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Our Bodies :: Maximize Your Health Care Coverage

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Dear Dr. Levister: I am looking for ways to make the most of my family’s health care coverage. We are currently covered by an HMO. Any tips?

Dear P.L.:

Successfully fighting your way through the increasingly complicated world of health care coverage can be costly, and frustrating. Medicine gets better every year in its ability to help people overcome disease. The real challenge is making the system work for you, delivering the care you need with a minimum of delay and obstruction.
Here are a few ways you can maximize your health care coverage:
When Your HMO Says No: A new California law gives consumers the right to an independent appeal when an HMO says that a treatment, procedure or referral to a specialist is not medically necessary. First you appeal within the HMO. If your appeal is denied, you have the right to an outside review by independent doctors who do not work for the health plan.
Enhanced Medi-Cal Benefits: This is the federal-state program that provides free medical care for the poor. The income ceiling for people 65 and older or disabled, has been raised, enabling more people to qualify for the program. The new standard has been boosted to the adjusted income of $926 a month for a single person and $1,248 a month for a couple. For eligibility information call (800) 434-0222.
Coverage for Pregnancy: Pregnant women now have the right to get health insurance “out of season.” For example, a married couple, young and healthy, who have health insurance at work, might decide they don’t need or can’t afford, to pay for coverage. When open enrollment or “open season” comes along they just skip it. No chance to sign up again for one year. Under the revised law, if the wife becomes pregnant within that year she doesn’t have to wait until next year to sign up as long as she enrolls the baby within 30 days of its birth.
The new California Patients Guide is a useful tool for anyone trying to make sense of the complex health care coverage system. Write to FTCR, 1750 Ocean Park Blvd., Suite 200, Santa Monica, Ca. 90405 or call (310) 392-0522.

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