Consumer Rights: Those With Serious or Chronic Conditions

Applies to all types of plans.

Because of your special health care needs, there are certain parts of this law that you should
pay close attention to.

For enrollments or people thinking about enrolling in any plan, you may want to investigate the following information a plan must give you if you request it:

Whether the plan will pay for a certain drug, and the right to inspect the list of drugs the plan will pay for, known as the formulary.

A description of the procedures the plan follows to decide whether drugs, devices or treatments are experimental or investigation. Plans may not cover these so you may want to find out exactly what the plan will and won’t cover. But, even if a plan decides not to cover a benefit, you may be able to get coverage through New York State’s external appeal process. Click here for more information.

The clinical review criteria for a particular condition or disease and a description of how the plan uses that criteria to decide what benefits and referrals are covered. The plan must also tell you what other types of clinical information the plan might review in making a decision.

The hospital affiliations of particular health care providers.

Benefit limits and prior authorization requirements; this information must be given to you without your requesting it.

Also, you can ask any licensed HCP to provide you with information on her or his qualifications, training and experience, including participation in continuing education programs. This information will help you decide if a particular HCP can meet your needs.

If your plan denies you needed care because the plan says it is not medically necessary or because the plan says it is experimental/investigational or a clinical trial, you can ask the State for an external appeal. These appeals will be decided by independent, external reviewers with medical expertise who may overturn your plan’s decision. More information on this process is available here.

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