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Your Rights as a Health Insurance Consumer

Health Insurance Resource Center

You have many rights and protections if you have health insurance coverage through an HMO or insurer (health plan) subject to New York Law.

  1. Health plans must give you important information about your coverage.
  2. Health care providers must tell you the health plans in which they participate and upon request, the fees they will charge if they do not participate.
  3. Hospitals must tell you the health plans in which they participate and fee information if you request it.
  4. Health plans must make sure you can get the health care services you need (access to care).
  5. Coverage must be provided for emergency services with no additional charge to you beyond your in-network copayment, coinsurance or deductible.
  6. You are protected from surprise bills.
  7. Women have coverage for certain health care services.
  8. Health plans must have a grievance and utilization review process in place for you to appeal coverage denials.

The above provider and hospital disclosure requirements (2) and (3), and a right to an independent dispute resolution process for emergency bills and surprise bills apply to consumers who receive health care services in New York even if they do not have health insurance coverage through an HMO or insurer subject to New York Law.

The following provides detailed information on each of these important protections. Also, be sure to check your health insurance contract for the terms and conditions of your coverage.


Information Your Health Plan Must Give You
(Insurance Law Sections 3217-a & 4324 and Public Health Law Section 4408)

HMOs and insurers (health plans) subject to NY law (coverage that is not self-insured) must give you the following information. It will be in your insurance policy or in a separate document. You also have the right to request this information from any health plan if you are shopping for coverage:

Health plans must give you the following information if you ask for it, including if you are shopping for coverage:

If your insurer has not provided this 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 information either upon your enrollment or request, you should submit a complaint to the NYS Department of Health, Office of Health Insurance Programs, Bureau of Consumer Services - Complaint Unit, Corning Tower - OCP Room 1609, Albany, New York 12237; or call 1-800-206-8125; or e-mail managedcarecomplaint@health.ny.gov.

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Information Your Doctor and Other Health Care Providers Must Give You
(Public Health Law Section 24)

Providers must give patients and prospective patients the following information:

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Information Your Hospital Must Give You
(Public Health Law Section 24)

Hospitals must post on their websites:

Hospitals must, in registration or admission materials provided prior to non-emergency hospital services:

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Access to Care
(Insurance Law Sections 3217-a, 3217-b, 3217-d, 3241, 4306-c, 4324, 4325 & 4804 and Public Health Law Sections 4403 & 4408)

You have the following access to care protections if you have health insurance coverage through an HMO or insurer (health plan) subject to New York Law (coverage that is not self-insured).

Right to Go Out-of-Network When Your Health Plan Does Not Have An In-Network Provider:

Choice of Primary Care Doctor:

Specialty Care:

When Your Provider Does Not Participate With Your Health Plan:

When Your Provider Leaves Your Health Plan's Network:

Network Adequacy:

Gag Clauses:

If your HMO is not following these access to care requirements, you should submit a complaint to the NYS Department of Health, Office of Health Insurance Programs, Bureau of Consumer Services - Complaint Unit, Corning Tower - OCP Room 1609, Albany, New York 12237; or call 1-800-206-8125; or e-mail managedcarecomplaint@health.ny.gov.

If your insurer is not following these access to care requirements, select this link to submit a complaint to our Consumer Assistance Unit.

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Emergency Care
(Insurance Law Sections 3216, 3221, 3241(c), 4303, 4900, 4902 & 4905, Financial Services Law Article 6 and Public Health Law Sections 4900, 4902 & 4905)

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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Protection from Surprise Bills for Health Care Services
(Financial Services Law Article 6)

What You Need to Know To Protect Yourself From Surprise Bills If You Have HMO or Insurance Coverage Subject to NY Law (coverage that is not self-insured).

What You Need to Know to Protect Yourself From Surprise Bills If You Are Uninsured Or If Your Employer or Union Provides Self-Insured Coverage (that is not subject to New York law).

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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)

HMOs and insurers (health plans) that provide comprehensive health insurance coverage that is subject to NY law (coverage that is not self-insured) are required to cover the following services. (You should check your health insurance policy for the 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
(Insurance Law Sections 3217-d(a), 4306-c(a), 4802 & Article 49 and Public Health Law Section 4408-a & Article 49)

HMOs and insurers (health plans) subject to NY law (coverage that is not self-insured) are required to have a grievance procedure (for contractual denials) and a utilization review procedure (for medical denials) for you to use to appeal their determinations.

Grievance Procedure

Utilization Review Procedure for Decisions on Medical Care

You can also appeal any denial of care that your HMO or insurer (health plan) decides is not medically necessary, experimental or investigational, a clinical trial or a rare disease treatment (utilization review decisions).

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

The Department has published a health insurance complaint ranking that includes information on Department complaints, grievance determinations, and appeals relating to medical necessity. Select this link to see the latest Health Complaint Ranking.

Updated 3/12/2015

 

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