• Ask if the doctor or specialist the person is now seeing is in the HMO network.
• Understand the person's medical needs -- for special equipment, drugs, and help with activities. Determine if these needs are covered.
• Find out if the HMO is used to dealing with the illness the person has.
• Determine the specific services offered for this type of illness.
• Ask who decides what is medically necessary.
• Ask if there is a special Plan of Care for the illness.
• Ask if the person will get the best drugs for the condition or if generic substitutes will be offered.
• Ask how many people with this type of illness are under the plan in your area.
• Verify that the patient may see the specialists listed in the directory.
• Ask if the plan allows visits to specialists without a primary care doctor's referral.
• If a referral is required, find out how long it lasts and if a new referral is required for every visit.
• Ask what percentage of doctors on the list are board certified (have passed a special test given by the board of their specialty).
• Ask if the doctor has a financial incentive to do tests or to keep the patient from having tests or seeing a specialist.
• Ask if the plan covers visits to doctors outside the plan's referral list. (Out-of-network coverage may be limited to a certain dollar amount.)
• Ask how many doctors in the HMO specialize in geriatric care.
• If the person in your care must travel to a specific locale for extended stays, be sure the HMO allows visits to a different HMO there.
• Ask how the person will be charged if an emergency room visit is needed while traveling.
• Ask about the process for appealing a medical decision.
• Once you have decided on an HMO, get confirmation in writing regarding the items or services that are most important to the person in your care.

NOTE: To find out how many patient complaints were registered against an HMO, call your state insurance commissioner in the phone book under State Government.

How to Appeal an HMO's Decision Regarding a Medical Procedure, Prescription, or Specialist Referral

When a treatment is denied, the goal is to reverse the denial as quickly as possible. Remember that the HMO can prolong a case in court, so the goal is to resolve the case without litigation.

• Call the HMO and ask for a copy of its formal appeals process. (Federal law requires HMOs to have such a process.)
• Make detailed notes of all conversations with the HMO; include the date and the staff person's name.
• Determine exactly why the HMO refused to cover the treatment.
• Ask the HMO clerk for an explanation; if the matter is not resolved, ask for the HMO medical director's explanation of denial of treatment.
• If you still feel the situation is not resolved, start a written appeal process.
• Ask the doctor for a written explanation why treatment is medically necessary (also ask the specialists you have visited for a letter of support.)
• Save all bills related to the problem.
• For consumer advice or support for the appeal, call the state insurance department, state health department, advocacy group for the disease, or local [LINK] Area Agency on Aging. [LINK]