Your Rights as a Health Insurance Consumer

As a health insurance consumer in New York State, you have the tools you need to make informed decisions about your health care and you have the power to challenge decisions made by New York HMOs and health insurers.

As a consumer in New York State, you have the right to obtain basic information about your plan, to receive quality care and appeal denials of service and claims, and to have your claims paid in a timely manner.

Obtaining Information

• You have the right to obtain a comprehensive description of the health services covered by your HMO or insurer.
• You have the right to know whether or not you need prior authorization for medical treatment. For example, you have the right to know if prior approval is needed for the following: hospital admissions, surgery, mental health and substance abuse treatment, diagnostic tests, chiropractic services and physical therapy.
• You have the right to know exactly what you need to do in order to get a referral to a specialist.
• You have the right to know how much you are required to pay when you visit a participating provider and a non-participating provider. For example, your contract may require you to pay a $10 co-payment every time you see an in-network doctor and a higher amount if you go outside your network.
• You have the right to know your HMO’s or insurer’s procedures for protecting the confidentiality of your medical records and other sensitive information.
• You have the right to know what you need to do in order to file grievances or appeals with your HMO or health insurer.
• You have the right to know your plan’s procedures in making decisions about the experimental nature of drugs and medical treatments.
• You have the right to know about the types of methodology your plan uses to reimburse particular types of health care providers or services. For instance, you have the right to know whether or not providers are paid per visit or per patient.
• You have the right to know the names of the chief officers, board members, and HMO owners. Salary information is filed annually with the State Insurance Department.

Receiving Prompt Quality Care

• You have the right to access emergency services 24 hours a day. By law, a situation is considered to be an "emergency" if a prudent layperson believes that failing to act immediately would put your health or the health of others in danger.
• You have the right to an adequate network of primary doctors and medical specialists as part of the services provided by your HMO.
• If you have a chronic or disabling condition, you have the right to request a standing referral for a specialist so that you don’t have to get prior approval from the primary care physician each time you need to see the specialist.
• If you are in the second trimester of your pregnancy or have a life threatening, degenerative, or disabling condition or disease and have just enrolled in a new plan, you have the right to continue seeing your current provider for 60 days. You also have the right to continue seeing your current provider for the duration of post-partum care related to your delivery. In these cases, your non-participating provider must agree to the terms of your plan.
• You or the provider have the right to be paid within 45 days of your health insurer's or HMO's receipt of the claim unless additional information on the claim is needed.

To help you contact health plans, the Insurance Department has a Company Directory on our Web site. Select this link for our Company Directory where you can get a list of licensed Health Insurance Companies.

Appealing Decisions by HMOs and Insurers

HMOs and insurers with a managed care contract are required to have a grievance procedure. A grievance can be filed for any determination other than a determination that the services in question are experimental/investigational or not medical necessity.

• You have the right to file a grievance if you are denied a referral, you are denied coverage because a benefit is determined not to be covered under your subscriber contract, or if you have a complaint concerning any plan determination (other than a determination that the services in question are experimental/investigational or not medical necessity).

  Examples of complaints concerning covered benefit determinations and access to referrals that could be challenged through the grievance procedure include but are not limited to the following:

  • You are denied a referral to a specialist or other provider
  • You are denied coverage for failure to obtain a referral or pre-authorization
  • You are denied coverage or receive only partial coverage for a prescription drug
  • You are required to pay a specialist fee beyond the standard co-pay
  • You are denied a referral outside the HMO’s network of physicians
  • You are not reimbursed for treatments rendered when you are out of New York State
  • You are denied coverage or coverage is limited for services covered under your subscriber contract which could include mental health, substance abuse or physical therapy treatment
  
  
• You have the right to file grievances by phone concerning benefit determinations or referrals and plans are required to have a toll free hotline for grievance calls.
• You have the right to have any grievance where a delay would increase the risk to your health, such as coverage for surgery, decided within 48 hours to ensure that your health is not jeopardized.
• You have the right to have other grievances decided within 30 or 45 days of receipt of all necessary information (depending on the type of grievance).

You can also appeal any denial of care that your HMO or insurer has decided is not medically necessary, experimental or investigational.

• You have the right to have denials of care concerning whether or not a procedure is medically necessary or experimental made by clinical reviewers, not administrative reviewers to ensure that these decisions are made in the best interest of your health.
  
• You have the right to appeal a utilization review determination on an expedited basis if you are undergoing a course of treatment or your health care provider believes an immediate appeal is warranted. Expedited appeals must be decided within two business days.

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

• Hospital admission
• Magnetic Resonance Imaging (MRI) examination or other diagnostic tests
• Emergency room treatment
• Deviated septum repair
• Growth hormone treatment
• Knee replacement surgery
• Prosthetic devices such as computerized artificial limbs or Durable Medical Equipment such as motorized wheelchairs.
• Biopsy
• Continued therapy including physical therapy and mental health visits

Examples of procedures and services that could be challenged for reasons relating to experimental/investigational include but are not limited to:

• Stem cell transplant
• Artificial disk replacement
• Botox injections for migraine headaches

Consumers who are unable to resolve problems with their HMOs and insurers can file complaints with the New York State Insurance Department. Select this link to learn how to file a complaint.

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

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