Consumer Frequently Asked Questions
What is a pre-existing condition and can it be excluded from my health coverage?
Answer: A pre-existing condition is any condition for which a person received treatment or treatment was recommended within the preceding six months.
Any individual enrolling in a new health plan covered by NYS law may be subject to up to a 12 month waiting period (six months for Medicare Supplement policy holders) before expenses related to the pre-existing condition are covered. However, the plan must subtract from the waiting period the time that the person had continuous coverage in a previous plan. Continuous coverage means that the person had less than a sixty three day gap between coverages. The insurer shall count a period of creditable coverage for all benefits or may elect to credit coverage based on Categories of Benefits specified in the policy or certificate.
Must my health insurance plan pay for my diabetic supplies and self-management education?
Answer: You are entitled to payment of all diabetic supplies and education under NYS law, provided that your plan is subject to NYS Department of Financial Services jurisdiction. Your plan may not be subject to this Department's jurisdiction if it is a self-insured plan or a union welfare fund. Employer group plans covering employees in more than one state and is subject to collective bargaining do not have to provide this coverage. Medicare Supplement policies do not provide this coverage.
What are my options if I wish to file a complaint against a self-insured plan, union plan, or Multiple Employer Welfare Association (MEWA)?
Answer: The above entities are exempt from state regulation under ERISA. They are however regulated by the United States Department of Labor. You may make complaints to the US Department of Labor.
U. S. Department of Labor
200 Constitution Ave., N. W.
Washington, D. C. 20210
What is "open enrollment"?
Answer: Open enrollment means that any individual, and dependents of such individual, and any small group, including all eligible employees or group members and dependents of employees or members, applying for individual or small group health insurance coverage, including Medicare supplement coverage, must be accepted at all times throughout the year for any hospital and/or medical coverage offered by the insurer to individuals or small groups in this state. Once accepted for coverage, an individual or small group cannot be terminated by the insurer due to claims experience.
In other words, an insurance company in New York State cannot refuse to insure an individual or small group on the basis of health, occupation, age, sex, etc. However, an applicant for an individual health insurance policy may be denied coverage where the individual is eligible for comparable group coverage through an employer.
Can HMOs prohibit doctors from telling their patients about more expensive procedures?
Answer: No. NYS law prohibits the HMO from restraining their providers from telling patients about more costly procedures.
My insurance company refuses to pay my hospital emergency room bill saying that it was not an emergency. Can they do this?
Answer: The company must cover any hospital ER bill provided that a prudent lay-person would have considered the incident to be an emergency at the time of the ER admittance.
How can I dispute my HMO's decision as to the necessity of my treatment?
Answer: NYS law requires the HMO to provide grievance procedures so that such decisions can be challenged.
What additional health insurance will I need when I turn 65 and go under Medicare?
Answer: Medicare (parts A & B) provides extensive medical benefits. There are however, gaps in coverage. To help cover these gaps in coverage, there are standardized Medigap plans throughout the country. The plans go from Plan A (least coverage for lowest cost) to Plan J (most coverage for highest cost). Not all health insurers sell all 10 plans. In addition, enrollment in a Medicare HMO can help cover the gaps in Medicare.