The California Patient's Guide
Your Health Care Rights and Remedies
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Table of Contents
Introduction
Your Rights to Continuous Care, Second Opinions, Referrals and Information
WHAT DUTIES DO MY DOCTOR AND HMO HAVE TO ENSURE THAT I WILL RECEIVE CONTINUED CARE?
HOW CAN I END THE PATIENT/PHYSICIAN RELATIONSHIP?
CAN MY DOCTOR END THE PATIENT/PHYSICIAN RELATIONSHIP?
WHAT ARE MY RIGHTS TO CONTINUE TREATMENT WITH A DOCTOR WHOSE CONTRACT WITH MY HEALTH CARE PLAN IS TERMINATED?
WHAT ARE MY RIGHTS TO CONTINUED COVERAGE BY MY CURRENT DOCTOR WHEN I JOIN A NEW HEALTH PLAN?
WHAT ARE MY RIGHTS TO OBTAIN A SECOND OPINION?
WHO CAN PROVIDE A SECOND OPINION?
IN WHAT SITUATIONS WILL MY PLAN AUTHORIZE A SECOND OPINION?
WHAT IS THE TIMELINE FOR MY PLAN AUTHORIZING A SECOND OPINION?
WHAT HAPPENS IF MY PLAN DENIES MY REQUEST FOR A SECOND OPINION?
HOW LONG CAN MY PLAN TAKE TO AUTHORIZE MY REFERRAL TO A SPECIALIST?
CAN MY HMO RESTRICT WHAT MY DOCTOR TELLS ME ABOUT MY CONDITION OR TREATMENT OPTIONS?
I'VE HEARD THAT HMOs SOMETIMES PROVIDE FINANCIAL INCENTIVES TO DOCTORS TO NOT PROVIDE CERTAIN TREATMENT OR CARE TO THEIR PATIENTS. IS THIS LEGAL?
Your Right to Informed Consent
WHAT IS INFORMED CONSENT?
WHY IS INFORMED CONSENT IMPORTANT TO ME?
IS MY INFORMED CONSENT ALWAYS REQUIRED FOR ALL MEDICAL TESTS OR PROCEDURES?
IS THE DOCTOR REQUIRED TO TAKE THE TIME TO TALK TO ME ABOUT INFORMED CONSENT?
HOW DO I GIVE THE DOCTOR INFORMED CONSENT?
WHEN SHOULD MY DOCTOR DISCUSS THE RISKS AND BENEFITS OF A PROPOSED COURSE OF TREATMENT AND ANY TREATMENT ALTERNATIVES WITH ME?
WHAT KINDS OF QUESTIONS SHOULD I ASK SO I CAN GIVE "INFORMED CONSENT?"
IS THE DOCTOR LIMITED BY MY INFORMED CONSENT?
WHAT ARE MY RIGHTS IF THE DOCTOR DOESN'T GET MY CONSENT, OR PERFORMS SERVICES BEYOND THE SCOPE OF MY INFORMED CONSENT?
WHERE ELSE CAN I GO FOR HELP?
Your Rights to Medical Records and Confidentiality
HOW CAN I OBTAIN MY OWN MEDICAL RECORDS?
WHAT INFORMATION IS SUBJECT TO PROTECTIONS CONCERNING MEDICAL RECORD CONFIDENTIALITY?
DO DOCTORS AND HMOs NEED TO OBTAIN MY CONSENT BEFORE RELEASING MY MEDICAL RECORDS?
WHAT DOES AN AUTHORIZATION FORM FOR RELEASE OF MY MEDICAL RECORDS HAVE TO INCLUDE TO BE VALID?
CAN MY DOCTOR OR HMO RELEASE MY MEDICAL RECORDS WITHOUT MY CONSENT?
WHEN CAN MY EMPLOYER OBTAIN AND USE OR DISCLOSE MY MEDICAL RECORDS WITHOUT MY CONSENT?
WHEN CAN AN INSURANCE COMPANY OBTAIN ACCESS TO MY MEDICAL RECORDS WITHOUT MY CONSENT?
WHAT CAN I DO TO PROTECT MY MEDICAL RECORD INFORMATION FROM BEING DISCLOSED WITHOUT MY CONSENT?
WHAT IS THE MEDICAL INFORMATION BUREAU?
WHAT REMEDIES DO I HAVE IF SOMEONE ILLEGALLY OBTAINS OR DISCLOSES MY MEDICAL RECORDS?
OTHER RESOURCES
Your Right to Emergency Medical Care
WHAT IS CONSIDERED AN "EMERGENCY MEDICAL CONDITION" THAT REQUIRES EMERGENCY MEDICAL CARE?
DOES A WOMAN IN LABOR HAVE AN EMERGENCY MEDICAL CONDITION?
WHAT ARE MY RIGHTS TO EMERGENCY CARE?
WHAT DOES IT MEAN TO HAVE MY MEDICAL CONDITION SCREENED?
WHAT DOES IT MEAN TO HAVE MY CONDITION STABILIZED?
WHEN CAN I BE TRANSFERRED TO ANOTHER HOSPITAL?
WHAT ARE MY LEGAL RIGHTS IF I AM HARMED WHILE RECEIVING EMERGENCY CARE?
WHAT ARE MY HEALTH CARE PLAN'S OBLIGATIONS WITH REGARD TO PAYING FOR EMERGENCY SERVICES I RECEIVE?
WHERE CAN I GO FOR HELP WITH QUESTIONS OR COMPLAINTS REGARDING A HOSPITAL'S EMERGENCEY SERVICES?
Your Rights to Coverage of Pre-Existing Conditions
WHAT IS A "PRE-EXISTING CONDITION"?
CAN MY HEALTH PLAN DENY COVERAGE FOR TREATMENT OF MY PRE-EXISTING CONDITION?
WHAT CAN I DO IF I AM DENIED COVERAGE?
WHERE ELSE CAN I GO FOR HELP?
Your Rights to File Grievances with your Health Plan and the Department of Managed Health Care
WHEN SHOULD I FILE A GRIEVANCE WITH MY PLAN?
WHAT ARE MY RIGHTS TO FILE A GRIEVANCE AGAINST MY HEALTH PLAN?
WHAT STEPS SHOULD I TAKE BEFORE I FILE A GRIEVANCE?
WHAT IS MY HEALTH PLAN'S TIMELINE FOR RESOLVING MY GRIEVANCE?
WHAT IS THE TIMELINE FOR RESOLVING MY GRIEVANCE IN AN EMERGENCY CASE OR WHERE A SERIOUS THREAT TO MY HEALTH IS INVOLVED?
WHEN MAY I SUBMIT A GRIEVANCE TO THE DEPARTMENT OF MANAGED CARE (DMHC)?
WHAT IS THE DEPARTMENT OF MANAGED HEALTH CARE'S TIMELINE FOR RESOLVING MY GRIEVANCE?
CAN THE DEPARTMENT OF MANAGED HEALTH CARE PENALIZE MY HEALTH PLAN FOR NOT COMPLYING WITH THE GRIEVANCE STANDARDS?
Your Rights to Have your HMO's Decisions Independently Reviewed and to Sue Your HMO
WHAT ARE MY RIGHTS TO AN INDEPENDENT REVIEW OF AN HMO DENIAL?
IS THERE A DIFFERENCE BETWEEN FILING A GENERAL GRIEVANCE WITH THE DEPARTMENT OF MANAGED CARE AND SEEKING AN INDEPENDENT REVIEW?
WHAT HMO DECISIONS ARE SUBJECT TO INDEPENDENT REVIEW?
IS THERE AN "EMERGENCY REVIEW"?
IS THERE A SPECIAL REVIEW PROCESS FOR EXPERIMENTAL TREATMENTS?
HOW DOES THE INDEPENDENT REVIEW PROCESS WORK?
WHAT IS THE RELATIONSHIP BETWEEN SUING AN HMO & APPEALING DENIALS OF CARE THROUGH MY PLAN'S INTERNAL GRIEVANCE PROCESS OR THROUGH THE INDEPENDENT REVIEW PROCESS?
TIMELINE FOR BASIC REVIEW
TIMELINE FOR EXPEDITED REVIEW
ARE THERE ANY EXCEPTIONS TO THE REQUIREMENT THAT I USE THE INDEPENDENT REVIEW PROCESS BEFORE FILING A LAWSUIT??
WHAT ARE THE LIMITS ON MY ABILITY TO SUE AN HMO?
WHO IS NOT LIMITED BY ERISA IN THEIR RIGHT TO RECOVER DAMAGES?
HOW DOES ERISA LIMIT THE ABILITY OF PRIVATE SECTOR EMPLOYEES TO RECOVER DAMAGES IN A LAWSUIT?
WHAT ARE MY RIGHTS UNDER CALIFORNIA LAW TO SUE MY HMO?
WHAT ARE MY RIGHTS UNDER CALIFORNIA LAW TO SUE MY HMO?
UNDER WHAT CIRCUMSTANCES CAN I SUE MY HMO?
WHERE CAN I SUE?
Your Rights to Appeal and Litigate Benefit Denials Under ERISA
DOES ERISA APPLY TO MY HEALTH PLAN?
HOW LONG DOES MY HEALTH PLAN HAVE TO MAKE A DECISION ON MY INITIAL CLAIM FOR BENEFITS?
WHAT ARE MY RIGHTS UNDER ERISA PERTAINING TO REVIEW OF BENEFIT DENIALS?
WHAT CAN I DO IF MY APPEAL IS DENIED?
WHAT STEPS SHOULD I TAKE TO PREPARE TO BRING A LAWSUIT?
Health Care Coverage Options
Medicare
Medi-Cal
Healthy Families Program
Child Health And Disability Prevention Program (CHDP) And California Children Services (CCS)
Appendix A: Department of Managed Health Care's Consumer Complaint Form
Appendix B: Vital Steps to Receiving the Health Care You Need-A Checklist
Appendix C: Sample Letter
Appendix D: Strategic Advice For Patients: Tactics to Use and Understand
Appendix E: Useful Code Sections of the California Knox-Keene Health Care Service Plan Act of 1975 and Regulations
Glossary
Acknowledgements