Does the ADA Apply To HMOs?
Yes, unequivocally, even though the HMOs do not admit it.
If you are in a private HMO, Title III of the ADA applies. If you are in a medical assistance, public (sometimes mandatory) HMO, Title II applies. Whichever type of HMO you’re in, it must comply with the relevant ADA provisions.
Okay, How does the ADA apply?
First, discrimination against people with disabilities occurs in the health area the exact same way it occurs in the non-health context. Do not be intimidated by the capital letters MD or HMO!
Second and most critical, people with disabilities have the right to have their individual and specific medical and health issues treated the same as, equally as, and as fully and completely as a nondisabled person is treated. The HMO cannot discriminate against you based on your disability or because you have a disability. The important point is to define exactly how the discrimination is occurring.
Be aware of some code words used to attempt to disguise what is really discrimination:
Medically necessary as in “A motorized wheelchair is not medically necessary for Mrs. Jones because there is another person in the house who can push her in a manual chair.”
Medical condition as in, “Mr. Smith cannot receive physical therapy because he was born with cerebral palsy (his alleged “medical condition”) and persons receive physical therapy only if they need it as a result of an accident.”
Medical appliance as in, “The HMO will not pay for an augmentative communication device because it is not a medical appliance.”
Covered benefit as in, “If a person needs in-home nursing care and attendant services for nine hours a day, they are not covered benefits at that level. The HMO will pay for such services, but only in a nursing home.”
What can people with disabilities do to enforce their ADA rights against their HMO?
Our experience suggests that both public and private HMOs can be held accountable. But it takes a lot of effort and time.
Specifically: Each time–yes, each time–your or your doctor’s request for services is turned down, you must appeal in writing and request an oral hearing. Nearly every HMO has an appeal process, usually a three-step appeal process.
When you hear a denial that is really a cover for discrimination, you must use the HMO’s appeal process and argue that the denial is discrimination in violation of the ADA. Don’t be surprised if you must appeal all the way.
Tell the HMO, if necessary, that you will fight this to the end.
This article was originally published in the March 2001 issue of Mouth Magazine. Visit their website at www.mouthmag.com/
