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Patient Bill of Rights: Managed Care

If you are covered by a health care plan offered in New York State, you have rights as a patient under the New York State Managed Care Bill of Rights (NYSMCBOR). A summary of your rights under this law is provided below (as issued by the NYS Office of the Attorney General).

YOUR RIGHT to receive emergency care: All health insurance plans must cover an emergency room visit, even without prior approval. Your symptoms, however, must be sudden, severe, or painful enough that a “prudent lay person” could expect that not receiving immediate medical attention would cause serious health problems.

YOUR RIGHT to information if you ask for it: The HMO must give you a list of drugs the plan will pay for, and whether a certain drug is on that list. The HMO must give you benefit approval guidelines, if requested in writing. The HMO must tell you with which hospitals its providers are affiliated, as well as the procedures it uses to decide whether drugs, devices or treatments in clinical trials are investigational or experimental.

YOUR RIGHT to information if you don’t ask for it: HMOs must disclose benefits for which your plan will or won’t pay, including dollar amounts and visit limits. The HMO is required to tell you if prior approval is necessary. The HMO must tell you how to file a complaint or challenge a denial of benefits.

YOUR RIGHT to child immunization: No health plan may charge a co-payment for immunizations or any other preventative health services for children under 19 years old.

YOUR RIGHT to challenge decisions: There are two ways to challenge a decision or practice of your plan: (1) Utilization review allows patients to question the plan’s decision to deny a benefit based on a lack of “medical necessity.” (2) Internal grievance procedures - which are mandatory only for HMOs - allow a review of complaints regarding all other types of care. The plan must inform you how to use the appropriate procedure, how long the process will take, and your right to have someone represent you. You also have the right to appeal the reviewer’s findings to another plan official

YOUR RIGHT to information from your doctor: No health plan may punish or forbid a health care provider from informing you of all treatments that apply to a medical condition.

YOUR RIGHT to choose providers: Every HMO must have enough providers within a reasonable distance from where their members live. You must have a choice of at least three primary care physicians.

YOUR RIGHT to certain specialty care: If an HMO decides it does not have an adequate provider, the HMO must refer you to an appropriate provider outside the network at no additional cost. Also, you have a right to receive standing referrals to specialists.

YOUR RIGHT to continuing care: If you join an HMO, the HMO must pay for your continuing treatment with a provider, even if the provider does not belong to the HMO, as long as (1) the provider meets the HMO’s requirements and agrees to their payment rates, and (2) either (a) you are undergoing a course of treatment for a life-threatening or disabling and degenerative disease, in which case you may continue to see the provider for up to 60 days, or (b) you are in the second or third trimester of pregnancy, in which case you may continue to see the provider through delivery and up to 60 days thereafter.

If you are receiving ongoing treatment from a provider who leaves your HMO, the HMO must pay for continued treatment (unless the provider left for reasons of fraud, imminent harm to patient care or State sanctions) as long as the provider meets the HMO’s requirements and agrees to their payment rates for up to 90 days after you have been notified that the provider is no longer with the HMO. However, the HMO must pay for you to see your provider if you are in your second or third trimester of pregnancy until up to 60 days after delivery.