Health Equity

DFS remains committed to closing the health equity gap and reducing health disparities.

• Learn more about how New York State is working to build a more equitable and accessible health care system.

Mental Health and Substance Use Disorders

There are many protections and coverage requirements for mental health and substance use disorder services under comprehensive health insurance policies that are sold in New York.

• Learn more about Mental Health and Substance Use Disorder coverage in New York.

Health Insurance Coverage for Dyslexia

Since January 1, 2025, the “Dyslexia Diagnosis Access Act” requires fully insured health insurance policies issued in New York to cover comprehensive neuropsychological examinations for dyslexia upon the referral of a physician when performed by a health care professional acting within their scope of practice upon policy issuance or renewal.

• Learn more about Dyslexia and Health Insurance Coverage for Neurological Exams

Women's Healthcare

Comprehensive health insurance policies sold in New York must include coverage for women’s health care services, including preventive care screenings, cancer screenings and treatment, contraceptives, infertility, maternity care, maternal depression, and medically necessary abortions.

• Learn more about When Women’s Health Care Protections Apply.

Gender Affirming Care

Learn more about New York protections, treatment your Insurer is required to cover, and how to manage and appeal denials of service.

• Learn more about Health Coverage for Transgender New Yorkers

COBRA, Age 29 and Continued Coverage Information

The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers who work for employers with 20 or more employees and their families the right to continue to purchase group health insurance for limited periods of time when they would otherwise lose coverage due to certain events. Qualifying events include voluntary or involuntary job loss, reduction in hours, transition between jobs, death, divorce and other life events.

• Learn more about COBRA, Age 29 and Continued Coverage Information

Confidentiality for Victims of Domestic Violence

You have the right to request that claim-related communications from your health insurer be sent to you in alternative ways if disclosing the information could endanger you. “Claim-related information” means claim or billing information relating specifically to you, including your name, address, any services you received, and the name and address of your provider or doctor. Your request will remain in effect until you revoke it.

• Learn more about health insurance confidentiality for victims of domestic violence.
• See a sample confidential communication request form that a health insurer may ask you to submit.
• Visit the OPDV website to download and print a Reference Guide for Health Insurance Rights for Victims and Survivors of Domestic Violence.

New York State Paid Family Leave

Under the New York State Law, all eligible employees are entitled to job-protected, paid time off to bond with a newly born, adopted, or fostered child, to care for a family member with a serious health condition, to assist loved ones when a spouse, domestic partner, child or parent is deployed abroad on active military service, or when an employee or their minor dependent child are subject to a mandatory or precautionary order of quarantine or isolation due to COVID-19.

• Learn more about Paid Family Leave in New York State

Help for the Seriously Ill and Their Caregivers

If your claim or your request for a specific treatment is denied, you have certain rights. A grievance can be filed for any determination other than a denial based on the policy provisions excluding services which are deemed not medically necessary, experimental or investigational. A utilization review appeal can be filed for any denial of care that the HMO or insurer has decided is experimental, investigational or not medically necessary, and an external appeal is available if you have been denied coverage for participation in a clinical trial.

• Learn more about how to get Help For the Seriously Ill and Their Caregivers.

Child Health Plus

Every child in New York under the age of 19 who does not have health insurance is eligible for the Child Health Plus program. Visit the Department of Health for more information on Child Health Plus or call (800) 698-4543 or your local department of social services.

Healthy NY

DFS oversees the Healthy NY program which, in partnership with HMOs and other insurance companies in New York State, offers comprehensive health insurance for small businesses.

Medicare and Medigap Insurance

Medicare beneficiaries pay nothing for most preventive services if the services are received from a doctor or other health care provider who participates with Medicare (also known as accepting assignment). For some preventive services, the Medicare beneficiary pays nothing for the service, but may have to pay coinsurance for the office visit to receive these services.

• Learn more about Protections for Medicare Beneficiaries Residing in New York State

External Appeals

If your insurer or HMO denies health care services as not medically necessary, experimental/investigational or out-of-network, you have the right to file an appeal with DFS. This is known as an External Appeal. Health care providers also have the right to appeal when services are denied.

• Learn how to file an External Appeal.
• Search prior appeal decisions using our External Appeals Database.

Consumers in New York are protected from surprise bills when treated by an out-of-network provider at a participating hospital or ambulatory surgical center in their health plan’s network. Additionally, consumers with health insurance coverage provided by an insurer or HMO are protected from surprise bills when a participating doctor refers them to a non-participating provider. Consumers in New York are also protected from bills for emergency services in hospitals, including inpatient care following emergency room treatment.

• Learn how to protect yourself from a surprise medical bill and the patient-provider dispute resolution process.

Appointing a Designee

If you need assistance with a preauthorization request, complaint, grievance, or appeal with your health insurer, you can designate a person or persons or organization to assist you by completing the New York Standard Health Insurance Designee Form and submitting it to the address or fax number on your member identification card or by the method specified by your insurer.

• This form is available in other languages on the File a Complaint page.

Your Rights as a Health Insurance Consumer

You have many rights and protections if you have health insurance coverage through an HMO or insurer (health plan) subject to New York Law (your health insurance ID card says “fully insured”).

• Health plans must give you important information about your coverage.
• Health care providers must tell you which health plan networks they are in, and upon your request, the fees they charge if they are not in-network.
• Hospitals must tell you which health plan networks they are in and their fee information if you request it.
• Health plans must make sure that you can get the health care services you need (access to care).
• Health plans must cover emergency services in a hospital and make sure that you only have to pay your in-network copayment, coinsurance, or deductible.
• You are protected from surprise bills.
• You are protected from air ambulance bills (when covered under your policy).
• Your ID card must include information about your coverage.
• You are protected from incorrect provider directories.
• Women have coverage for preventive health care services.
• Health plans must have a grievance and utilization review process for you to appeal coverage denials.
• You have a right to an external appeal.

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

Information Your Health Plan Must Give You 

(Related Laws and Regulations: Insurance Law §§ 3217-a and 4324; Public Health Law § 4408; and 11 NYCRR § 38)

Health plans 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 a health plan if you are shopping for coverage:

Health Care Coverage:

• A description of the benefits, limits, and exclusions.
• The definition of medical necessity.
• Which health care services require you to get authorization in advance from your health plan and how to request authorization.

Your Financial Responsibility:

• Your responsibility for payment of premiums, coinsurance, copayments, and deductibles.
• Any caps on payments for services and your financial responsibility for services that aren't covered.
• Your responsibility for payment when a provider is not part of your health plan's network.
• If you have out-of-network coverage:
  • How your health plan determines the amount to pay for out-of-network services.
  • How your health plan's payment compares to the usual cost of out-of-network services.
  • Examples of costs for certain out-of-network services.
  • How you can estimate what you will have to pay for out-of-network services.

The Grievance Procedure, including:

• The right to file a grievance, including for denials of referrals or because a benefit is not covered under your contract.
• The right to file a grievance orally.
• The toll-free number to file a grievance.
• The timeframes for determinations.
• How to appeal a grievance determination.
• Your right to pick someone to help you with your grievance.

The Utilization Review Procedure when services are denied as not medically necessary, experimental or investigational, a clinical trial, a rare disease treatment, or out-of-network including:

• The toll-free number for you to use to request an appeal.
• The timeframes for determinations.
• Notice that all denials will be made by medical personnel and will include the medical reason.
• How to appeal, including the timeframes.
• Notice of your right to an independent external appeal.
• Your right to pick someone to appeal for you.

Access to Care:

• Emergency Services. How to get emergency services and that prior authorization cannot be required.
• Selecting Providers. How to get services from your health plan providers, including how to tell if a provider is accepting new patients and how to change providers.
• OB/GYN Services. Notice that you do not need a referral for obstetric and gynecologic services.
• Out-of-Network Referrals. Notice that you may get a referral to an out-of-network provider when your health plan does not have an in-network provider with the training and experience to meet your health care needs, and how to request an out-of-network referral.
• Standing Referrals. Notice that you may request a standing referral to a specialist if you need ongoing care.
• Provider Directory. The provider directory must be posted on your health plan’s website and must include the following information:  
  • A listing by specialty, of the name, address, telephone number, and contact information of all in-network providers and facilities, and whether the provider is accepting new patients. 
  • In the case of physicians, the listing must also include board certification information, languages spoken, and any affiliations with in-network hospitals. 
  • In the case of mental health and substance-related and addictive disorder providers, the listing must include:
    • Affiliations with in-network facilities certified or authorized by the NYS Office of Mental Health (OMH) or the Office of Addiction Services and Supports (OASAS). 
    • Restrictions on the availability of the provider’s services. For example, if there is an age limit on the patients the behavioral health provider treats or any limits on the behavioral health conditions the provider treats.
    • If the behavioral health provider is a facility, the listing must include the level of care offered by the facility including inpatient, outpatient, partial hospitalization, and intensive outpatient programs. 
    • The city/town where the behavioral health provider is located.
    • Whether the behavioral health provider offers telehealth services.
    • If the behavioral health provider is a health care professional, the listing must include languages spoken by the health care professional. 

Contacting Your Health Plan:

• Your health plan must give you its address and telephone number.
• Your health plan must describe how you can submit a claim for health care services. Health plans must accept claims submitted online, by email, or by fax.
• 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 its policies.

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

• Officers and Directors. The names, addresses, and positions of the board of directors and officers of your health plan.
• Financial Statement. Your health plan's most recent annual financial statement.
• Individual Policies / Contracts. The most recent individual health insurance policies.
• Complaints. Information about consumer complaints.
• Confidentiality. How your health plan protects the confidentiality of medical records.
• Drug Formularies. Drug formularies used by your health plan, including whether individual drugs are covered.
• Quality Assurance. A description of your health plan's quality assurance program, if any.
• Experimental or Investigational. How decisions are made that a treatment is experimental or investigational.
• Hospital Affiliations. Participating provider affiliations with hospitals.
• Clinical Review Criteria. Clinical review criteria relating to a particular disease.
• Provider Applications. The application procedures and necessary qualifications for providers to participate in your health plan's network.
• Provider Network Status. Whether a certain provider is in-network.
• Out-of-Network Payment. The approximate dollar amount your health plan will pay for an out-of-network service.

Information Your Doctor and Other Health Care Providers Must Give You

(Related Laws: Public Health Law § 24)

Doctors and other providers must give you information about which health plan networks they are in, the amount they will charge you for services, the hospitals where they could admit you, and the other providers they may schedule to treat you. See Information Your Doctor and Other Health Care Professionals Must Give You.

Information Your Hospital Must Give You 

(Related Laws: Public Health Law § 24)

Hospitals must post on their websites: Their charges or how to get the information, which health plan networks they are in, and information about the doctors that could treat you in the hospital.

Hospitals must, in registration or admission materials that they give you before non-emergency hospital services: Tell you to check with your doctor arranging your hospital services to find out if your doctor is scheduling other providers to treat you and how to find out if they are in-network. See Information Your Hospital Must Give You. 

Access to Care 

(Related Laws: Insurance Law §§ 3217-a, 3217-b, 3217-d, 3241, 4306-c, 4324, 4325, and 4804 and Public Health Law §§ 4403 and 4408)

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

• You may get a referral or authorization to an out-of-network provider when your health plan does not have an in-network provider with the appropriate training and experience to meet your health care needs. This will be at no additional cost beyond what you would pay to see an in-network provider.
• Contact your health plan for information on how to get a referral or authorization to an out-of-network provider. 

Choice of Primary Care Doctor:

• If you have health insurance coverage that requires you to pick a primary care provider (PCP), you can pick any available in-network PCP.
• If you have a life-threatening or degenerative and disabling condition and you need ongoing specialty care, you may request that your specialist coordinate your care, instead of your PCP. Health plans that require referrals must have procedures to allow you to make this request.

Specialty Care:

• You have the right to request a standing referral to a specialist or specialty care center if you require ongoing specialty treatment and your health plan requires referrals.

When Your Provider Is Not In Your New Health Plan’s Network:

• If you enroll in a new health plan and your provider is not in-network, you may continue a course of treatment with your provider for up to 90 days, or through your pregnancy and postpartum care directly related to the delivery if you are pregnant, if your provider agrees to accept reimbursement from your health plan as payment in full. You only have to pay your in-network cost-sharing (copayment, coinsurance, and deductible).

When Your Provider Leaves Your Health Plan's Network:

• If your provider leaves your health plan’s network, you may continue a course of treatment for up to 90 days or through your pregnancy and postpartum care directly related to the delivery if you are pregnant. You only have to pay your in-network cost-sharing (copayment, coinsurance, and deductible). Your provider must accept reimbursement from your health plan at the previously agreed to rate as payment in full, except for your in-network cost-sharing (copayment, coinsurance, and deductible).  

Network Adequacy:

• Health plans must have a network of providers adequate to meet the needs of members.

Gag Clauses:

• Health plans may not prohibit your doctor from discussing all treatments for a medical condition with you.

Emergency Care

(Related Laws: Insurance Law §§ 3216, 3221, 3241(c), 4303, 4900, 4902, and 4905; Financial Services Law Article 6; and Public Health Law §§ 4900, 4902, and 4905)

• Emergency Services. Your health insurance policy must cover emergency services in a hospital based on the "prudent layperson standard." This means emergency services must be covered if you have a medical or behavioral condition that is acute and includes severe pain. If you do not get immediate medical attention it will:
  • Put your health in serious jeopardy;
  • If you are pregnant, put the health of your unborn child in serious jeopardy;
  • In the case of a behavioral condition, put your health or the health of others in serious jeopardy;
  • Cause serious impairment to your bodily functions;
  • Cause serious dysfunction of a bodily organ; or
  • Cause serious disfigurement.
• No Prior Approval. Your health plan cannot require you to request prior approval for emergency services.
• Payment for Emergency Services.  You are only responsible for paying your in-network cost-sharing (copayment, coinsurance, and deductible) for out-of-network emergency services, including inpatient services that follow an emergency room visit. Let your health plan know if you receive a bill from an out-of-network provider for emergency services that is more than your in-network cost-sharing.
• Providers Must Only Bill In-Network Cost-Sharing. Your provider can only bill you for your in-network copayment, coinsurance, or deductible for emergency services, including inpatient services following an emergency room visit.

Protection from Surprise Bills for Health Care Services

(Related Laws: Financial Services Law Article 6)

You are protected from surprise bills when an out-of-network provider treats you at an in-network hospital or ambulatory surgical center or you are referred by an in-network doctor to an out-of-network provider. 

Learn more about Surprise medical bills and the New York IDR process.

Protection from Air Ambulance Bills 

(Related Laws: 42 U.S.C. §§ 300gg-112 and 300gg-135; 45 CFR § 149.440; Insurance Law §§ 3217-i and 4306-h) 

• Coverage. Air ambulance services must be covered under individual and small group health insurance policies and may be covered under large group health insurance policies (covers a group of more than 100). If your health insurance policy covers air ambulance services, you are only responsible for your in-network cost-sharing, even if the service was from an out-of-network provider. 
• If you get a denial. 
  • If your health plan denies coverage for air ambulance services as not medically necessary, you have the right to file an external appeal with the Department of Financial Services. 
  • If you think you have been wrongly denied coverage for air ambulance services by your health plan for reasons other than medical necessity, or you were billed for more than your in-network cost-sharing, you can file a complaint with DFS.

Health Insurance ID Cards

(Related Laws and Regulations: 11 NYCRR § 52.69)

Your health plan identification card (ID card) must include the following information:

• Your name, your dependents’ names, and identification numbers;
• Copayment or coinsurance amounts (if you have them) for in-network providers for: 
  • primary care office visits; 
  • specialist office visits; 
  • urgent care;
  • emergency room visits; and 
  • prescription drugs for a 30-day supply;
• Deductibles (if you have them); 
• Out-of-pocket maximum limits;
• A telephone number where you can get consumer assistance;
• The name and website of the health plan providing the coverage;
• The name of your coverage and type (e.g., POS, HMO, EPO, PPO, or fee-for-service); 
• The name of the health care provider network(s) (if there is one); 
• The name of the prescription drug formulary (if there is one); and
• The phrase “fully insured coverage” (which means your coverage follows New York law).

Protections from Provider Directory Misinformation

(Related Laws and Regulations: 11 NYCRR § 52.77)  

If you get provider directory information from your health plan that is not correct, you only have to pay your in-network cost-sharing (deductible, copayment, and coinsurance) for those services. This includes when:     

• An out-of-network provider is incorrectly listed as an in-network provider in your health plan’s online provider directory; 
• An out-of-network provider is incorrectly listed as an in-network provider in your health plan’s hard copy provider directory, and the directory was wrong when it was published; 
• Your health plan tells you in writing that a provider is in-network when the provider is not in-network when you ask for this information over the telephone; or 
• Your health plan doesn’t tell you the network status of a provider in writing within one business day of your request for this information by telephone.

Women’s Healthcare

(Related Laws: Insurance Law §§ 3216, 3217-a, 3221, 4303, 4306-b, and 4322 and Public Health Law § 4406-b)

Health insurance policies must cover the following services, and many of these services do not have cost-sharing (copayment, coinsurance, and deductible). You should check your health insurance policy for the terms and conditions of your coverage.

• OB/GYN Services. Women do not have to get a referral for OB/GYN services for annual examinations, care resulting from the annual examinations, treatment of acute gynecologic conditions, and any care related to a pregnancy. Well-woman preventive visits do not have cost-sharing.
• Bone Mineral Density. Coverage for bone mineral density measurements and testing with no cost-sharing.
• Cancer Screenings. Coverage for cervical cancer screening and breast cancer screening (mammograms, 3D mammograms, ultrasounds, MRIs, and pathology evaluations) with no cost-sharing.

• Contraceptives. Coverage for contraceptive drugs, devices, and products, although religious employers may ask for a health insurance policy without contraceptive coverage and their employees may purchase the coverage directly from the health plan. Health plans must cover these contraceptives without cost-sharing:

  • Contraceptive drugs, devices, or products;
  • Emergency Contraceptives, including over-the-counter ones;
  • Over-the-counter contraceptives;
  • Voluntary sterilizations;
  • Patient education and counseling on contraceptives; and
  • Follow-up services related to contraceptives, including management of side effects, counseling for continued adherence, and device insertion and removal.

  You can get a 12-month supply of contraceptives dispensed at the same time. 

  Your health plan doesn’t have to cover all contraceptives on their formulary so long as each different kind of drug is covered. You can ask your health plan to cover a contraceptive not on their formulary if the covered contraceptive is not available or is medically inadvisable. Your health care provider should complete a Contraceptive Exception Request Form and send it to your health insurer.

• Abortion Services. You are covered for abortion services, including prescribed drugs, with no cost-sharing. (Religious employers may ask for a health insurance policy without abortion coverage, and if so, your health plan will provide this coverage to you directly by a rider to your health insurance policy.) 
• Mastectomy Coverage. After a mastectomy, you have the right to stay in the hospital until you and your doctor decide it is medically appropriate for you to go home.
• Breast Reconstruction. Reconstructive surgery after a mastectomy on the breast or chest wall on which the mastectomy has been performed and on the other breast to produce a symmetrical appearance, breast prosthetics, and treatment of lymphedema. Breast or chest wall reconstruction surgery includes the tattooing of the nipple-areolar complex if performed by a health care professional.
• Maternity Care. You have the right to remain in the hospital for 48 hours after delivery and at least 96 hours after a Caesarean section. If you decide to leave the hospital earlier, you have the right to one home health care visit. Coverage for educational programs for new mothers in the hospital is also required. You also get coverage without cost-sharing for breastfeeding support, counseling, and supplies, including the rental or purchase of a breast pump, for the entire time you are breastfeeding.
• Infertility.  Health insurance policies must cover the infertility services as follows: 
  • Basic infertility services. These services include tests to determine the cause of infertility and  artificial insemination. 
  • Fertility Preservation. Coverage for fertility preservation services if you are having treatment or surgery that may affect your fertility (for example, chemotherapy or other cancer treatments).
  • IVF Coverage for Large Groups. Large group coverage (covers a group of more than 100) must cover three (3) IVF cycles.
  • No Discrimination. When deciding when to cover infertility benefits, health plans cannot discriminate based on your expected length of life, present or predicted disability, degree of medical dependency, perceived quality of life or other health conditions, or personal characteristics, including age, sex, sexual orientation, marital status, or gender identity.

Appealing Decisions by HMOs and Insurers 

(Related Laws: Insurance Law §§ 3217-d(a), 4306-c(a), 4802, and Article 49 and Public Health Law § 4408-a and Article 49)

Health insurance policies must have a grievance procedure (for contractual denials) and a utilization review procedure (for medical denials) for you to use to appeal your health plan’s determination.

Grievance Procedure

• A Grievance Is a Complaint You Send to Your Health Plan when:
  • Your health plan denies a benefit because it is not covered under your health insurance policy for other than medical necessity reasons.
  • You are denied a referral to a requested provider.
  • You have a complaint about any plan determination other than a medical necessity, experimental or investigational treatment, clinical trial, or rare disease treatment for which the utilization review procedure is used.
• File By Phone. You have the right to file grievances by phone for benefit determinations or referrals, and health plans must have a toll-free hotline for grievance calls.
• Timeframe For You To Send A Grievance. You have 180 days to send a grievance to your health plan from the date of the denial or decision.
• Timeframes For Grievance Decisions. Your health plan must make a decision upon receipt of your grievance or grievance appeal in the following timeframes:
  • Urgent. The earlier of 48-hours of receipt of necessary information or 72 hours of receipt of the grievance. For an appeal, the earlier of 2 business days of receipt of necessary information or 72 hours of receipt of the appeal.   
  • Pre-Service. 15 calendar days if you didn't receive the care yet.
  • Post-Service. 30 calendar days if you received the care.
  • All Others.  45 calendar days of receipt of necessary information. If an appeal, 30 business days of receipt of information.
• Grievances for Out-of-Network Service Denials. You may have your grievance for an out-of-network service treated as a medical denial (utilization review appeal) with a right to an independent external review if:
  • Your health plan said the out-of-network service is not materially different from a service that can be provided in-network; and
  • Your doctor submits a written statement to your health plan that the out-of-network service is materially different from the health service your health plan approved; and
  • Your doctor provides two documents of medical evidence that: (1) the out-of-network service is likely to be more clinically beneficial to you than the in-network service your health plan recommended; and (2) the risk would not be increased over the in-network health service.
• Grievances for Out-of-Network Referral Denials. You may have your grievance for a referral to an out-of-network provider treated as a medical denial (utilization review appeal) with a right to an independent external review if:
  • You requested a referral to an out-of-network provider because your health plan did not have an in-network provider with the training and experience to meet your health care needs who is able to provide the requested health care service; and
  • Your doctor submits a written statement to your health plan that the in-network providers recommended by your health plan do not have the training and experience to meet your health care needs; and
  • Your doctor recommends an out-of-network provider with the appropriate training and experience to meet your health care needs who is able to provide the requested service.
  • Learn how to file an External Appeal.

Utilization Review Procedure 

The utilization review procedure applies when your health plan decides that your health care services are not medically necessary, experimental or investigational, a clinical trial, a rare disease treatment, or when you receive a formulary exception denial, or when you appeal a denial of an out-of-network service or referral (utilization review decisions).

• Timeframes For Utilization Review Decisions. Your health plan must make decisions in the following timeframes:
• Urgent. Within 72 hours.
  • Pre-Service. Generally, within 3 business days for care you have not received yet. If your health plan needs information, it must ask for it within 3 business days. You and your provider have 45 calendar days to send the information. Your health plan must make a decision within 3 business days of receiving the information or 15 calendar days after the end of time you had to send the information.
  • Concurrent. Generally, within 1 business day for care you are currently receiving. If your health plan needs information, it must ask for it within 1 business day. You and your provider have 45 calendar days to send the information. Your health plan must make a decision within 1 business day of receiving the information or 15 days after the end of time you had to send the information.
  • Post-Service. Generally, within 30 calendar days for care you received. If your health plan needs information, it must ask for it within 30 calendar days. You and your provider have 45 calendar days to send the information. Your health plan must make a decision within 15 calendar days of receiving the information or within 15 calendar days after the end of time you had to send the information.
• Clinical Peer Reviewers. You have the right to have a medical necessity denial (including denials because a service is experimental or investigational, a clinical trial, or a rare disease treatment) made by medical professionals.
• Timeframe For You to Appeal A Utilization Review Denial. You have 180 days to appeal a utilization review denial with your health plan from the date of denial.
• Timeframes For Utilization Review Appeal Decisions. When you appeal, your health plan must make utilization review appeal decisions in the following timeframes:
  • Urgent. Within the earlier of 2 business days of receipt of the information or 72 hours of receipt of the appeal.
  • Pre-Service. Within 30 calendar days if one level of appeal and 15 calendar days if two levels of appeal.
  • Post-Service. Within the earlier of 30 calendar days of receipt of the necessary information or 60 calendar days of receipt of the appeal if one level of appeal and 30 calendar days of receipt of the appeal if two levels of appeal.

Right To External Appeal 

You have a right to an external appeal if your health plan upholds one of the following denials. You must submit an external appeal application within 4 months of the denial. 

• Medical necessity. 
• An experimental or investigational treatment.
• A clinical trial.
• A rare disease treatment. 
• An out-of-network service (if your doctor submitted the required information to your health plan).
• An out-of-network referral (if your doctor submitted the required information to your health plan).
• A formulary exception request.
• The out-of-network emergency service was not an emergency.
• The out-of-network service was not a surprise bill   
• Incorrect cost-sharing was applied to your bill for either emergency services or a surprise bill.
• There is a question about whether the claim for out-of-network care you received was coded correctly by the provider and reflects the treatment you received and the protections related to cost-sharing and surprise billing.

Learn how to file an External Appeal.

Asking a Representative to Help You with Health Insurance Authorizations, Complaints, Grievances, and Appeals 

If you need help with a preauthorization request, complaint, grievance, or appeal with your health insurer, you can designate a person or organization to help you by completing the New York State Standard Form to Designate a Representative to Assist with Health Insurance Authorizations, Complaints, Grievances, and Appeals form and submitting it to the address or fax number on your member ID card or other method permitted by your insurer.

Health Care Provider Rights and Responsibilities

(Insurance Law §§ 3217-b, 3224-a, 3224-b, 3241, 4325, and 4803 and Public Health Law §§ 23, 24, 4403, 4406-c, and 4406-d)

The New York Insurance Law and Public Health Law include important protections for health care providers with respect to network participation, provider contracting, claims processing, prompt payment for health care services, and dispute resolution for surprise bills and bills for emergency services in relation to HMOs and insurers subject to these laws (health plans). The Public Health Law also includes disclosure requirements for health care providers. 

Participation in a Health Plan’s Network

Any Willing Provider. New York does not have a willing provider law, and HMOs and insurers are not required to accept any provider who wishes to join their network.

Network Adequacy. HMOs and insurers must maintain a provider network that is sufficient to meet the health needs of insureds and provide an appropriate choice of providers.

Network Application and Qualification. HMOs and insurers must make available, upon request, written application procedures and minimum qualification requirements that a health care professional or health care facility must meet to be considered for participation in the health plan's network.

Credentialing of Providers. HMOs and insurers must complete review of a health care professional's or health care facility’s application to participate in their network within 60 days.

Notification. HMOs and insurers must notify a health care professional or health care facility as to whether or not the health care professional or health care facility is credentialed, or if additional time is needed because the health plan is waiting for additional information from a third party. The HMO and insurer must make every effort to obtain the information as soon as possible.

Timeframe. If an incomplete health care professional application is received, or if the HMO or insurer offering a managed care plan is not currently accepting additional health care professionals of the applicant's type, the health plan should respond to the health care professional with such notice as soon as possible, but no later than  60 days from receipt of the application.

Provisionally Credentialed Health Care Professionals Joining a Group Practice. A health care professional who is newly licensed or has relocated to New York and has not previously practiced in New York can be "provisionally credentialed" if the health care professional joins a group practice of health care professionals that participates with an HMO or insurer, submits a completed credentialing application, and does not receive a response to the application within 60 days. The provisionally credentialed health care professional is considered a participating provider as of the day following the 60th day of the health plan's receipt of the completed application and until the health plan issues a determination on the credentialing application. The group practice must notify the health plan in writing that if the credentialing application is denied, the group practice or the health care professional will: (1) refund any payments made for in-network services that exceed the insured's out-of-network benefits; and (2) not pursue the insured for any payments that exceed the insured's in-network cost-sharing.

• The provisionally credentialed health care professional may not be designated as a primary care physician until he or she is fully credentialed.
• Interest and penalties under the Prompt Pay Law do not apply to claim denials submitted during the provisionally credentialed period, but nothing prevents a health plan from paying a claim for a provisionally credentialed health care professional.
• A health plan may not deny a claim upon appeal for services provided by a provisionally credentialed health care professional solely based on the ground that the claim was not timely filed.

Provisionally Credentialed Physicians Employed by Facilities. For physician credentialing applications, a physician who is:

• newly licensed or has relocated to New York and has not previously practiced in New York; OR
• has changed his or her corporate relationship so that it results in a new tax ID number and who previously had a participating provider agreement with the HMO or insurer immediately prior to the change;

AND the physician becomes employed by a general hospital or diagnostic treatment center licensed under Public Health Law Article 28, or a facility licensed under Mental Hygiene Law Articles 16, 31, or 32 that participates with a health plan and whose other employed physicians participate with the health plan, can be "provisionally credentialed” upon the health plan’s receipt of the physician’s and facility’s completed portions of the health plan’s credentialing application and the health plan being notified in writing that the physician has been granted hospital privileges.

• The health plan must pay the facility once the physician is fully credentialed with the health plan for the services provided by the provisionally credentialed physician for up to 60 days after the completed application is submitted.
• If the physician is not credentialed, the health plan is not responsible for paying for the services. The facility is not permitted to pursue reimbursement from the insured except to collect the in-network copayment, coinsurance, or deductible.
• The provisionally credentialed physician may not be designated as a primary care physician until he or she is fully credentialed.

Provider Contract Provisions

Required Provider Contract Provisions. HMOs and insurers must include the following items in participating provider contracts:

• Payment Calculation. The method by which payments to the provider will be calculated, including any retrospective or prospective adjustments;
• Time Periods. The time periods within which calculations will be completed, the dates payments and adjustments will be due, and the dates upon which payments and adjustments will be made;
• Information Relied Upon. A description of the information relied upon to calculate payments or adjustments, and how a provider can access a summary of the calculations or adjustments;
• Dispute Process. The process to resolve disputed, incorrect, or incomplete information, and the process to adjust payments that were made using the incorrect or incomplete information; and
• Arbitration. The right of either party to seek arbitration under Article 75 of the Civil Practice Laws and Rules for disputes regarding payment terms of the contract.
• Provider Directory. A requirement for the provider to have in place business processes to ensure the timely provision of provider directory information to the HMO and insurer when the provider begins or terminates a network agreement or when there are changes to the provider’s information. 
• Reimbursement to Insureds. A requirement for the provider to reimburse the insured for amounts over the in-network cost-sharing when the HMO or insurer provides the insured with inaccurate network status information that the provider is in-network.   

Liability. HMOs and insurers cannot transfer liability to the provider (other than a medical group for HMOs) for activities, actions, or omissions of the health plan.     

Financial Risk. HMOs and insurers cannot transfer financial risk to providers in a manner inconsistent with Public Health Law § 4403(1)(c) or penalize providers for an unfavorable case mix so as to jeopardize the quality of, or the insured's appropriate access to, medically necessary services.

Adverse Reimbursement Change. HMOs and insurers must give health care professionals at least 90 days written notice before implementing a contract change that could have a material adverse impact on the health care professional’s aggregate level of payment, unless such change is otherwise required by law or required because of changes in fee schedules, reimbursement methodology, or payment policies established by a government agency or the American Medical Association's current procedural terminology (CPT) codes, reporting guidelines and conventions, or is expressly provided under the terms of the contract. If the health care professional objects to the change, the health care professional may give written notice to terminate the contract within 30 days of the date of notice of the change, and termination will be effective on the implementation date of the change.

Hospital Emergency Admissions. HMOs and insurers are not permitted to deny payment to a hospital for a claim for medically necessary inpatient services resulting from an emergency admission solely because the hospital did not timely notify the health plan that the services had been provided. HMOs, insurers, and hospitals may agree to requirements for timely notification of medically necessary inpatient services resulting from an emergency admission and to reduction in payment for failure to timely notify, provided that:

• Any requirement for timely notification provides for a reasonable extension of timeframes for emergency services provided on weekends or federal holidays;
• Any agreed to reduction in payment for failure to timely notify does not exceed $2,000 or 12% of the payment amount due for the services, whichever is less; and
• Any agreed to reduction in payment for failure to timely notify shall not be imposed if the hospital could not determine, after reasonable efforts, the patient's insurance coverage at the time the inpatient services were provided.

Termination and Non-Renewal of Provider Contracts with Health Care Professionals

Explanation of Reasons. HMOs and insurers cannot terminate a contract with an in-network health care professional licensed, registered, or certified pursuant to Education Law Title 8 unless the health plan gives the health care professional a written explanation of the reasons for the proposed contract termination and an opportunity for a review or hearing. This requirement does not apply in cases of imminent harm to patient care, a determination of fraud, or a final disciplinary action by a state licensing board that impairs the provider's ability to practice.

Notice Requirements. HMOs and insurers must include the following in a notice of a proposed contract termination:

• The reasons for the proposed action;
• Notice that the health care professional has the right to request a hearing or review, at the health care professional's discretion, before a panel appointed by the health plan;
• A time limit of not less than 30 days within which the health care professional may request the hearing; and
• A time limit for a hearing date which must be held within not less than 30 days after the date the hearing was requested.

Hearings. HMOs and insurers must adhere to the following requirements with respect to any hearing:

The hearing panel must be made up of three persons appointed by the health plan. At least one member of the panel must be a clinical peer reviewer in the same discipline and the same or similar specialty as the health care professional under review. The panel may consist of more than three persons however one third must be clinical peers.

The hearing panel must render a timely decision. Decisions must include reinstatement of the health care professional, provisional reinstatement of the health care professional subject to conditions, or termination. Decisions must be in writing.

A hearing panel's decision to terminate the health care professional will be effective at least 30 days after the health care professional receives the decision. However, the termination cannot be effective earlier than 60 days from the receipt of the notice of termination.

Non-renewal of a Participating Provider Contract. Either the health plan or the health care professional may exercise the right of non-renewal at the expiration of the provider contract. If no express expiration date is given, either the health care professional or the health plan can exercise the right of non-renewal each January 1st (after the contract has been in effect for a year) upon 60 days’ notice to the other party. A non-renewal is not considered a termination, and no appeal rights are granted.

Termination and Non-Renewal of Hospital Contracts

Cooling-Off Period. If a contract between an HMO or insurer and a hospital is not renewed or is terminated by either party, the parties must continue to abide by the terms of the contract for two months from the date of termination or, in the case of a non-renewal, from the end of the contract period. Within 15 days after the commencement of the two-month period, the HMO or insurer must provide notice to all potentially affected insureds. This requirement does not apply when both parties mutually agree in writing to the termination or non-renewal and the HMO or insurer provides notice to insureds at least 30 days before the termination. The Department of Health can also waive the two-month period upon the request of either party to a contract that is being terminated for cause.

Performance and Practice Information

Evaluation Information. HMOs and insurers must develop policies and procedures to ensure that participating health care professionals are regularly informed of the information maintained by the health plan to evaluate the performance or practice of health care professionals.

Provider Profiling. HMOs and insurers must consult with health care professionals when developing methodologies to collect and analyze provider profiling data.

Profiling Data. Any profiling data used by an HMO or insurer to evaluate health care professionals must be measured against stated criteria and an appropriate group of participating health care professionals using similar treatment modalities serving comparable patient populations.

Opportunity to Discuss. Health care professionals must be given the opportunity to discuss the unique nature of the health care professional's patient population which may have a bearing on the provider's profile and to work cooperatively with the HMO or insurer to improve the health care professional's performance.

Impermissible Termination. No HMO or insurer may terminate or refuse to renew a participating health care professional's contract solely because the health care professional has:

• Advocated on behalf of a patient.
• Filed a complaint against the health plan.
• Appealed a decision of the health plan.
• Provided information or filed a report with an appropriate government body regarding the health plan's actions.

Reasons for Termination. No participating health care professional contract with an HMO or insurer may contain provisions which supersede or impair the health care professional's right to a notice of reasons for the termination and an opportunity for a hearing.

Patient Care and Treatment 

Treatment Information. HMOs and insurers cannot restrict a provider from telling their patient:

• All treatments available for the patient's condition, including treatments that may not be covered by the health plan.
• The provisions or terms of the patient's health plan as they relate to the patient.

Filing Complaints. HMOs and insurers cannot restrict a provider from filing a complaint to an appropriate governmental body regarding policies or procedures the provider believes may negatively impact the quality of care or access to care.

Patient Advocacy. HMOs and insurers cannot prohibit or restrict a provider from advocating on behalf of a patient for coverage of a particular treatment.

Claims Processing

Accept Claims. HMOs and insurers must accept and initiate the processing of all health care claims submitted by physicians that are consistent with the current version of the American Medical Association's Current Procedural Terminology (CPT) codes, reporting guidelines and conventions, and the centers for Medicare and Medicaid services (CMS) health care common procedure coding system (HCPCS).

Claims Software. HMOs and insurers must provide the name of the commercially available claims editing software product that the health plan utilizes and any significant edits on their provider websites and in provider newsletters. Health plans must also provide such information upon the written request of a participating physician.

Claim Submission. HMOs and insurers must accept claims submitted in writing, including through the internet, by e-mail, or by fax.

Prompt Payment of Health Care Claims

Time to File Claims. Providers must submit health care claims within 120 days after the date of service for the claims to be valid and enforceable against HMOs and insurers, unless the parties agree to a time period that is more favorable to the provider. (However, providers may agree to submit claims within 90 days after the date of service for Medicaid managed care plans and Child Health Plus coverage.)

Promptly Pay Claims. HMOs and insurers must pay claims for health care services within 30 days of receipt if the claims are submitted through the internet or by e-mail and within 45 days of receipt if the claims are submitted on paper or by fax, except in cases where the obligation to make payment is not reasonably clear or there is evidence that the bill may be fraudulent.

Obligation To Pay. If the obligation to pay is not reasonably clear, an HMO or insurer must pay any undisputed portion of the claim and either notify the insured or provider, in writing, within 30 calendar days of the receipt of the claim that the health plan is not obligated to pay and the reasons, or request additional information needed to determine liability to pay the claim or make the payment.

Timeframe. Upon receipt of the information requested, or an appeal of a claim for the denied health care services, an HMO or insurer must comply with the 30 or 45-day requirement for clean claims.

Reconsideration. Participating health care providers may request reconsideration of a claim that is denied solely because it was untimely submitted. If the provider can demonstrate that his or her non-compliance was a result of an unusual occurrence and that he or she has a pattern or practice of timely submitting claims, the HMO or insurer must pay such claim, but may reduce the reimbursement due by up to 25% of what the HMO or insurer would have paid had the claim been timely submitted.

Hospital Claims. Within 30 days of receipt of payment of a claim for which payment has been adjusted based on a particular coding to a patient, a hospital has the opportunity to submit the affected claim with medical records supporting the hospital's initial coding of the claim (unless the hospital has a mutually agreed upon process with the HMO or insurer). Upon receipt, the HMO or insurer must review such information to ascertain the correct coding for payment and process the claim in accordance with the 30 or 45-day prompt payment timeframes. If the HMO or insurer processes the claim consistent with its initial determination, it must provide a statement with the decision explaining why the initial adjustment was appropriate. If the HMO or insurer increases the payment based on the information submitted by the hospital, but fails to do so within the required timeframes, it must pay interest on the amount of such increase at the rate set by the commissioner of taxation and finance for corporate taxes, computed from the end of the 45-day period after resubmission of the additional medical record information.

Violation. Each claim or bill processed after the 30 or 45-day prompt payment time period is a separate violation.

Payment of Interest. For any violation of the prompt payment law, interest is due. Interest is calculated as the greater of 12% per annum or the rate set by the commissioner of taxation and finance for corporate taxes pursuant to New York Tax Law § 1096(e)(1). Interest is calculated from the date the claim or health care payment was required to be made. When the amount of interest due is less than two dollars, the HMO or insurer is not required to pay the interest.

File a Prompt Payment Complaint

The Department of Financial Services investigates complaints involving licensed insurance entities. 

Before contacting us regarding a potential prompt pay violation, please do the following:

• Contact the insurer or HMO to verify that the claim was received.
• Determine the type of coverage. If the patient is covered by a self-funded plan or Medicare, DFS lacks jurisdiction to assist.
• Review your records to ensure the claim has not been paid or denied.
• If the insurer or HMO has requested additional documentation and you have not supplied it, the claim is not delinquent and should not be submitted as a complaint.

You can file a Prompt Pay Complaint online via the secure DFS Portal.

You will receive immediate confirmation and be assigned a file number.

You will have 30 minutes to process the complaint form. If you do not complete the form within 30 minutes, you will be prompted to refresh and the information you have entered before refreshing will be lost.

To get started, visit the DFS portal:

DFS Portal

Overpayment Recovery Efforts

Notice. Other than recovery for duplicate payments, HMOs and insurers must give providers 30 days’ notice before engaging in overpayment recovery efforts. The notice must include:

• The patient's name;
• Service date;
• Payment amount;
• Proposed adjustment; and
• A reasonably specific explanation of the proposed adjustment.

Opportunity to Challenge. HMOs and insurers must give providers the opportunity to challenge an overpayment recovery and must establish written policies and procedures for providers to follow when challenging the recovery. Any such challenge must set forth the specific grounds for the challenge.

Time Limit for Starting Overpayment Recoveries. HMOs and insurers are only permitted to initiate overpayment recovery within 24 months of the date the original payment was received by the provider, except in cases involving fraud, intentional misconduct, abusive billing, or when initiated at the request of a self-funded plan, required by a federal or state government program, or coverage that is provided by the State or a municipality to its employees, retirees, or members.

Offsets. If a provider asserts underpayment of a claim, the HMO or insurer may defend or offset the assertion by overpayments that were made within the timeframe extending as far back as to the underpayment in question. If the underpayment is confirmed, the HMO or insurer may lessen or balance the amount owed to the provider by identifying an amount the HMO or insurer overpaid to the provider from the time of the underpayment to the present. However, the HMO or insurer may not collect overpayments in excess of the provider underpayment, unless the overpayment occurred within the last 24 months or an exception applies as described above.

IDR for Emergency Services 

Patient Hold Harmless and Claim Payment. Providers must hold patients harmless for any amount that is more than the patient's in-network cost-sharing (copayment, coinsurance, and deductible) for emergency services in hospital facilities. Health plans must pay providers a reasonable amount for the service rendered or attempt to negotiate reimbursement with the provider. Providers may dispute the amount that the health plan pays through the independent dispute resolution process.

Independent Dispute Resolution (IDR) for Emergency Services. Providers have a right to IDR to dispute a health plan payment for emergency services, including payment for inpatient services following an emergency room visit.

Learn how to submit a dispute through the IDR process.

Surprise Bill Requirements for Providers

Patient Billing. An out-of-network provider is prohibited from billing a patient for any amount other than the patient's in-network cost-sharing (copayment, coinsurance, or deductible) for a surprise bill. Learn more about surprise medical bills.

Surprise Bill Certification Form. An out-of-network provider must provide a Surprise Bill Certification Form to an insured when the out-of-network provider bills the insured for a surprise bill, other than a bill for the insured’s copayment, coinsurance, or deductible. 

Independent Dispute Resolution (IDR) for Surprise Bills. Providers have a right to dispute a health plan’s payment for a surprise bill through the IDR process. Learn how to submit a dispute through the IDR process.

Disclosure of Balance Billing Protections. Providers must make publicly available (post in the provider’s public location, post on their public websites, and provide to patients) a one-page notice in clear and understandable language containing information on:

• The Federal requirements and prohibitions relating to prohibitions on balance billing for emergency services and surprise bills;
• New York requirements prohibiting balancing billing for emergency services and surprise bills; and
• Information on contacting New York and Federal agencies in case an individual believes that a provider has violated any state or federal prohibitions on balance billing for emergency services and surprise bills.

Model Disclosure Form. The Department of Financial Services has a model disclosure form that providers can use.

Health Care Professional and Physician Disclosure Requirements

When Scheduling Appointments. A health care professional, or a group practice of health care professionals, a diagnostic and treatment center, or a health center defined under 42 USC §254b on behalf of health care professionals rendering services at the group practice, diagnostic and treatment center, or health center, must disclose to patients or prospective patients the following information:

• Health Plan Participation. The health plans in which the health care professional, group practice, diagnostic and treatment center, or health center is a participating provider. This must be given in writing or through a website prior to the provision of non-emergency services and verbally at the time an appointment is scheduled.
• Hospital Affiliations. The hospitals with which the health care professional is affiliated. This must be given in writing or through a website prior to the provision of non-emergency services and verbally at the time an appointment is scheduled.
• Cost of Services. That the amount or estimated amount that the health care professional will bill the patient for health care services is available upon request if the health care professional does not participate with a patient's or prospective patient's health plan. Health care professionals must provide this information to patients prior to the provision of non-emergency services. Upon receipt of a request from a patient or prospective patient, the health care professional must disclose to the patient or prospective patient in writing the amount or estimated amount that will be billed for health care services provided or anticipated to be provided absent unforeseen medical circumstances. With respect to a health center, this may be provided in the form of a schedule of fees provided under 42 USC § 254b(k)(3)(G)(i).

Physicians Arranging Services in Office or Coordinating or Referring a Patient for Services. A physician that schedules a health care provider to perform anesthesiology, laboratory, pathology, radiology, or assistant surgeon services in connection with care to be provided in his or her office, or a physician that coordinates or refers a patient for such services, must provide a patient or prospective patient with the following at the time of referral to or coordination with such provider:

• The provider's name, if the physician schedules a specific provider in a practice.
• The provider's practice.
• The provider's address.
• The provider's telephone number.

Physicians Arranging for Inpatient or Outpatient Services in a Hospital. A physician that arranges for any other physicians to treat a patient during the patient's scheduled hospital admission or scheduled outpatient hospital services must provide the patient and the hospital at the time non-emergency services are scheduled with the following information regarding the other physicians whose services are scheduled at the time of the pre-admission testing, registration, or admission:

• The physician's name, if the physician schedules a specific physician in the practice.
• The physician's practice.
• The physician's address.
• The physician's telephone number.
• How to determine the health plans in which the physician participates.

Hospital Disclosure Requirements

Hospital Website. A hospital must post on its website:

• Charges. A list of its standard charges for items and services provided by the hospital (or how to obtain this information if the list of charges is not posted).
• Health Plan Participation. The health plans in which it is a participating provider.
• A Statement Providing the Following Information About Charges of Physicians in the Hospital:
  • That physician services provided in the hospital are not included in the hospital's charges.
  • That physicians who provide services in the hospital may or may not participate with the same health plans as the hospital.
  • That the prospective patient should check with the physician arranging for the hospital services to determine the health plans in which the physician participates.
• Physician Groups With Which the Hospital Has Contracted. The name, address, and telephone number of the physician groups that the hospital has contracted with to provide services such as anesthesiology, pathology, or radiology and instructions how to contact these groups to determine the health plan participation of the physicians in the groups.
• Physicians Employed By The Hospital. The name, address, and telephone number of physicians employed by the hospital and whose services may be provided at the hospital, and the health plans in which they participate.
• Registration or Admission Materials. A hospital must, in registration or admission materials provided prior to non-emergency hospital services, to:

Advise a Patient or Prospective Patient to Contact the Physician Arranging the Hospital Services to Determine:

• The name, practice name, address, and telephone number of any other physician whose services will be arranged by the physician.
• Whether the services of physicians who are employed or contracted by the hospital to provide services such as anesthesiology, pathology, and radiology are reasonably anticipated to be provided to the patient.

Inform Patients How to Determine Physician Network Status. Provide patients or prospective patients with information how to timely determine the health plans that physicians, who are reasonably anticipated to provide services to the patient at the hospital and who are employees of the hospital or contracted by the hospital to provide services including anesthesiology, pathology and radiology, are in network with.

The Department has the authority to investigate significant price increases for prescriptions drugs sold, offered for sale, purchased, or advertised within New York. DFS requires drug manufacturers to show a reasonable justification for sudden prescription drug price increases. As of June, 2024, DFS also requires drug manufacturers to report prescription drug price increases 60 days in advance of the effective date of the increase.

• Learn more about drug prices and what to do if you experience a significant increase or “spike” in the price of a prescription drug.
• Drug manufacturers needing to report a drug price increase, should visit the Prescription Drug Manufacturer Filings page.

Pharmacy benefit managers (PBMs) are companies that manage prescription drug benefits on behalf of health plans. PBMs must be licensed to operate in New York. DFS monitors PBM activities to address problematic practices in the industry, help lower prescription drug and health insurance costs, and protect New Yorkers who need access to medications.

• Learn more about Pharmacy Benefit Managers.

DFS shares information intended to help you make informed decisions about the need for financial protection and, should you choose to obtain long term care insurance, to help you choose a policy that will meet your individual needs.

• Understanding Long Term Care and LTC Insurance Policies

Health insurance premiums are the monthly amount that you or your employer pay to an insurance company. The insurance company collects premiums from all of its policyholders and uses that money to pay medical claims. The insurance company can also use premiums to pay for administrative expenses and to earn a profit. 

Health insurers must submit proposed rate changes to DFS. DFS then reviews the application and the insurer’s calculations to make sure that a rate increase is justified and not excessive. During review, DFS may consider comments from policyholders or the public.

DFS allows policyholders to submit comments about an insurer’s proposed premium rate increase. Insurers must also send their customers a notice about a proposed premium rate increase when they file the application with DFS. 

• Learn more about Health Insurance Premiums and Applications for Rate Increases.

Each year, New York State (via the DFS and Department of Health) receives complaints about health insurance companies from consumers and health care providers. Complaints typically involve issues related to prompt payment, reimbursement, coverage, benefits, rates and premiums. 

The following guide contains a ranking of HMOs and health insurance companies based on complaint statistics and enrollee satisfaction surveys and includes information on the number of successful appeals to independent external review agents. This Guide may help you when choosing a health insurance company and also contains telephone numbers for health insurance companies.

• 2026 New York State Consumer Guide to Health Insurers (PDF)
• See previous years' versions of the New York State Consumer Guide to Health Insurers.

If you are unable to find the answer to your questions here on our website, check our FAQs. If you still have questions, or want to file a complaint with DFS call the DFS Hotline at (800) 342-3736, Monday to Friday, from 8:30 AM to 4:30 PM or send us an email.