Care for Illnesses

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.

Questions and Answers

What if my health plan will not approve the treatment my doctor recommends?
What is a second opinion?
When can I get a second opinion?
How do I get a second opinion?
What if I want to see a specialist who is not in the network?
What is informed consent?

What if my health plan will not approve the treatment my doctor recommends?
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.

What is 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.

When can I get a second opinion?
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.

How do I get a second opinion?
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.

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.

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.

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Resources

Agency for Healthcare Research and Quality
Next Steps After Your Diagnosis
Government agency with tips to help you learn more about your problem and how it can be treated
1-800-358-9295 (publications only)
www.ahrq.gov/consumer/diaginfo.htm
www.ahrq.gov

American College of Surgeons
Information on common operations and choosing a surgeon
1-312-202-5000
www.facs.org

Cancer Information
Government agency with information on cancer treatments
1-800-422-6237 (Spanish)
www.cancer.org (Spanish)

Lab Tests Online
Information on lab tests
www.labtestsonline.org

Medline Plus
Information on many health topics
www.medlineplus.org (Spanish)

National Guideline Clearinghouse
Government agency with care guidelines for many health problems
www.guideline.gov

National Institutes of Health
Government agency with information on many health issues
www.nih.gov

Patient Advocate Foundation
Patient assistance programs which ensure access to health care services, maintenance of employment and preservation of financial stability
www.patientadvocate.org
1-800-532-5274 (Spanish)

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