.

There are 10 standard policies, labeled A through J. Drug coverage is included in the H, I and J policies. There is a special open enrollment period running from Jan. 1 to March 4. Someone on Medicare who lost HMO coverage is guaranteed the right to buy a Medi-gap policy, regardless of current state of health.

Each of the policies--A through J--has standard benefits required by federal law. No matter where you buy policy A, for example, it will cover the same things. Yet the prices vary widely. It is your job as a consumer to get the best deal. One place to look for some help is an Internet site, https://www.quotesmith.com. It offers medical insurance price quotations from numerous companies for various polices, including Medi-gap coverages. It shows that in Los Angeles County, for example, the premium for a Medi-gap plan F policy will range from $1,188 a year to $2,010.

Enhanced Medi-Cal Benefits

This is the federal-state program that provides free medical care for the poor. The income ceilings for those who are older than 65, or disabled, have been raised, enabling more people to qualify for the program.

The new standard has been boosted to a “countable” income of $926 a month for a single person and $1,248 a month for a couple. “Countable” means the income after various exclusions are permitted. For application information, call (877) 597-4777. For further help with eligibility questions, call the Health Insurance Counseling and Advocacy Program (HI-CAP). The statewide phone number is (800) 434-0222. It is connected to an automatic system that will send your call to the local HI-CAP office for your area. The Web site is https://www.cahealthadvocates.org.

Insurance for the Disabled

Medicare covers those older than 65 and the disabled of all ages. Some 7 million people who have been certified as disabled by the federal government often face difficulties in trying to obtain Medi-gap supplemental insurance. A new state

law gives them an opportunity to get guaranteed access to specific policies if they buy the insurance by April 30. They cannot be discriminated against--rejected, or asked to pay more--because of any preexisting health condition.

Coverage for Pregnancy and Adoption

The federal government, with the cooperation of medical groups, is beginning a special campaign through leaflets in doctors’ offices to remind pregnant women of their right to get health insurance “out of season.”

For example, a married couple, young and healthy, who have health insurance at work, might decide they don’t need, or can’t afford, to pay for the coverage. When open enrollment season comes around at the office or the factory, they just skip it. No chance to sign up again for a whole year.

The wife then finds out she is pregnant several months later. If the employer already offers insurance coverage, she doesn’t have to wait until next year to sign up. As long as she enrolls the baby within 30 days of its birth, the child will have full coverage, for the delivery, for any complications and for postnatal care. For those adopting a child, medical coverage is assured if they enroll the child in a health plan within 30 days of the date of adoption.

Pregnancy “can be a devastating expense if people do not have coverage,” said Leslie Kramerich, acting assistant secretary of labor for the Pension and Welfare Benefits Administration, which is running the campaign to remind consumers of their rights. “A premature baby with health problems can cost hundreds of thousands of dollars.”

The right to add a baby to the insurance rolls outside the regular open season enrollment period is guaranteed under the Health Insurance Portability and Accountability Act. It is not a new benefit, but federal officials believe too few women are aware of the rule.

Retirement Health Benefits

Many employers offering medical insurance for retired workers have been slashing benefits. This can be a real deterrent for people who want to keep working beyond age 65, the date they can enroll in Medicare. People enrolling in Medicare have a guaranteed right to purchase Medi-gap supplemental policies within six months after turning age 65. If they delay, companies can refuse to sell it to them.

But a new California law gives people the right to buy Medi-gap at any age of retirement, whether they wait until 67, 75, 80 or later. “This should take the pressure off people to quit when they reach 65,” said a spokesman for state Sen. Jackie Speier (D-San Francisco), who authored the legislation.

Children’s Vaccines

Another provision of Speier’s bill guarantees that doctors will be paid for the full costs of children’s vaccines, although reimbursement for the medication may not yet be covered by the insurance company or HMO. Doctors often have been paying for the medications themselves while waiting for health plans to reimburse them. This time they will be protected financially.

Breast Cancer Surgery and Insurance

The federal government campaign to remind people of their health care rights will highlight the help available to women who have had a mastectomy. If their insurance plan covers the surgery, it must also pay for the costs of:

* Reconstruction of the breast on which surgery was done.

* Surgery and reconstruction of the healthy breast to assure that there is a symmetrical balance between the breasts.

* A prosthesis, if one is needed. These protections are guaranteed by the federal Women’s Health and Cancer Rights Act.

Breast and Cervical Cancer Treatment for the Uninsured

A new federal law provides a unique expansion of Medicaid (called Medi-Cal in California) to cover the full costs of treatments for breast and cervical cancer for moderate-income women who lack health insurance. Coverage applies to women who do not have insurance and whose income is less than 250% of the federal poverty standard--about $35,000 a year for a family of three. To qualify, they must have had the cancer detected through the free screening program offered by the Centers for Disease Control, available at community health centers and local hospitals. The national information number for the screening program is (888) 842-6355. The number in California is (800) 511-2300. The Web site is https://www.cdc.gov./cancer.

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Bob Rosenblatt welcomes your questions, suggestions and tips about coping with the changing world of health care. You can contact him by writing Bob Rosenblatt, Health, Los Angeles Times, Times Mirror Square, Los Angeles, CA 90053, or by e-mailing bob.rosenblatt@latimes.com. Health Dollars & Sense runs the second Monday of each month.