Care of Illness

If you have an illness, you and your doctor will talk about treatments. Your doctor should tell you all of your treatment choices, even if your health plan does not cover all of them. If you need to decide about an important treatment, ask how much time you have to decide.

Before You Decide on a Treatment

  • Ask about the risks and benefits of each treatment. Decide what risks you are willing to take.
  • Ask which treatments are most likely to help you. Which are least likely to help you?
  •  Ask how much time each treatment will take. How much time will it take to recover?
  •  Ask how much each treatment will cost you.
  • Ask about the side effects of each treatment. Decide how much discomfort or pain you are willing to take.
  • Sign an informed consent form for you and/or your children.  This means:
    • You understand what is being done and why.
    • You understand the risks and benefits of the treatment.
    • You understand what other treatments you can choose.
    • You agree to have the treatment.

Getting a Second Opinion

It is advice you get from a second doctor. Usually people ask for a second opinion when a doctor has recommended surgery or a certain treatment, or given a diagnosis, and they want to make sure it is the best decision for them.

Your health plan should cover a second opinion:

  • When your problem or the cause (or diagnosis) is not clear.
  • When you have doubts about surgery.
  • When you have doubts about a treatment for a serious health problem.
  • When your treatment is not working.

Ask your doctor for a referral. Usually, your medical group or health plan must approve your doctor's referral. If your problem is urgent, your plan must reply to your request in 3 days. Urgent means it is a serious threat to your life.

If you want to see a specialist and there isn’t one in your health plan's network who can give you the care you need, ask your health plan to approve a referral to a specialist who can. If you go to the specialist on your own, without a referral and prior approval, your plan probably will not pay for the visit.

Referrals

Decline or Delay in Treatment

If your health plan declines treatment recommended by a doctor, you can file a complaint with your plan. If your health problem is urgent, ask the plan for an expedited review. Your plan must give you a decision in 3 days. Urgent means that your health problem is a serious threat to your life. If your health plan still does not approve the treatment, you can apply for an Independent Medical Review/Complaint.

California laws limit how long you have to wait for an appointment to receive treatment. In general, you should be able to get an urgent appointment within 48 hours (96 hours if it needs prior approval). Learn more about waiting times.

File a complaint with your plan

Apply for an Independent Medical Review/Complaint

Learn more about waiting times


What if I want to see a specialist who is not in the network?
If there is not a specialist in your health plan's network who can give you the care you need, ask your health plan to approve a referral to a specialist who can. If you go to the specialist on your own, without a referral and prior approval, your plan probably will not pay for the visit.

Resources