Know Your Rights

By the New York State Insurance Department

As a consumer, 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. The Insurance Department's health complaint ranking shows that consumers are winning their appeals more than half the time.

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. Do you need to contact your primary care physician in advance or do you just need to call a 1-800 number?

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 complaints with your HMO or health insurer.

You have the right to know how your plan makes decisions about experimental drugs and treatments.

You have the right to know about any compensation arrangements your plan has with its health care providers. 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 receive 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 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. Click here 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 one concerning medical necessity.