There are many protections in place for health care consumers who have coverage through an HMO or insurer subject to New York Law. New York Insurance Law and Public Health Law require health plans to disclose certain information to consumers, establish requirements for access to care, mandate coverage for emergency services using a prudent layperson standard, ensure women have the right to coverage of certain health care services, and require insurers and HMOs to have a process in place for consumers to appeal coverage denials. The following provides detailed information on each of these important protections:
- Obtaining Information From Your Health Plan
- Access to Care
- Emergency Care
- Women's Healthcare
- Appealing Decisions by HMOs and Insurers
Obtaining Information From Your Health Plan
HMOs and insurers must disclose certain information to consumers. Some information must be given to consumers who have coverage with an HMO or insurer, while other information must be provided upon request from a consumer. HMOs and insurers may incorporate this disclosure information in the insurance policy or certificate or in a separate document.
The following information must be disclosed to consumers who have coverage with an HMO or insurer and upon request to prospective members:
Health Care Coverage:
- A description of health care benefits, benefit maximums, limitations and exclusions from coverage, including the definition of medical necessity.
- Which health care services require prior authorization and how to request prior authorization.
- Your financial responsibility for payment of premiums, coinsurance, co-payments and deductibles, along with annual limits on your financial responsibility, caps on payments for covered services and your financial responsibility for non-covered services.
- How the health plan reimburses providers.
- Your financial responsibility for payment when a provider is not part of your health plans network.
The Grievance Procedure, including:
- The right to file a grievance for any dispute with the health plan, other than for medical necessity or experimental / investigational treatment disputes.
- The right to file a grievance orally when the dispute relates to referrals or covered benefits.
- The toll-free number to use to file a grievance.
- The time frames and circumstances for expedited and standard grievances.
- How to appeal a grievance determination.
- The right to designate a representative for the grievance process.
- Notice that all clinical decisions will be made by qualified clinical personnel and all notices of determinations will include information about the basis of the decision and any further appeal rights.
The Utilization Review Procedure when services are denied as not medically
necessary, experimental or investigational, including:
- When utilization review will occur.
- The toll-free number of the utilization review agent.
- The time frames under which utilization review determinations will be made for prospective, concurrent and retrospective determinations.
- Notice that all denials will be made by qualified clinical personnel and will include the clinical basis for the denial.
- The right to a reconsideration.
- How to appeal, including the time frames for standard and expedited appeals along with a notice of the right to externally appeal and external appeal instructions.
- The right to designate a representative to appeal on your behalf.
- Any further appeal rights.
- Access to Care:
- How to obtain emergency services, and that prior authorization cannot be required.
- How to select and access your health plans primary and specialty care providers, including how to tell if a participating provider is accepting new patients and how to change providers.
- When applicable, notice that you have direct access to obstetric and gynecologic services.
- When applicable, notice that you may obtain a referral to a health care provider outside the health plans network when the health plan does not have a provider with the appropriate training and experience to meet your particular health care needs, along with the procedures to request an out-of-network referral.
- When applicable, notice that a member who needs ongoing care from a specialist may request a standing referral.
- When applicable, notice that if you are a new health plan member and your provider does not participate, you may continue an ongoing course of treatment with the non-participating provider for up to 60 days if you have a life-threatening or disabling condition, or through post-partum care if you are in the second trimester of pregnancy.
- When applicable, notice that if your provider leaves your health plans network, you may continue an ongoing course of treatment for up to 90 days or through your post-partum care if you are in the second trimester of your pregnancy.
- Any other requirements for treatments or services.
- Your health plan must provide a listing by specialty, which may be in a separate document updated annually, of the name, address and telephone number of all participating providers and facilities. If the listing is for a physician, it must include board certification information.
- Contacting Your Health Plan:
- Your health plan must provide a list of all appropriate mailing addresses and telephone numbers to be used by members to obtain information or authorization.
- Your health plan must describe how it meets the needs of non-English speaking members.
- Your health plan must provide a description of how you can participate in the development of health plan policies.
The following information must be disclosed upon request to consumers who have coverage with an HMO or insurer and to prospective members:
- A list of names, business addresses, and official positions of the membership of the board of directors, officers and members of the corporation.
- A copy of the most recent annual certified financial statements of the corporation.
- A copy of the most recent individual direct payment subscriber contracts.
- Information relating to consumer complaints.
- The procedures for protecting the confidentiality of medical records.
- Drug formularies used by the health plan, including, if requested, whether individual drugs are included or excluded from coverage.
- A written description of the health plans quality assurance program, if any.
- The description of the procedures followed in making decisions about whether a drug, medical device, or treatment in a clinical trial is experimental or investigational.
- Individual health care practitioner affiliations with participating hospitals.
- Specific clinical review criteria relating to a particular disease including clinical information considered during utilization review.
- The written application procedures and minimum qualification requirements for health care providers to participate in the health plans network.
If your insurer has not provided this disclosure information either upon your enrollment or request, select this link to submit a complaint to our Consumer Assistance Unit.
If your HMO has not provided this disclosure information either upon your enrollment or request, you should submit a complaint to the Office of Managed Care, New York State Department of Health, Corning Tower, Empire State Plaza, Albany, New York 12237.
Access to Care
Health plans must ensure that members have access to health care services. Certain access to care protections apply to all HMO and insurance coverage, while others apply only to HMO coverage and to managed care contracts offered by insurers (which most insurers do not offer).*
Choice of Primary Care Physician:
- If you have a life-threatening or disabling condition, you may request that your specialist coordinate your care, rather than your primary care physician. HMOs and insurers offering a managed care contract must have procedures to allow you to make this request.
- If you have any insurance or HMO coverage that requires you to select a primary care provider, and your primary care provider becomes unavailable to render services, your HMO or insurer must provide written notice to you within 15 days from when your HMO or insurer became aware of the unavailability.
- If your HMO or insurer offering a managed care contract does not have a provider in network that can treat you, your health plan must make a referral to a non-participating provider at no additional cost to you.
- If you have HMO coverage or coverage under a managed care contract offered by an insurer you have the right to request a standing referral to a specialist or specialty care center if you require ongoing treatment.
When your provider does not participate with your health plan:
- If you enroll in a new HMO or managed care contract offered by an insurer and your provider does not participate, you may continue an ongoing course of treatment with the non-participating provider for up to 60 days if you have a life-threatening or disabling condition, or through post-partum care if you are in the second trimester of pregnancy. Your provider must agree to accept reimbursement from the HMO or insurer offering a managed care contract as payment in full.
When your provider leaves your health plans network:
- If your provider leaves the network of your HMO or insurer offering a managed care contract, you may continue an ongoing course of treatment for up to 90 days or through your post-partum care if you are in the second trimester of your pregnancy. Your provider must agree to accept reimbursement from the HMO or insurer offering a managed care contract at the previously agreed to rate.
Network Adequacy for HMO coverage:
- HMOs must have a network of providers adequate to meet the needs of members.
- You have the right to choose your primary care physician. Your HMO must have at least three primary care physicians within a reasonable distance from where you live.
- Your HMO may not exclude any appropriately licensed provider as a class.
- HMOs and insurers may not restrict your doctor from discussing all treatments for a medical condition with you.
If your HMO is not following these access to care requirements, you
should submit a complaint to the Office of Managed Care, New York State
Department of Health, Corning Tower, Empire State Plaza, Albany, New
If your insurer is not following these access to care requirements, select this link to submit a complaint to our Consumer Assistance Unit.
* Please note, a managed care contract offered by an insurer is defined as a contract which requires that all health care services be provided by a referral from a primary care provider and that services be rendered by a provider participating in the insurers network. In addition, in the case of an individual contract or a group contract covering no more than 300 lives, imposing a co-insurance obligation of more than 25% upon out-of-network services, which has been sold to five or more groups, a managed care contract also includes a contract which requires all services be provided pursuant to a referral from a primary care provider and that services provided pursuant to the referral be rendered by a participating provider in order for the member to obtain the maximum reimbursement.
All HMOs and insurers providing coverage for inpatient hospital care must provide coverage for treatment in hospital emergency rooms.
- Emergency room visits are covered based on the prudent layperson standard. Under the prudent layperson standard, an emergency condition means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of immediate medical attention to result in placing the persons health in serious jeopardy, serious impairment of the persons bodily functions, serious dysfunction of a bodily organ, or serious disfigurement.
- Your health plan cannot require that you seek prior approval for emergency care.
If your health plan is not following these requirements for emergency services, select this link to submit a complaint to our Consumer Assistance Unit.
There are several laws that protect a womans access to health care, depending on the type of health insurance coverage a woman has. However, you should check your HMO or insurance policy for the specific terms and conditions of your coverage.
- Women covered under an HMO or insurance policy that requires referrals are entitled to direct access to primary and preventative OB/GYN services for two examinations annually and any care related to a pregnancy, if such services are otherwise covered under the policy. In addition, HMOs and insurers may not limit direct access to primary and preventive obstetric and gynecologic services required as a result of the examinations or as a result of an acute gynecologic condition, if such services are otherwise covered under the policy.
- HMOs and insurers providing major medical or similar comprehensive coverage must provide coverage for bone mineral density measurements and testing.
- HMOs and insurers providing hospital, surgical or medical coverage must provide coverage for cervical cancer screening and breast cancer screening (mammograms).
- If an HMO or insurer provides prescription drug coverage, they must cover contraceptive drugs and devices, although religious employers may request a contract without contraceptive coverage, and their employees may purchase the coverage directly from the HMO or insurer.
- HMOs and insurers that provide coverage for inpatient hospital care must provide inpatient hospital coverage for a mastectomy. After a mastectomy, a woman has the right to stay in the hospital until she and her doctor decide she is ready to go home.
- HMOs and insurers providing surgical, medical, or comprehensive coverage must pay for reconstructive surgery after a mastectomy on the breast on which the mastectomy has been performed and on the other breast to produce a symmetrical appearance. In addition, federal law requires HMOs and insurers to provide coverage of breast prosthetics and treatment of lymphedemas.
- HMOs and insurers providing hospital, medical or surgical coverage must provide coverage for maternity care. A new mother covered under a policy that includes coverage for inpatient hospital services has the right to remain in the hospital for 48 hours after delivery and at least 96 hours after a Caesarean section. If the mother decides to leave the hospital earlier, she is entitled to one home health care visit. Coverage for educational programs for new mothers in the hospital is also required.
- Group HMO and insurance policies that provide medical or surgical coverage may not exclude coverage of the diagnosis and treatment of a correctable medical condition otherwise covered under the policy solely because the medical condition results in infertility. However, some exclusions may apply to the coverage of infertility, including in vitro fertilization (IVF), gamete intrafallopian tube transfer (GIFT) and zygote intrafallopian tube transfers (ZIFT).
If your health plan is not following these requirements for womans health care services, select this link to submit a complaint to our Consumer Assistance Unit.
Appealing Decisions by HMOs and Insurers
HMOs and insurers with a managed care contract are required to have a grievance procedure. A grievance can be filed for any determination other than one concerning medical necessity.
- You have the right to file a grievance if you are denied a referral, you are denied coverage because a benefit is determined not to be covered under your subscriber contract, or if you have a complaint concerning any plan determination other than one involving medical necessity.
Examples of complaints concerning covered benefit determinations and access to referrals that could be challenged through the grievance procedure include but are not limited to the following:
- You are denied a referral to a specialist or other provider
- Your hospital stay is curtailed
- You are denied coverage or receive only partial coverage for a prescription drug
- You are required to pay a specialist fee beyond the standard co-pay
- You are denied a referral outside the HMOs network of physicians
- You are not reimbursed for emergency room care
- You are not reimbursed for treatments rendered when you are out of New York State
- You are denied coverage or coverage is limited for services covered under your subscriber contract which could include mental health, substance abuse or physical therapy treatment
- You have the right to file grievances by phone concerning benefit determinations or referrals and plans are required to have a toll free hotline for grievance calls.
- You have the right to have any grievance where a delay would increase the risk to your health, such as coverage for surgery, decided within 48 hours to ensure that your health is not jeopardized.
- You have the right to have other grievances decided within 30 or 45 days depending on the type of grievance.
You can also appeal any denials of care that your HMO or insurer has decided is not medically necessary.
- You have the right to have your denials of care about whether or not a procedure is medically necessary made by clinical reviewers, not financial reviewers to ensure that these decisions are made in the best interest of your health.
- You have the right to appeal a utilization review determination on an expedited basis if you are undergoing a course of treatment or your health care provider believes an immediate appeal is warranted. Expedited appeals must be decided within two business days.
Examples of procedures and services that could be challenged for reasons relating to medical necessity include but are not limited to:
- Cataract removal
- Bone marrow transplant
- Magnetic Resonance Imaging (MRI) examination
- Breast reconstructive surgery following mastectomy
- Rotator cuff surgery
- Deviated septum repair
- Knee replacement surgery
- Kidney/heart/liver transplant
- Artificial limbs and other prosthetic devices
Consumers who are unable to resolve problems with their HMOs and insurers can file complaints with the New York State Insurance Department. Select this link to learn how to file a complaint.
The Department has published a health insurance complaint ranking that includes information on Department complaints, grievance determinations issued by managed care insurers, and appeals relating to medical necessity. Select this link to see the latest Health Complaint Ranking.