Consumer Rights: Question a Decision Made by Your Plan

Whenever you have a problem or a disagreement with your plan about your health care or your coverage, you can file a formal complaint to get the plan to meet your needs.

There are different ways to file complaints. One process is called a “Grievance Procedure.” If you are in a Managed Care Organization (MCO), New York State law has defined grievance procedures that all MCOs must follow. Other types of plans have developed their own grievance procedures that are described in the plan’s member materials.

The other process for filing a complaint is called a“Utilization Review” (UR). New York State law has defined procedures that all health insurance plans, including MCOs, must follow.

Which process you use depends on what type of plan you’re in, what kind of problem you have, the reason your plan used in denying you coverage, and whether you’re on Medicare or Medicaid (If you are receiving Medicare, click here. If you are receiving Medicaid, click here.).

By law, many of the complaints consumers have are handled by processes that are internal to the individual plan. That is, the plan itself decides whether to cover a treatment, test or referral—and the plan also has the final say if you appeal their decision. In these instances the plan is judge and jury.

But, there are certain types of health plan decisions that New Yorkers are able to appeal to an independent, external reviewer. Click here for details.

You should always file a complaint if you have a problem or disagreement with your plan. Plans do reconsider—and each reconsideration is done by different staff people within the plan. The
more determined you are, the more likely it is that your problem will be resolved in your favor. Remember, the squeaky wheel gets the grease.

Also, if your disagreement fits the guidelines for an external appeal, you will need to go through the plan’s internal process first before you can go to someone outside your plan to review the decision.

Keep in mind, you can always, at any point, file a complaint about your plan with the State agencies below:

For any problem related to the quality of your health care, such as not being able to get a referral to care you need, contact the State Department of Health Managed Care Hot-Line at 800-206-8125 or write to: New York State Department of Health, Bureau of Managed Care, Complaint Unit, Room 1911, Corning Tower, Empire State Plaza, Albany, NY 12237.

For problems related to payments for benefits, contact the State Insurance Department by calling their Consumer Services Bureau at 800-342-3736 or write to: New York State Insurance Department, Consumer Service Bureau, 25 Beaver St., New York, NY 10004.

For problems where you think a law has been broken or fraud might be involved, contact the
Attorney General’s Health Care Bureau at 1-800-771-7755.

If you receive your health insurance through your employer, it’s a good idea to tell the Personnel or Employee Benefits Dept. whenever you have a problem with your plan. They can be your best ally because they represent all the company’s employees enrolled in the plan. As a result, your employer probably has more leverage with your plan than you have.