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When Your Health Plan Says 'No'
A Baltimore woman with bone cancer learned that her health plan would not pay for a stem cell transplant. The plan said that since she was in remission after undergoing chemotherapy the transplant was not necessary. But her doctor said that such transplants can only be done during remission and that without the procedure the cancer would probably recur.
An Eastern Shore woman's doctor ordered an echocardiogram to diagnose her heart problem, but her health plan refused to pay for it, saying that cardiac catheterization was sufficient.
Another woman's health plan would not pay for her prescription for a certain ulcer medication. The plan would pay for alternative medications, but she had tried them and they weren't effective.
What can you do when your HMO or health plan refuses to pay for care that it says is not medically necessary, appropriate or efficient? Thanks to a new Maryland law, you can make one phone call (1-877-261-8807, toll-free in Maryland) and receive help with appealing your health plan's denial of coverage. The three patients above used this assistance and were able to get their health plans to pay for the treatments they needed.
Here's the process provided for in the law:
1. The denial notice. When your health plan decides that it will not authorize or pay for a treatment, it must inform you of its decision in writing. That letter must explain the plan's appeals or "grievance" process, and also tell you that the Health Education and Advocacy Unit (HEAU) of the Maryland Attorney General's Office is available to assist you. (If the treatment involves an emergency situation, you should call the Maryland Insurance Administration - see below.)
2. Mediation. The HEAU will first try to resolve the problem with your health plan through mediation, which is a process of gathering information about the dispute, sharing the information among all the parties, and trying to bring about a cooperative resolution. The HEAU will ask the plan to reconsider its denial and will provide information from your doctor that shows how the treatment meets the criteria for medical necessity. For example, if your doctor prescribed two visits a week to a physical therapist and your plan said that only one visit per week was medically necessary, the HEAU could gather materials from your doctor demonstrating why two visits are needed for your full recovery.
3. Formal appeal to the health plan. If mediation is unsuccessful, the HEAU will help you or your doctor prepare a formal appeal with the plan's internal grievance process. All health plans have such a process to consider challenges to denials. In most cases, the health plan must give you its answer to your appeal within 30 working days.
4. Appeal to the Maryland Insurance Administration. If, after reviewing your grievance, the plan stands by its original decision to deny payment or coverage, the HEAU will assist you in appealing to the Maryland Insurance Administration. This agency will have independent medical experts review the decision by the health plan. If these experts determine that the treatment is medically necessary, appropriate and efficient, the Maryland Insurance Administration has the authority to overturn the health plan's decision and order it to pay for the treatment.
Help for Other Healthcare Disputes
The Health Education and Advocacy Unit does more than help consumers with appealing "medical necessity" denials by their HMO or health plan. Its staff and volunteer mediators also help consumers:
How to Contact the HEAU
toll-free in Maryland or (410) 528-1840
In Emergency Situations
If you or your doctor believe that you need urgent care, but your health plan does not agree, you should call the Maryland Insurance Administration's toll-free number (1-800-492-6116). That agency will render a decision within 24 hours and can order the plan to pay for the treatment.
Attorney General of Maryland 1 (888) 743-0023 toll-free / TDD: (410) 576-6372