Consumer Rights and Responsibilities

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 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 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 & 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 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:

• 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 to receive 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 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. 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.  

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.

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.
  • 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.
• Health Plans Must Cover Emergency Services. Your health plan must protect you from bills for out-of-network emergency services in a hospital. 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 which follow an emergency room visit.

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.)

• 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). Cost-sharing also doesn’t apply to other screening and diagnostic imaging to detect breast cancer, including ultrasounds, MRIs, and 3D mammograms.
• Contraceptives. Coverage for contraceptive drugs, devices and products, although religious employers may ask for a contract 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 deemed medically inadvisable. Your health care provider should complete a Contraceptive Exception Request Form and send it to your health insurer.
• 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. New moms 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 the mom is breastfeeding.
• Infertility. Basic infertility services (for example, tests to determine the cause of infertility ) are covered. Comprehensive infertility services (including artificial insemination) are also covered. Some exclusions may apply to infertility benefits, including in vitro fertilization (IVF), gamete intrafallopian tube transfer (GIFT) and zygote intrafallopian tube transfers (ZIFT) for individual and small group coverage.
  • IVF Coverage for Large Groups. Large group coverage (for employers that have 101 or more employees) must cover three (3) IVF cycles.
  • Fertility Preservation. Coverage for fertility preservation services for individuals having treatment or surgery that will affect their fertility (for example, chemotherapy or other cancer treatments) is also covered for individual, small and large group coverage.
  • No Discrimination. When deciding when to cover infertility benefits, health plans are prohibited from discriminating based on a person’s 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.

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.

  • Learn how to file an External Appeal.

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).

• Learn more about filing an External Appeals.

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.