Consumer Rights: Information About a Health Care Plan

All types of health insurance plans must provide specific information to every member and to anyone who is thinking about becoming a member. This information will help you decide if the plan will meet your needs. New York State law requires that plans put this information in the member handbook or in the member contract. Other information will be provided to you only if you request it.

* All plans must tell you, automatically:

What the plan covers. This includes what benefits the plan will pay for, the dollar amount limits, and any other limits (both annually and over a lifetime) including the number of allowed visits that the plan will pay for; what they won’t pay for, and how the plan defines
“medical necessity”. Plans will only pay for benefits considered to be medically necessary.

The requirements for prior authorization, that is, when a benefit must be approved by the plan for payment before you can receive it.

The Utilization Review (UR) procedures, including the plan’s toll-free number, how long it will take, your right to appeal the decision and how to appeal, your right to pick someone to represent you, your right to an external appeal, a description of the external appeal process including how long it will take (see UR and External Appeal sections for details)

The Grievance Procedures including the plan’s toll-free number, how long it will take, your right to appeal the decision and how to appeal, your right to pick someone to represent you. (see Grievance section for details)

What your costs for the health plan are, including co-payments, deductibles, care that is not covered or when you see a HCP who is not in the MCO’s network.

How to choose and how to change a HCP, and how to tell if a particular HCP is accepting new patients.

How members of a health plan may participate in the plan’s policy-making.

How the plan meets the needs of people who have trouble communicating in English.

How Emergency Care is covered.

Descriptions of how MCOs pay HCPs for their services.

The mailing addresses and phone numbers members need to get information about the plan or authorizations by the plan for benefits.

* Managed Care Organizations must also tell you:

That you can get a referral to a provider outside the MCO’s network, and how to get that referral, when your MCO’s network doesn’t include someone with the training and experience you need.

That you can get a standing referral to a specialist if you need ongoing care from that specialist.

That people with life-threatening or degenerative & disabling diseases or conditions who need special medical care over a long period of time may ask for a referral to a specialist who will then act as their PCP.

That people with the health problems described above can be referred to a specialty care center.

The names and addresses for all HCPs and facilities, such as hospitals, clinics and labs, that are in the plan’s network.

* If you ask, all plans provide this information—but only if you ask:

Whether the plan will pay for a certain drug. (You also have the right to inspect the list of drugs the plan will pay for, the formulary.)

If you request it in writing, specific clinical review criteria for a particular condition or disease and how these criteria are used. The clinical review criteria are the guidelines a plan uses when approving benefits.

What hospitals a HCP is affiliated with.

Information about consumer complaints about the plan that have been filed with the New York State Department of Insurance and with the plan.

The procedures the plan uses to decide whether drugs, devices or treatments in clinical trials are investigational or experimental.

A list of the board of directors, officers, owners or partners.

The most recent annual financial statement.

The most recent direct pay (individual) subscriber contract.

The procedures for protecting the confidentiality of information about members.

Written procedures describing the plan’s quality assurance program.