Consumer Rights: Purchase Health Coverage

The law provides important consumer protections in those policies, including:

• You can not be charged more because you have a health problem. Uniform premium rates are set for each HMO in each area of New York.

• The benefit package is comprehensive so it will meet the needs of most consumers, including people who have serious health problems.

• HMOs must offer individual consumers the choice of a Point of Service (POS) plan. POS options are more expensive but they allow you to go to HCPs outside the HMO’s network at higher out-of-pocket costs to you. If you use the POS option, the HMO will usually charge you a deductible and then the HMO will pay a percentage of the “usual and customary” cost of the benefit which may be considerably less than what a provider charges.

• Rules are set on when a HMO must cover a pre-existing health condition. (Click here for more information.)

• You are guaranteed, by Federal law, the right to renew your policy, as long as you pay your premiums, don’t move out of the plan’s service area or commit fraud.

Shop around for coverage. The State Insurance Department publishes a book which lists all the HMOs that sell individual coverage, including their phone numbers. To get the book, call 1-800-342-3736 and ask for the“Consumer’s Guide for Standard Individual HMO and Point of Service Coverage.”

Health Insurance for Children through age 18:

If your children have no health insurance, you may be eligible for a New York State program called Child Health Plus which provides health insurance coverage for children through age 18. For many families, Child Health Plus policies are much less expensive than regular HMO policies, since New York State pays part of the cost (depending on income). For more information about Child Health Plus call 1-800-698-4KIDS, or click here.

Health Insurance for Adults between the ages of 19 and 64:

If you have no health insurance, you may be eligible for a New York State program called Family Health Plus, which provides health insurance coverage for adults. It provides free insurance for adults who qualify and is funded by both the State and the Federal governments. For more information about Family Health Plus, call the NYS Department of Health toll free: 877-934-7587, or click here.