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Your Rights as a Health Insurance Consumer

Health Insurance Resource Center

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
(Insurance Law Sections 3217-a & 4324 and Public Health Law Section 4408)

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:

The following information must be disclosed upon request to consumers who have coverage with an HMO or insurer and to prospective members:

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.

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Access to Care
(Insurance Law Sections 3217-a, 3217-b, 4324, 4325 & 4804 and Public Health Law Sections 4403 & 4408)

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:

Specialty Care:

When your provider does not participate with your health plan:

When your provider leaves your health plan’s network:

Network Adequacy for HMO coverage:

Gag Clauses:


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 York 12237.

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 insurer’s 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.

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Emergency Care
(Insurance Law Sections 3216, 3221, 4303, 4900, 4902 & 4905 and Public Health Law Sections 4900, 4902 & 4905)

All HMOs and insurers providing coverage for inpatient hospital care must provide coverage for treatment in hospital emergency rooms.

If your health plan is not following these requirements for emergency services, select this link to submit a complaint to our Consumer Assistance Unit.

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Women’s Healthcare
(Insurance Law Sections 3216, 3217-a, 3221, 4303, 4306-b & 4322 and Public Health Law Section 4406-b)

There are several laws that protect a woman’s 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.

If your health plan is not following these requirements for woman’s health care services, select this link to submit a complaint to our Consumer Assistance Unit.

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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.

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 can also appeal any denials of care that your HMO or insurer has decided is not medically necessary.

Examples of procedures and services that could be challenged for reasons relating to medical necessity include but are not limited to:

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.

Updated 3/04/2013

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