HMO Complaints
All HMOs are required to have a complaint system, often called a
grievance
procedure, to resolve written complaints by members. The HMO is required
to provide forms for written complaints, including the address and
telephone
number of where complaints should be directed. Additionally, on providing
the necessary forms for a complaint to a member, the HMO must notify
the
member of any time limits applying to a complaint. Complaints must
be
resolved within 180 days of being filed with the HMO (with a few
exceptions).
Prohibited Practices
HMOs are prohibited from excluding a member’s preexisting conditions
from coverage and from unfairly discriminating against a member based
on
age, sex, health status, race, color, creed, national origin, or
marital status.
HMOs are also prohibited from terminating a member’s coverage
for reasons
other than nonpayment of premiums or copayments, fraud or deception
in the member’s use of services, a violation of the terms of
the contract, failure
to meet or continue to meet eligibility requirements prescribed by
the
HMO, or a termination of the group contract under which the member
was
covered.
