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Consumer Rights and Responsibilities

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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.

  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
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Related Laws: 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 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, co-payments, 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 pays 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 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 use 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 or a rare disease treatment including:

  • The toll-free number for you to use.
  • 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's 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.
  • Continued Care For New Health Plan. Notice that if you are a new health plan member and your provider does not participate, you may continue a course of treatment with the non-participating provider for up to 60 days if you have a life-threatening or disabling condition, or through your pregnancy if you are in the second trimester.
  • Continued Care When Your Provider Leaves Network. Notice that 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 if you are in the second trimester.
  • Provider Directory. Your health plan must provide a listing by specialty, of the name, address, and telephone number of all participating providers and facilities. It must also include doctor board certification information, languages spoken and any affiliations with participating hospitals. The listing must be posted on your health plan's website. The listing must be updated within 15 days of the addition or termination of a provider from your health plan's network or a change in a doctor's hospital affiliation.

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 through the internet, by e-mail, 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 & 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 Contracts. The most recent individual direct payment subscriber contracts.
  • 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.

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 (800) 206-8125; or email [email protected].

Information Your Doctor and Other Health Care Providers Must Give You
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Related Laws: Public Health Law Section 24

Providers must give patients and prospective patients the following information:

  • Health Plan Participation. The health plans in which your provider participates. This must be given in writing or through a website before you receive non-emergency services and verbally when you schedule an appointment.
  • Hospital Affiliations. The hospitals with which your provider is affiliated or that could admit you. This must be given in writing or through a website before you receive non-emergency services and verbally when you schedule an appointment.
  • Cost of Services. If your provider does not participate with your health plan, your provider must tell you the estimated amount your provider will bill you for services if you ask.
  • Providers Scheduled by Your Doctor. If your doctor schedules anesthesiology, laboratory, pathology, radiology or assistant surgeon services to be provided in your doctor's office or refers you for these services, your doctor must tell you:
    • The provider's name, if your doctor schedules a specific provider in a practice.
    • The provider's practice.
    • The provider's address.
    • The provider's telephone number.
  • When Your Doctor Schedules Your Hospitals Services. If your doctor schedules any other doctors to treat you in a hospital your doctor must tell you:
    • The doctor's name.
    • The doctor's practice.
    • The doctor's address.
    • The doctor's telephone number.
    • How to determine whether the doctor participates with your health plan.
Information Your Hospital Must Give You
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Related Laws: Public Health Law Section 24

Hospitals must post on their websites:

  • Charges. A list of their charges (or how to obtain this information if the list of charges is not posted).
  • Health Plan Participation. The health plans in which they are participating providers.
  • Information About Charges Of Doctors In The Hospital:
    • Services provided to you by doctors in the hospital are not included in the hospital's charges.
    • Doctors who provide services in the hospital may or may not participate with the same health plans as the hospital.
    • You should ask the doctor arranging your hospital services if the doctor is in your health plan's network.
    • Doctors That Could Provide Services to You. The name, address, and telephone number of the doctor 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 if they participate with your health plan.
    • Doctors Employed By The Hospital. The name, address, and telephone number of doctors employed by the hospital to treat patients and the health care plans in which they participate.

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

    Tell You To Contact Your Doctor. Tell you to check with the doctor arranging your hospital services to determine:

    • The name, practice name, address, and telephone number of any other doctor who will be arranged by your doctor to treat you.
    • Whether doctors who are employed or contracted by the hospital for services such as anesthesiology, pathology and radiology are expected to treat you.
    • How to Tell If Your Doctor Participates With Your Health Plan. Tell you how to find out whether doctors who are employees of the hospital (such as for anesthesiology, pathology and radiology) participate with your health plan.
Access to Care
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Related Laws: 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:

  • 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 particular health care needs. This will be at no additional cost beyond what would you pay to see an in-network provider.
  • Contact your health plan to receive information on how to obtain 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 Does Not Participate With Your Health Plan:

  • If you enroll in a new health plan and your provider does not participate, you may continue a course of treatment with the non-participating provider for up to 60 days if you have a life-threatening or disabling condition, or through your pregnancy if you are in the second trimester. Your provider must agree to accept reimbursement from your health plan as payment in full.

When Your Provider Leaves Your Health Plan's Network:

  • If your provider leaves the network of your health plan, you may continue a course of treatment for up to 90 days or through your pregnancy if you are in the second trimester. Your provider must agree to accept reimbursement from your health plan at the previously agreed to rate.

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.

If your HMO is not following these access to care requirements, you should submit a complaint to the New York State Department of Health, Office of Health Insurance Programs, Consumer Services Complaint Unit, Corning Tower - OCP Room 1609, Albany, New York 12237; or call (800) 206-8125; or email [email protected].

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

  • Definition of Emergency Condition. 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 that is acute and includes severe pain.
    • You expect that 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 that you seek prior approval for emergency care.
  • Hold Harmless. Your health plan must protect you from bills for out-of-network emergency services in a hospital if you have coverage through an HMO or insurer subject to NY law (coverage that is not self-insured). You do not have to pay non-participating provider charges for emergency services (typically for services in a hospital emergency room) that are more than your in-network copayment, coinsurance or deductible (this protection may only apply when your health insurance coverage renews after March 31, 2015). Let your health plan know if you receive a bill from a non-participating provider for emergency services.
  • If You Are Uninsured or Have Employer or Union Self-insured Coverage. You may be able to file a dispute through the independent dispute resolution process if you do not have HMO or insurance coverage that is subject to New York Law (for example, if you are uninsured or your employer or union self-insures) and you receive a bill from a doctor for emergency services provided on and after March 31, 2015 in New York that you believe is excessive.
Protection from Surprise Bills for Health Care Services
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Related Laws: 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).

Protect Yourself From A Surprise Bill.

When You Receive Services From A Non-Participating Doctor At A Participating Hospital Or Ambulatory Surgical Center, the Bill You Receive For Those Services Will Be A Surprise Bill If:

  • A participating doctor was not available; or
  • A non-participating doctor provided services without your knowledge; or
  • Unforeseen medical circumstances arose at the time the health care services were provided.
  • It will not be a surprise bill if you chose to receive services from a non-participating doctor instead of from an available participating doctor.

When You Are Referred By Your Participating Doctor To A Non-Participating Provider, the Bill You Receive For Those Services Will Be A Surprise Bill If you did not sign a written consent that you knew the services would be out-of-network and would result in costs not covered by your health plan. A referral to a non-participating provider occurs when:

  • During the course of a visit with your participating doctor, a non-participating provider treats you; or
  • Your participating doctor takes a specimen from you in the office (for example, blood) and sends it to a non-participating laboratory or pathologist; or
  • For any other health care services when referrals are required under your plan.
Women's Healthcare
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(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.)

  • 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.
  • Bone Mineral Density. Coverage for bone mineral density measurements and testing.
  • Cancer Screenings. Coverage for cervical cancer screening and breast cancer screening (mammograms).
  • Contraceptives. Coverage for contraceptive drugs and devices (if prescription drugs are covered), although religious employers may request a contract without contraceptive coverage and their employees may purchase the coverage directly from the health plan.
  • Mastectomy Coverage. Coverage for a mastectomy. After a mastectomy, a woman has the right to stay in the hospital until she and her doctor decide it is medically appropriate for her to go home.
  • Breast Reconstruction. 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, breast prosthetics, and treatment of lymphedemas.
  • Maternity Care. A new mother 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.
  • Infertility. 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).
Appealing Decisions by HMOs and Insurers
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Related Laws: 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

  • A Grievance Is a Complaint You Send to Your Health Plan when:
    • A benefit is denied because it is not covered under your health insurance contract for other than medical necessity reasons.
    • You are denied a referral to a requested provider.
    • You have a complaint concerning 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 to be used.
  • File By Phone. You have the right to file grievances by phone for benefit determinations or referrals, and health plans are required to 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 denial or decision.
  • Timeframes For Grievance Decisions. Your health plan is required to make a decision upon receipt of your grievance or grievance appeal in the following timeframes:
    • Urgent. 72 hours for urgent care.
    • Pre-Service. 15 days if you didn't receive the care yet.
    • Post-Service. 30 days if you received the care.
    • All Others. 60 days (or 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) and subject 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 the 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) and subject 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.

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).

Timeframes For Utilization Review Decisions. Your health plan is required to 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 days to send the information. Your health plan must make a decision within 3 business days of receiving the information or 15 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 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 days for care you received. If your health plan needs information, it must ask for it within 30 days. You and your provider have 45 days to send the information. Your health plan must make a decision within 15 days of receiving the information or within 15 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 is required to make utilization review appeal decisions in the following timeframes:
    • Urgent. Within 72 hours.
    • Pre-Service. Within 30 days if one level of appeal and 15 days if two levels of appeal.
    • Post-Service. Within 60 days if one level of appeal and 30 days if two levels of appeal.

    Right To External Appeal. If your health plan upholds a denial based on 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), or an out-of-network referral (if your doctor submitted the required information to your health plan) you have a right to an external appeal.