Your Right to 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 copayments,
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.
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