Consumers Have Rights When Joining an HMO

Consumers Have Rights When Joining an HMO

Chicago – The Illinois Department of Insurance reminds Illinois consumers about their rights and legal protections related to HMO networks. Continuing health care services from a provider during an ongoing course of treatment is crucial. Illinois laws protect HMO members when their provider leaves a network and when members join an HMO, but the member must make a request within a certain timeframe.

Under the Managed Care Reform and Patient Rights Act of Illinois (215 ILCS 134/et seq) this is referred to as “Transition of Care.” Below are a few questions and answers to better help consumers understand their rights.

Who is eligible for Transition of Care?
Consumers who are receiving an ongoing course of treatment or have entered their third trimester of pregnancy are eligible for Transition of Care. Here are some examples of ongoing treatment: cancer treatments, physical therapy, chronic illness, hospitalizations, chemical dependency, infertility treatment, and invasive procedures such as surgery.

What happens if my doctor leaves my HMO network?
If you are notified that your doctor is leaving the network, but remains in the service area, you can request a 90-day transitional period. You must make the request within 30 days after notification that your physician is leaving the network.

What if I join an HMO, but my previous doctor is not in the HMO network?
If your previous doctor is not a member of your network, but is within the service area you can request a 90-day transitional period. You must make the request within 15 days of joining the HMO.

How long does the transitional period last?
The transitional period is approximately 90 days. If you are pregnant, your transitional period may be extended through the post-partum care related to your delivery.

What role does my physician have in this transition?
You are only eligible for transition of care if your physician agrees to continue providing care under your health plan’s guidelines during this transitional period.

How can I request transition of care services?
Your HMO should provide details on this service in the policy, certificate, member handbook and/or website. You can also contact your HMO by phone through the number provided on the back of your member card. If your provider is leaving the network, or you are enrolling in an HMO that does not include your physician, and you want transition of care services, you should immediately contact your HMO and provide the following information:
A request for transition of care services;
Name of the physician with whom you want to continue care;
Your medical condition that requires ongoing care; and
Reasons you want transition of care.

If you have questions about your rights under the Managed Care Reform and Patient Rights Act, call (877) 527-9431 or visit insurance.illinois.gov

Photo: DarkoStojanovic/pixabay.com

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