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Access to Care

A sufficient number of physicians to service the insured population in each geographic area is key to adequate access. Medical facilities, such as hospitals, outpatient treatment centers and specialty treatment centers, must be conveniently located. Access also depends on hours of operation and the accommodation of members with special needs.

Access to Providers

Q. Does the plan provide a complete list of all physicians and other providers included in the network?

A. This information should be provided on request, but is especially important when a plan is selected and during open enrollment periods. In addition to a provider directory, many plans provide members with an 800 number that can be used to find out whether a provider is still in the plan or whether new providers have joined since the last directory was published.

Q. What percentage of employees’ current providers are included in the network?

A. Employees can be surveyed to determine which providers they want in the network. If those providers are not already included in the network, they can be solicited to join so long as they meet the quality standards set by the plan.

Q. Are physicians and providers located within a reasonable distance of employees’ work and/or homes? What geographical standards does the plan use in assembling its network?

A. The proximity of providers to members’ homes and workplaces can be determined by comparing the zip codes of providers with employee zip codes. This is typically referred to as a geo-access study and almost all large HMOs have the technological ability to perform such studies. Many health care purchasers require plans to have a choice of at least two primary care physicians within a 15-mile radius and/or a 30-minute drive from the patient’s home. What is reasonable in metropolitan areas and in rural areas will differ.

Q. How many and what percent of primary care physicians are accepting new patients in each geographic area?

A. Some physicians may agree to participate in a network so they can continue to treat current patients, but may not accept any new patients.

Q. Does the patient have the right to change physicians at any time?

A. Some plans allow patients to select a primary care physician only when first joining the plan and during the annual open enrollment.

Q. What are the plan’s standards for telephone response time? What are the hours of operation? What is the average waiting time for an appointment and the wait once the member arrives for a scheduled appointment?

A. If hours of operation or waiting times are unreasonable, then the plan is not adequately accessible.

Out-of-Network Care

Q. Are patients permitted to use a doctor or hospital outside of the network for a higher fee? If so, what is the difference in fees?

A. Some states prohibit HMOs from covering out-of-network care, except in emergencies. Other managed care plans may allow out-of-network care for a higher fee (PPO and POS plans). In POS plans, deductibles and copayments — that may not apply to in-network care — usually apply to out-of-network care. PPO plans usually require payment of deductibles and copayments for all care but the amounts are higher for out-of-network care. Reimbursements to the patient may be based on the fee negotiated with network providers. That is likely to be less than the fee a non-network provider would charge, resulting in higher out-of-pocket costs for patients. If the plan allows out-of-network care, premiums will be higher.

Q. What if the plan does not include a needed specialist? Can the patient see a non-network specialist for the same cost as an in-network specialist?

A. While managed care plans will typically allow patients to see a non-network specialist if the plan does not include the needed specialist, the plan usually retains the right to select that specialist.

Q. What are the provisions for employees and/or their dependents, or retirees, who live outside of the network area? Are their benefits covered at in-network rates?

A. Retirees who move away, or dependents who are away at college, may still be covered under the managed care plan. Even employees may live outside the boundaries of the network. The plan should provide for reimbursement equal to that for in-network care for those who do not have reasonable access to network doctors.


Q. Which type of physicians can plan participants choose as their primary care provider?

A. Most plans use general practitioners, internists and pediatricians as primary care providers. Some plans allow women to select an OB/GYN as their primary care physician and some plans allow participants with chronic illnesses to select an appropriate specialist as their primary care provider.

Q. How is a patient referred to a specialist? What criteria are used by the plan?

A. Most managed care plans require that members obtain a referral to see a specialist. Such requirements can be unreasonable for routine care, such as visits to an OB/GYN. Also, doctors who are not in favor of a particular type of treatment, such as chiropractic care, may hesitate to make referrals, even if the care is covered by the plan. The plan should allow at least two OB/GYN visits per year without a referral, and unlimited visits in the case of pregnancy. If the plan covers chiropractic or other specialty care, a specified number of visits should be covered without referral.

Transition Issues

Q. What if a patient is in ongoing treatment when the plan is implemented, and that individual’s current doctor is not in the new plan?

A. The plan should allow such employees to remain under their current physician’s care until that particular treatment has been completed.

Q. What about the employees with long-standing doctor/patient relationships?

A. For such employees, who often have chronic illnesses, the plan should provide for continued treatment for some period of time, phasing out treatment with the current doctor gradually.

Q. What are the turnover rates for doctors in the plan? Does the plan give notice of a doctor’s intent to leave the network? What happens to members under treatment when a doctor leaves?

A. One of the biggest complaints about managed care plans is that it is very disruptive when a doctor leaves the plan. At least one state has passed a law which require plans to notify members when a provider leaves the network. To lessen the impact of turnover, a plan should allow patients to complete any current treatments with that doctor, then assist them in locating a new doctor.

Special Needs

Q. What percent of physicians and other medical staff speak a language other than English? Does the plan accommodate those with disabilities?

A. AFSCME’s membership is diverse, and plans covering our members should accommodate that diversity. This information should be broken down by the language spoken, special equipment, and by facility and/or geographic area.

Q. Does the network include hospitals and ambulatory care facilities with specialties in areas like neonatal and pediatric care, intensive care, cardiac care, emergency and trauma care, burn units, and AIDS treatment?

A. Ask the plan to provide lists and locations of specialized facilities.

Emergency Care

Q. How does the plan define an emergency? How does it handle emergency care?

A. Most plans limit or deny payment for visits to an emergency room for illness or injury that the plan does not consider urgent or life-threatening. Plans have developed several ways of handling emergencies. Some large plans provide emergency services around the clock at their own clinics and hospitals. Some plans have a telephone call-in service with doctors or nurses who advise patients as to whether their condition is an emergency. Some look at the patient’s symptoms, rather than the diagnosis, to determine whether the patient could have perceived the situation to be urgent or life-threatening. A number of states have passed laws which require plans to pay for emergency room services if a “prudent layperson” would have considered the condition an emergency.

Scope of Services

Q. What services are provided by the network in addition to traditional illness/injury care? Are network physicians supported and trained to provide wellness, health promotion and disease prevention services?

A. One of the advantages of managed care plans is that they cover preventive care, typically not covered by traditional indemnity health plans. Many HMOs are even beginning to cover alternative therapies, such as acupuncture and biofeedback. The union should be certain that the plan covers both currently covered services and new preventive services.

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