

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”).
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.
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:
Your Financial Responsibility:
The Grievance Procedure, including:
The Utilization Review Procedure when services are denied as not medically necessary, experimental or investigational, a clinical trial or a rare disease treatment including:
Access to Care:
Contacting Your Health Plan:
Health plans must give you the following information if you ask for it, including if you are shopping for coverage:
If your HMO has not provided this information either upon your enrollment or request, you should submit a complaint to the New York 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].
Related Laws: Public Health Law Section 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.
Related Laws: Public Health Law Section 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.Related Laws: Insurance Law Sections 3217-a, 3217-b, 3217-d, 3241, 4306-c, 4324, 4325 & 4804 and Public Health Law Sections 4403 & 4408)
Right to Go Out-of-Network When Your Health Plan Does Not Have An In-Network Provider:
Choice of Primary Care Doctor:
Specialty Care:
When Your Provider Is Not In Your New Health Plan’s Network:
When Your Provider Leaves Your Health Plan's Network:
Network Adequacy:
Gag Clauses:
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
Related Laws: Financial Services Law Article 6
How to Protect Yourself From Surprise Bills If You Have HMO or Insurance Coverage Subject to NY Law (coverage that is not self-insured).
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.
(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.)
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
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:
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.
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.
If you are unable to find the answer to your questions here, check our FAQs. If you are still having trouble, you can file a complaint or contact us for further assistance: