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Know Your Rights As A Patient

In this era of rising health-care costs, various forms of managed health care, including HMOs and PPOs, are becoming increasingly popular. However, in response to perceived abuses, the Illinois legislature enacted the Managed Care Reform and Patients Rights Act (the "Act") to protect the citizens of Illinois and to ensure that they receive the health care that they pay for.

For individuals insured through managed care plans provided by their employers, but purchased from third-party insurers, the Act provides certain rights and protections that the participants might otherwise be denied. (The Act does not apply to an employer who is self-insured.)

Rights and Protections

For example, the Act specifies that managed care providers must provide participants with certain basic information about their plan, including the names of participating doctors, the plan's service area, some information about how the plan operates, and (perhaps, most importantly) what the plan covers and does not cover. Plans subject to the Act also have to give participants at least 60 days' notice of a decision to terminate coverage, which gives a participant an opportunity to find new coverage.

But the Act does more than just require the disclosure of important information--it also takes steps to ensure that the care provided to an insured is determined by his or her doctor, not by the insurer. Specifically, the Act prohibits managed care organizations from interfering with a doctor's right to discuss health-care services with an insured, and allows an insured to pick his or her own primary care physician. If a doctor believes that treatment by a specialist is necessary, the Act requires the managed care provider to provide for a "standing referral" to the specialist. It requires plans to cover necessary emergency care no matter who provides it, and specifies that, if a doctor prescribes a drug, no substitution of a different drug may be made unless the insured consents.

Enforcement

The Act also provides enforcement mechanisms. If the managed care provider refuses to cover a treatment because it finds that the treatment is not medically necessary, the Act allows the insured to request that the insurer reconsider its decision. If the insurer still refuses to cover the procedure, the insured may appeal this refusal to an outside reviewer (one not employed by the managed care plan) for an independent determination of whether the procedure is necessary. The Act also prohibits retaliation against doctors who advocate a medically appropriate treatment, no matter how expensive it may be. Finally, the Act prohibits managed care providers from requiring that the participant waive any of these important rights in return for coverage.

Health care is expensive, and managed care is one option to help contain costs. However, the Act makes sure that this cost saving does not come at a greater cost, one measured not in dollars but in lives. If you have any questions about the Act, you may contact the Illinois Department of Financial and Professional Regulation, Division of Insurance, at (877) 527-9431 or online at www.idfpr.com.

This website is not intended to constitute legal advice or the provision of legal services. By posting and/or maintaining the website and its contents, Lucas Law does not intend to solicit business from clients located in states or jurisdictions outside of Illinois wherein Lucas Law or its individual attorney(s) are not licensed or authorized to practice law.

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