the consumers' guide to new york's managed care bill of rights

8/14/2019 The Consumers' Guide to New York's Managed Care Bill of Rights

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YOUR RIGHT TO

Information About a

Health Care PlanAll types of health insuran ce plans m ust provide

specific inform ation to every mem ber and to anyone

who is thinking about becom ing a m em ber. This

information will help you d ecide if the plan willm eet your needs. N ew York S tate law requires thatplans put th is information in th e m em ber hand -

book or in the m em ber contract. Other information

will be provided to you only if you request it.

All plans must tell you, automatically:I What th e plan covers. This includes what benefits th e

plan will pay for, the dollar a mount limits, and an yother limits (both ann ua lly and over a lifetime) includ-ing the nu mber of allowed visits th at th e plan will payfor; what th ey wont pa y for, and how the plan definesmedical necessity. P l a n s w i l l o n l y p a y f o r b en e f i t scons idered to be m ed ica l l y neces sary .

I The requiremen ts for prior aut horization, tha t is, whena benefit must be approved by th e plan for pa ymentbefore you can receive it.

I The U tilizat ion Review (UR) procedures, including th eplan s t oll-free nu mber , how long it will take, your rightto appeal th e decision a nd h ow to appeal, your right t opick someone to represent you, your right t o an exter-na l appeal, a description of the extern al appea l processincluding how long it will take (see UR and Extern alapp eal sections for det ails)

I The Grieva nce Procedures in cluding th e plans toll-freenum ber, how long it will take, your right t o appeal the

decision a nd h ow to appea l, your r ight t o pick someoneto repr esent you. (see Grievance section for det ails)I What your costs for t he h ealth plan a re, including co-

payment s, deductibles, car e th at is not covered or whenyou see a HCP who is not in th e MCOs net work.

I How to choose an d how to cha nge a H CP, and how totell if a part icular HCP is accepting new pat ients.

I How members of a hea lth plan m ay part icipate in th eplan s policy-mak ing.

I How the plan meets t he needs of people who have trou-ble communicating in English.

I How Emer gency Car e is covered.I Descriptions of how MCOs pay H CPs for th eir serviceI The mail ing addresses an d phone num bers members

need to get inform ation about th e plan or aut horiza-tions by th e plan for ben efits.

Managed Care Organizations must also tell you:I That you can get a referra l to a provider outside the

MCOs net work, a nd h ow to get tha t r eferra l, whenyour MCOs net work doesnt include someone wit h t hetr aining an d experience you n eed.

I That you can get a stan ding referra l to a specialist if you n eed ongoing care from th at specialist.

I That people with life-thr eatening or degenera tive &disabling diseas es or conditions who need special medical care over a long period of time ma y ask for a r eferral t o a specialist who will then act as t heir PCP .

I That people with th e health problems described abovecan be referred t o a specialty care center.

I The na mes an d addr esses for all HCPs an d facilities,such as hospitals, clinics an d labs, tha t a re in t he plannetwork.

If you ask, all plans provide this informationbuonly if youask:I Wheth er th e plan will pay for a cert ain dr ug. (You als

ha ve the right t o inspect the list of dru gs the plan willpay for, t he formular y.)

I If you r equest it in writin g, specific clinical r eview cri -teria for a pa rticular condition or disease an d howth ese criteria are used. The clinical review criteria ar eth e guidelines a plan uses when appr oving benefits.

I What hospita ls a HCP is affiliated with.I Inform at ion about consu mer complaint s about the pla

th at h ave been filed with the New York Stat eDepartment of Insuran ce and with t he plan.

I The procedures t he plan u ses to decide whether dr ugsdevices or tr eatm ents in clinical trials ar e investiga-tional or experimental.

I A list of the board of directors , officers , owners orpar tners .

I The most recent annu al financial stat ement.I The m ost recent d irect pay ( individua l) subscriber

contract.

I The pr ocedur es for protecting th e confidentia lity ofinforma tion about m embers.

I Written procedures describing the plan s quality assuance program .

2 G U I DE T O N E W YO RK S MAN AG E D C AR E B I LL O F R IG H TS

HEALTH CARETerms &PhrasesPLAN: Refers to any type of healt hinsurance plan. This can be a stan-dard insurance plan (known as indem-nit y or fee-for-service) or a managedcare plan. I n some cases, usuallywhen your employer is a large compa -ny, a company has set up a heal th

insurance plan of i ts own. These plansare called self-insured plans and fallunder federal guideli nes known asERISA and are exempt from New Yorklaw. To find out if your plan is t his type,check wit h your employer or union.

MCO: Managed Care Organization: Ahealth insurance plan t hat uses pri-mary care providers (PCP) and a spe-cific list of health care providers (theplans net work) whose services arecovered under the plan.

HCP:Healt h Care Provider: Anylicensed health care professional.This term appl ies not only to doctorsbut also to nurses, social workers, etc.

PCP:Primary Care Provider: Thehealth care professional who coordi-nates your health care needs if you areenrolled in an MCO.

BENEFIT: A medical service, t est ortreatment , a medical device or a pre-scripti on drug.

GRIEVANCE: A formal complaint odisagreement you or your Healt h CaProvider make wit h your MCO.

UTILIZATION REVIEW (or URThe process used by plans to dec idewhether or not a benefit i s medicalnecessary.


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YOUR RIGHT TO

Quest ion a Decision

Made by Your PlanWhenever you have a problem or a disagreem ent

with your plan about your health care or your cov-

erage, you can file a formal com plaint to get th e

plan to m eet your needs.Ther e are differen t ways to file complaint s. One process iscalled a Grievan ce Pr ocedur e. If you a re in a Ma na gedCar e Organizat ion (MCO), New York Sta te law h as definedgrievance procedur es tha t all MCOs mu st follow. Oth ertypes of plans h ave developed t heir own grievance proce-dures t hat are described in the plan s member m aterials.

The oth er pr ocess for filing a compla int is called aUt ilizat ion Review (UR). New York Sta te la w ha sdefined procedures th at a l l heal th insur ance plans,including MCOs, m ust follow.

Which process you u se depen ds on wha t t ype of plan youre

in, what kind of problem you ha ve, th e reason your planused in denying you coverage, an d whet her youre onMedicare or Medicaid (if youare receiving Medicare or

Medicaid , see pages 8-10) .

By law, man y of the com -plaints consumer s have areha ndled by processes tha tar e intern al to the individ-ual plan. That is , the planitself decides wheth er t ocover a tr eatm ent, test orreferraland the plan alsoha s th e fina l say if you

appea l th eir decision. Inthese insta nces the plan is

judge and jury.

But, there ar e certa in typesof hea lth p lan d ecisionstha t New Yorkers are ableto appeal to an indepen-dent, externa l reviewer.S ee page 7 for details.

You sh ould always file acompla int if you h ave aproblem or disagreement

with your plan . Plans do reconsideran d each r econsider-ation is done by different sta ff people within t he plan . Themore determ ined you a re, the more likely it is tha t yourproblem will be resolved in your favor. Remem ber, th esqueaky wheel gets th e grease.

Also, if your disagreem ent fits th e guidelines for an exter-na l appeal, you will need to go th rough t he plan s inter na lprocess first before you can go to someone out side yourplan t o review th e decision.

Keep in mind, you can always, at any point , fi le a com-plaint about your plan with the State agencies below:For an y problem relat ed to the quality of your h ealth car e,such as n ot being able to get a r eferr al to car e you n eed,contact th e S t a t e D ep a r t m e n t o f H e a l t h M a n a g e d Car e Hot-Lin e at 800-206-8125 or writ e to: New YorkStat e Departmen t of Health , Bureau of Mana ged Care,Complaint Unit, Room 1911, Corning Tower, Empire Sta tePla za, Alban y, NY 12237.

For problems related t o payments for benefits, contact t heS t a t e I n s u r a n c e D ep a r t m e n t by calling th eir Consumer S ervices Bu rea u a t 800-342-3736or writ e to: New YorkStat e Insura nce Departm ent, Consum er Service Bureau,

25 Beaver St ., New York , NY 10004.For pr oblems wh ere youthink a law has been bro-ken or frau d might beinvolved, conta ct th eAtt orn ey Gen eral sH e a l t h C a r e B u r e a u a t

1-800-771-7755 .

If you receive your h ealthinsuran ce thr ough your em-ployer, its a good idea totell the P ersonnel orEm ployee Benefits Dept.

whenever you ha ve a prob-lem with your plan. Theycan be your best a llybecause t hey represent a llth e compa nys em ployeesenrolled in t he plan . As aresu lt, your employer p rob-ably has m ore leverage withyour plan tha n you ha ve.

G UI DE T O N E W YO RK S M AN AG E D C AR E B IL L O F R IG H TS 3

YOUR RIGHT TO

EmergencyRoom Care Applies to all types ofhealth insurance plans.

You dont need approval fromyour PCP or your p lan before

you goto the emergency roomif:

Your symptoms start su dden-ly, an d ar e so severe or painfultha t a pruden t layperson (a

thoughtful, ordinar y person)with an averageknowledge of

medicine an d healt h, could

expect that not getting imme-diate medical attention would

cause serious hea lth problemsor dama ge to your body.

For exam ple, if you h aveseve re che st pa i n a nd you go t oth e emergency room because

you th ink you are having aheart at tack, even ifyou are

onlydiagnosed with serious

indigestion, the plan must payfor your emer gency room visit.

In t he case of mental healthproblems: if you or someone

else, again , acting as a pru -dent layperson, th inks youwould har m yourself or some-

one else.

All Enrollees

Medicaid En rollees

* Medicaid recipients may use t his pr ocess but Medicaid Fa ir Hear ing deci-

sions will override t he Sta tes Exter nal Review Decision.

Fair Hear ing Rights

Denials and complaints

UtilizationReview &Appeals

Externalappeals*

Grievance &Appeals

Routes to File a Complaintwith a Managed Care Organization

Denialsbased on

medicalnecessity

All oth erDenials an d

complaints


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BASIC RULES

When youhave acomplaint

Whenever you have aproblem or fi le a complaint,keep written records of:

NAMES ANDPHONE NUMBERSof t he people you contact ed and

the date you contact ed each of

those people.

WHATHAPPENEDDURING THECONVERSATION:what steps that person said t hey

would take; what steps you took.

COPIESOF ALLPAPERS,notices or lett ers, wit h dates on

them, that you sent or that were

sent t o you.

Filing a Grievance Available to members of managed careorganizations only.

Anytime you h ave a complain t or a pr oblem with yourMCO you h ave a gr ievan ce and can file a form al grievanceto get your MCO to cha nge its decision. Grievances can beabout a nyth ing, for example, if you thin k you had t o waittoo long to get a n a ppointm ent with a HCP or if you feel youwere tr eated ba dly by a HCP. The grievan ce procedur es are

used in cases where t he MCO decides tha t your complaintor problem is not a quest ion of medical necessity. The lawsets up the wa y your MCO must han dle your grievance.

Your MCO mu st t ell you h ow to file a grievance any t imeit denies a r equest for a referr al or decides tha t it wontpay for a service or t reat ment th at you or your H CP ask edfor. It m us t a lso tell you how to file a grievan ce in itsmember han dbook. If th e denial is based on medicalnecessity, your MCO must tell you h ow to use the U R pro-cedures. (S ee page 5)

When a n MCO refuses to pay for care or den ies you areferral t ha t you an d/or your H CP feel you n eed, the MCOmu st t ell you h ow to file a grievan ce. This is calledAN o t i ce of Gr i evan ce . It ha s to include:I A descript ion of th e grievan ce process.I How to file a grieva nce.I How long each pa rt of th e grievance process ta kes.I Your r ight t o pick someone to help you (your rep resen -

tative).I How to use the gr ievance process if you h ave tr ouble

commun icat ing in En glish.

You can fi le your grievance by telephone when:I Your MCO or your HCP denies you a referral to a t reat -

men t, test or ser vice you an d/or your HCP th ink youneed: for example, a referral t o a specialist.

I Your MCO decides it wont p ay for a benefit you th inkit sh ould pay for.

For t hese types of grievances, your MCO mu st h ave a t oll-free grievan ce phone num ber, answered by real people, 5days a week, during norma l business hours. After h our s,th e MCO must ha ve a way for you to leave a m essage(voice mail, answering m achine, etc.) and t he MCO m ustretu rn your call within 1 business da y. For exam ple, if you leave a messa ge on Wednesday night , the MCO has t ocall you back on Th ur sday.

Your MCO may ask you to sign a writt en acknowledgmentof your grievan ce which th e MCO sends you. The acknowl-

edgment will describe your complaint . You should rea dth is carefully an d chan ge your MCOs descript ion of yourcomplaint if its n ot accur at e. Your MCO will not sta rt toprocess your complaint un til you sign an d retu rn t hisacknowledgment u nless waiting for you to retu rn t heacknowledgment would increase the risk t o your h ealth .

Some grievances must be f iled in writ ing:Other th an denials of referrals or benefits, your MCO mask you t o file a gr ievance in wr iting; for exa mple, if youar e complaining about th e length of time you h ad t o wait

to get a n a ppointment with a HCP. In t hese cases, yourMCO will ask you either t o write a letter or t o fill out aform th at th e MCO will supply. After your MCO receivesyour lett er or complet ed form , your MCO mu st t ell youwhat inform at ion t hey need in order to make a decision.

How the grievance process works:Your MCO must send you a written n otice tha t th eyreceived your grievan ce w i t h i n 1 5 d a y s of the date th eyreceived it . This notice mu st include the n am e, addressand ph one number of th e person(s) or departm ent t ha twill ma ke th e decision a bout your gr ievan ce. The decisiowill be made by one or m ore qua lified people who work fyour MCO. If your grievan ce involves a hea lth qu estion,

one of th ese people mus t be a licensed, cert ified or regis-tered h ealth car e professiona l.

How long does the decision process take?W i t h i n 4 8 h o u r s after you call and r eport ed your griev-an ce by phone, and after t he r eceipt of all necessary informa tion, if a dela y in their decision would significan tlyincrease th e risk to your h ealth , the MCO must call youon th e phone wit h t heir decision. Your MCO h as t o followth at u p in writing within 3 business days. This is calledan expedited decision.

With in 30 days after you retur ned th e signed acknowledment your MCO provided and all necessary informa tionha s been supplied, when a delay would not increase therisk to your h ealth a nd your grievance is about th e MCOdenying you a referral or r efusing t o pay for a ben efit.

With in 45 da ys in writing in a ll oth er cases, such asbilling pr oblems.

The MCOs writt en decision a bout your compla int iscalled a Grievance Determina tion. It must include:

I The r easons for th e decision.I If its a m edical mat ter , the m edical basis for the decisioI How to appea l if you disa gree.I The forms youll need t o file an a ppea l.



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You have the right to appeal aGrievance Determinat ionYou can ap pea l your MCOs decision. Dont give u p!Sometimes MCOs chan ge a decision because a person ha sshown how seriously she/he t akes the problem by filing anappeal .

Your MCO mu st give you a t least 60 days to app eal. Allappeals a re in writ ing (by lett er or by a form th e MCO

sup plies); you can not a ppeal orally.Once you send your MCO an appeal, your MCO has 15days to send you a wri t ten a cknowledgment tha t t he MCOreceived your appea l. This writt en acknowledgment mu stinclude:I The na me, address an d phone num ber of th e person(s)

deciding your appeal. This cannot be t he sa me personwho decided your grievance. In healt h quest ions, th isperson or people mu st be health car e professionals,including at least one person who has expertise in tha tpart icular health field. If its not a health question,th en th e appeal person has t o be a higher level staffperson th an the one wh o originally decided against you.

I Any oth er inform at ion t he MCO needs to make its

decision.

How long does the appeal process take?W i t h i n 2 b u s i n e ss d a y s the MCO must tell you its deci-sion, if a delay would significan tly increas e th e risk t oyour heal th.

W i t h i n 3 0 d a y s i n w r i t i n g, in all oth er cases.

The MCOs writt en decision about your a ppeal is called anAppeals Notice. It m ust include t he r easons for t he deci-sion, and, if its a med ical ma tt er, th e medical basis forth e decision.

Your right to complain to New York State:At an y time, before, during or after you h ave goneth rough your MCOs grievan ce and a ppea ls processes, youcan file a complaint with th e S tate Departm ent of HealthManaged Care Hot-Line: 800-206-8125 for complaint sabout t he qua lity of your car e or with t he S tate InsuranceDepartm ent Consum er Services Bu reau: 800-342-3736 forproblems a bout p ayment for benefits or with t he AttorneyGenerals Healt h Ca re Bu reau: 1-800-771-7755.

Tell your MCO th at youknow you can file a com -plaint with the Sta te . Thisma y encour age your MCOto consider your appeal

carefully. The law says th atMCOs can not pun ish youor your HCP or a nyone whoad vocat es for you for filinga grievance or an appeal.

Records of grievancesYour MCO must keep arecord of every gr ievancefiled, includin g: th e dat esgrievan ces and a ppealswere filed, the decisions

an d the dat es they were made, the t itles of th e people whomade t he decisions a nd t heir credentials.

MCOs must report yearly to the Stat e Heal th Departm entthe n umber of grievances each has dea lt with. In th esereports informa tion must be kept confident ial tha t mightidentify you.

Every year The New York St ate In sura nce Departm entcompiles a report on complaints m ade about h ealth insu r-ance plans called The Annu al Health Insur ance ComplaintRan kings. You can get a copy from: The New York St at e

Insu ra nce Depar tm ent, Office of Public Affairs, 160Broad way, New York, NY 10013, 212-602-0428.

If you request it , your MCO must tell you h ow ma nygrievan ces it h as r eceived each year. It mus t a lso tell youhow man y of th e grievances it decided in t he enr olleesfavor. The n um ber of grievan ces filed with a n MCO canhelp you decide which MCO you m ay wa nt to join.

Utilization ReviewAvailable to members of al l health plans.

These are th e procedures all plans, no mat ter wha t type,use to determine wh ether to allow a benefit , tr eatm ent orreferr al that you or your HCP requests based on whetherth at benefit, treat ment or referr al is medically necessary.If the plan denies a benefit , treatm ent or r eferral becauseth e plan says it is not medically necessary, you ha ve th eright to question th e plans decision thr ough th e URappea l process. The plan m ust tell you h ow to file a URappea l when t hey ma ke th is kind of decision. The pla nsUR procedur es mu st a lso be described in your m ember

han dbook or cont ract.

The medical director, a licensed physician , mu st sup ervisean d oversee th e UR pr ocess. The det ails of th e plan s pr o-cedures mu st be filed with t he Stat e Health Depart mentan d available to you an d to your HCPs .

How to use the Uti lization Review Process:Your health plan must ha ve a toll free phone num ber,answered by rea l people, at least 5 days a week, duringnormal business hours. After hours, the plan must have away for you to leave a message (voice mail, answeringmachine, etc.) an d the plan m ust r etur n your call within 1business day. For exam ple, if you leave a mess age on

Friday n ight, t he plan has to call you ba ck on Monday.If your HCP wan ts t o extend your sta y in a hospital or spe -cialty care center (for example, a can cer inst itut e or reh a -bilita tion cent er) she/he must be able to cont act a UR per-son at t he plan for approval 24 hour s a day, 7 days a week.

Who perf orms the Util ization Review (UR)?The law says that people who are tr ained in intake a ndtr ained t o collect informat ion a nd wh o are su pervised by alicensed HCP can tak e an initial request for U R. If the URappr oves your or your HCP s request , tha t decision can bema de by a licensed HCP .


Remember, you canfile a complaint w ith

the Department of

Health, th e InsuranceDepartm ent or theAttorney GeneralsHealth Care Bu reauat any point in the

processes described inthis guide and any-tim e you h ave a prob-

lem with your plan.


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But , if th e plan d enies your or your HCP s requ est, whichis known as an a dverse determinat ion, then tha t decisionmu st be ma de by a physician, or, if the request wa s ma deby another type of HCP, th e decision m ust be made by alicensed HCP who is in th e same or similar field as t heprovider wh o requested t he benefit . For example, if th erequest was m ade by a social worker, th e adverse deter -mina tion must be ma de by a social worker a t th e plan orby a physician. Ph ysicians can a lways make a dversedeterminat ions.

How long does the UR process take?After t he plan r eceives all th e inform at ion it needs t o ma kea d ecision, it h as t o let you or your r epresent ative, (yourrepresentat ive can be your HCP), and your HCP k now thepla ns decision:IWith in 1 bus ines s day by phone an d th en in writing ifits for services t ha t you ar e alr eady r eceiving a nd you oryour HCP feels you n eed to cont inue (for exam ple, moredays in t he hospital). When your plan lets you and yourHCP k now, the plan must tell both of you h ow many moreservices th e plan a pproved, if an y, (for inst an ce, th e nu m-ber of added days in th e hospital), the n ew total of servicesapproved, the dat e th ese services begin an d th e next dat eth at t he plan will review wheth er th ese services continue

to be m edically necessary.IW i t h i n 3 b u s i n e ss d a y s, after th e plan ha s received allnecessar y informa tion and t hen in wr iting, if it concern spre-appr oving a benefit or referral.IW i t h i n 3 0 d a y s when its a decision a bout a benefit th atyouve alrea dy received: for exam ple, your doctor d id a pro -cedure a nd t he plan lat er decides it wont pa y for itbecause th e UR decides it was not medically necessar y.

I f t he p la n doesn t r e spond to t he r eques t i n t h e t imef ram es l i s ted above , th e p lan wi l l be cons id ered to

ha ve den ied th e bene f i t , t r ea tm en t o r r e f er ra l (an

ad verse de t e rmina t ion ) an d you can im m ed ia t e l ya p p e a l t h i s d e n i a l t o t h e p l a n .

What happens in an Adverse Determination?Your h ealth plans decision t o deny a benefit th at you oryour pr ovider request ed becau se the plan s ays it is notmedically necessary is called an a dverse determ inat ion. Inadverse determinations th e plan must send you a Noticeof Denia l . It must be in writing an d include:I The rea sons with th e medical explanat ion, if any;

I That you an d your r epresent at ive can request t he clini-cal review criteria (medical sta nda rds) the plan used tomake tha t decis ion;

IHow to appeal th e decision a nd wha t inform at ion t heplan n eeds for your a ppeal;

IYour r ight t o an externa l appeal .

Reconsiderat ion of Adverse DeterminationsIf the UR sta ff at th e plan m ade th eir decision withoutta lking it over with th e HCP who recomm ended your bene-fit or referral, the HCP can request t hat the plan reconsid-er its decision:

With in 1 bus ines s day , the HCP who requested th e benfit, treatm ent or referra l and th e UR person who made thorigina l decision m ust discuss it. After th e discussion, th eUR person m ust notify th e HCP of his/her decision.

You and your provider have the right to appeal anAdverse Determination.All appea ls will be ha ndled by a plan sta ff person wh o didnot ma ke th e original decision. If a doctor request ed th ebenefit th at wa s denied, th e plan sta ff person who ha ndleyour appea l must be a doctor in th e same or similar sp ecia

ty. There are t wo kinds of appeals, expedited an d sta nda rd

How long does the Expedited Appeal process takeAn appeal can be decided quickly where t he r equest is focont inu ed or exten ded services (for example, more days th e hospita l) or for m ore services for someone ha vingongoing tr eatm ent (for example, more r ehabilitation theapy after a st roke).

An expedited ap peal is also allowed in an y situa tion whereyour provider believes it is necessar y. But t her e are n o expdited appeals for benefits th at you h ave already r eceived.IW i t h i n 1 b u s i n e s s d a y after t he UR people at your plareceive an expedited appea l, you or your r epresen ta tive

and your HCP must be able to get in touch with a UR stafperson who h as th e qua lifications described above.IWith in 2 bus in es s da ys, after t he plan receives all necessary informa tion, a decision m ust be made.

If, after an expedited appeal, the plan ma kes an a dversedeterminat ion an d denies what you or your H CP want edyou can r equest an external appeal .

How long wil l a Standard Appeal t ake?You have at least 45 da ys after t he plan notifies you of anadvers e determ inat ion a nd youve been given all th e informat ion you need to file an appeal. It is up to the plan t odecide if you ha ve to appea l in writ ing or by phone.IW i t h i n 1 5 d a y s after you file your a ppeal, the plan h as

to send you a wr itten a cknowledgment of th e appeal.IW i t h i n 6 0 d a y s, after th e plan receives all the necessainform at ion, the plan m ust m ake a decision.IWith in 2 bus in es s da ys after m aking t heir decision,the plan must let you, your representat ive, and your HCP(when th at s appr opriat e) kn ow th eir decision.

The n otice of th e decision about either your expedited orstan dard appeal must include the reasons an d, when anadverse determina tion is upheld, the m edical explanationIt m ust also include your right t o file an external appea l,how to request an externa l appeal from the Sta teInsu ra nce Dept., including t he form s you a nd your pr ovi-der must submit to the Insura nce Department , the

Insu ra nce Depart ment s toll-free num ber, a description oth e externa l appeal process, including how long th eprocess will tak e.

I f t h e p l a n f a i l s t o r e sp o n d t o yo u r a p p e a l w i t h i n t h

t i m e f r a m e s l i st e d a b o ve , t h e p l a n s d e c i s io n t o d e n

coverage i s r ever sed .



7/16

YOUR RIGHT TO

An External AppealNew Y ork S tate law allows consu m ers to file an

external appeal when a h ealth care plan d enies

some types of health services.

The external appeal will be cond ucted by health

care professionals w ho have no connection to your

plan, your h ealth care provider or the health carefacility involved in your care. Th e external appealagents decision w ill be binding.

Consumers will be able to request an externalappeal if:I Your plan den ies any par t of a benefit becau se the plan

sa ys it is not medically necessar y; orI Your plan den ies a benefit because th e plan sa ys it is

experiment al; orI Your plan denies a benefit because it is a clinical tr ial.

Pr oviders will be able to request t his extern al appea l when

th e plan den ies payment for a ser vice alread y provided (ret-rospective review) becau se the plan sa ys it was not med-ically n ecessar y.

To be able to use the exter na l appeal process:I You or your pr ovider (where th is applies) mu st h ave

gone th rough the int ernal appeals procedure an dreceived a denia l, called a final adverse det ermina tion,or ;

I You a nd t he plan h ave agreed to waive the interna lappeals pr ocedure.

You must request a n external appeal from th e StateInsur ance Departm ent in wri t ing:

W i t h i n 4 5 d a y s of th e dat e of th e fina l adverse det ermi-na tion you r eceive, or wh en you and your plan a gree towaive the intern al appeal process.

When your plan sends you a final adverse determina tion,th e plan will send you inform at ion from th e Stat e tha tdescribes th e externa l appeal pr ocess, including th e form syou an d your pr ovider must send t o th e Insur an ce Dept. torequest a n externa l appeal and the fee, if any, you m ustpay to start this process. You must pa y the fee and send inth e forms wit hin 45 da ys of receiving your plan s finaladverse determinat ion.

If you d o not receive th e inform at ion or form s or you ha vequestions about t he extern al appea l process, including

wheth er you ar e eligible, ca l l t he Insur an ce Dep t . a t 800-400-8882 .

W i t h i n 4 5 d a y s of receiving the final adverse det ermina -tion from your plan, you or your provider can su bmit a nyinform at ion to docum ent your case. If the inform at ionyou or your provider su bmits is substa ntia lly differentfrom t he informa tion t he plan h ad when it ma de its deci-sion, th e plan ha s 3 da ys to reconsider it s decision.

There ar e 2 kinds of appeals, expedited and sta ndar d.

How long will a standard appeal take?I W i t h i n 3 0 d a y s th e independent r eviewer will make a

decision. You an d your pla n will be notified with in 2busin ess days of th e decision being ma de.

I Five ad d i t i ona l days, if th e reviewer needs addit iona linformation.

In some cases the appeal can be expedited:I The r eview will be complet ed in 3 d a y s if your doctor

stat es tha t a delay would pose an imminent or seriousth reat to your h ealth . Every reasonable effort will be

ma de to notify you a nd your pla n of th e decision imm e-diat ely by telephone or fax. This will be followed imm e-diately by a writt en n otice.

What crit eria will the external reviewer use in mak-ing the decision about medical necessity?The law sa ys tha t t he decision will be based on w h e t h e r t h e p l a n a c t ed r e a s on a b l y, w i t h s o u n d m e d i c a l ju d g -

m e n t a n d i n y o u r b e s t i n t e r e s t . Reviewers will tak e th efollowing into considera tion when m ak ing th eir decisions:I The plan s clinical st an dar ds;I Informa tion pr ovided concerning your health condition;I Your a tt endin g doctors recomm enda tion;I Gener ally accepted pr actice guidelines of govern men t

health agencies, na tional an d pr ofessiona l medical soci-eties, boards and associations.

How do I qualif y for a external review based on adenial because the plan says the benef it is experi-mental or investigational?An externa l appeal may be filed when an y treat ment ormedical service is denied becau se the pla n sa ys it isexperim ent al or invest igationa l. This includes par tici-pat ing in a clinical tr ial an d access to an off label dru g, amedicat ion t ha t h as been a pproved by the F DA for onecondit ion, but not for th e condit ion for which you ar e filingth e appeal. To qualify your doctor mu st certify that :I You ha ve a life-th rea ten ing or disabling condition or

diseas e. (A disablin g disease or condition mea ns, in t hiscase, th at your illness mus t ma tch th e definition ofdisabled p erson in th e social ser vice law; genera lly, acondit ion which prevent s you from workin g) AND,

I Sta nda rd medical services h ave been ineffective orwould be medically inappr opriat e OR,

I There isnt a more beneficial tr eatm ent covered by yourplan OR,

I Ther e is a clinical trial a vailable to you.

Your doctor mu st a lso recommend t his tr eat ment or clini-cal trial a nd give his or her r easons including 2 docu-men ts from ava ilable medical and scient ific evidence ortha t t he pr oposed benefit is a clinical tr ial.

The extern al r eviewers will approve experimenta l orinvestigational treat ment s based on:I The scientific and medical evidence tha t t he tr eatm ent

proposed is likely to be more beneficial tha n a ny sta n-dard t reatm ent OR,

I The reviewer confirms tha t th e proposed treat ment is aclinical tr ial th at is likely to benefit you.

Not ice o f th e decis ion will include t he r eason for thedecision and, wh ere t he plan s final adverse deter mina-tion is uph eld, the clinical ra tiona le. The decision will:



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I Be binding on both you a nd your plan (unless you orth e plan decide to go to court ),

I Not expan d your covered benefits or cha nge your p lansru les (e.g. prior-aut horization, reimbu rsemen t ra tes) asdescribed in your contr act, an d

I Be admissible in court .

Wil l the External Appeal cost me anything?You may be a sked by your plan t o pay $50 to file an exter-na l appeal. You must send a check, made out t o yourheal th plan, to the State Insur ance Department w i t h i n

45 days of receiving the final a dverse determ inat ion. Thischeck will be return ed to you if the extern al appea l is inyour favor. You will not be char ged th e $50 if you ar e onMedicaid, Child Health Plus or can not a fford to pay.

If You are on MedicaidMedicaid r ecipients may use t his externa l appeal pr ocess,but the decisions of Medicaid Fa ir Hea rings ( see page 10 )will override t he decisions of this St at e externa l appeal.

How do I Apply for an External Appeal?The extern al appea ls must be in writing according to pro-cedur es developed by New York Sta te on a form appr ovedby New York Sta te. To find out how to file an exter na l

appea l, consu mers sh ould call the S t a t e In s u r a n c eDepa rtm ent (800-400-8882) or v is i t th e ir webs i t e a t

www. ins . s ta t e .ny .us .

If you have a qu estion about wheth er you can file anexternal appeal , contact t he Sta te Insu rance Department .The Insu ra nce Dept. will rand omly assign your case to anexterna l review agent. The agent will have a ph one lineavailable 24 hour s a da y to handle questions about yourexternal appeals.

YOUR RIGHT TO

File a Gr ievance or an

Appeal if You Are in a

Medicare HMOIf you are on Medicare and enroll in a m ana ged

care organization, your MCO m ust provide allth e services you are en titled t o und er Medicare.

Medicare, un der Federal law , requ ires MCOs tofollow d efined grievance and appeal procedu res

th at d iffer from grievan ce and appeal procedures

in oth er types of MCOs.

Medicare Grievances:If you ar e questioning a MCO denial of health care youneed or p aym ent for h ealt h car e youve received, yoush ould always file an a ppea l. You can file a grieva nce forother k inds of compla ints or pr oblems with your MCO.Grievances can be about a nyth ing other th an a denial ofhea lth car e or pa ymen t for services. For exam ple, if you

thin k you h ad t o wait t oo long to get an a ppoint ment wita pr ovider or if you feel you wer e tr eat ed badly by aprovider you should file a grievan ce. Ea ch MCO set s itsown pr ocedur es for han dling your grievan ce. Read yourmem ber h an dbook to find out your MCOs procedures .Grievances are not r eviewed by any agency out side theMCO, so its import an t t o file an a ppea l if you n eed med -ical covera ge.

Medicare Appeals:Medicar e has both sta nda rd an d expedited appea l proce-

dur es. The expedited pr ocedur es will allow you, in somecases, to get a decision qu ickly.

In both expedited an d sta ndar d procedures, your a ppealreviewed first byby the MCO. After your appeal h as beenreviewed int ern ally by your MCO, if you still dont geteverything you asked for, your a ppeal will aut omaticallybe reviewed by th e Center for Hea lth Disput e Resolutio(CHDR). CHDR is a private compa ny tha t contr acts witMedicar e to review all MCO appea ls.

Here a re t he Medicare rules for r esolving appea ls:

When your appea l is about your MCO denying any type Medicare or HMO-covered ben efit or ser vice, or for p ay-

men t of a Medicar e covered ser vice, wheth er you receiveth e car e within or outside your MCO because your MCOrefused to provide it , th e appea l can be resolved thr oughth e following t wo processes:

Expedited Medicare review:You can get a quick MCO decision a bout a MCO den ial ocare with in 72 hours if your hea lth or ability to fun ctionat a ma ximum level could be seriously ha rm ed by waitinfor a stan dard decision.

Ask your doctor to requ est or su pport your expedit ed decsion. Your doctor can do this by teleph one. If your doctormakes t he request or supports your request , the MCOmu st expedite th e decision.

You or your repr esent at ive can also make t he requ est foran expedit ed review in writ ing or orally over th e tele-phone, without su pport from your doctor or other H CP. this situation the MCO willdecide wheth er your condi-tion calls for an expediteddecision. If th e MCO decidesnot t o expedite your case,the MCO must notify youand give you a written expla-nat ion of the r easons for itsdecision. Your cas e will thenbe decided in t he s ta ndardtim e fra me. You can file aMedicar e grievance aboutth e denial of an expeditedappea l, but d ont forget t ha tit is an int ern al MCO proce-dur e. Medicar e grievan cesdiffer from t he grievan ceprocedur es described onpage 4 of th is Guide.(Contact the organiza tionslisted in the box at right for

help with Medicare griev -ances and appeals.)


For more information a bou

Medicare & MCOs, contact:

I The Medicare Rights

Center: 800-333-4114

(Monday th rough Thursda y

9 a.m.-2 p.m.).

I New York Sta teWide

Senior Action Council,

Pa tient s Rights H otline800-333-4374 or 212-

316-9393.

I The Department of

Health Managed Care

Hotline: 800-206-8125.

I The New York Stat e

Office for t he Aging:

800-342-9871 or 518-474-5731.

I Your local O ffice for t he

Aging.


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If the MCO expedites your review, it mu st inform you ofits decision by phone within 72 hours of receiving therequest . With in two workin g days of ma king th eir deci-sion, th e MCO mu st follow-up the phone call with a letter .

If the requ est for a n expedited decision is from a H CP whois not in th e MCOs network, th en th e 72 hour ru le beginsafter th e HCP ha s supplied all the m edical informa tionnecessary for t he MCO to make a decision. The MCO h asto le t you kn ow within 72 h ours of th e request i f th eHCP ha s not supplied th e needed inform at ion.

The 72 hour deadline for m aking a decision can be extend-ed for 10 work ing da ys in t he following cases:I When a dela y would ben efit you. (for exam ple, for more

tests or a consultation).I If you reques t a dela y (for exam ple, to gat her inform a-

tion).

If the MCO denies the r equested care, the MCO mustau tomat ically forward your case within 24 hours of mak-ing the decision to CHDR. CHDR will th en ma ke an expe-dited decision in t he sa me t ime frames described above.

As with st an dar d Medicar e appeals, if CHDR agrees withyour MCO to deny the request ed car e, you are en titled toan ALJ hearing. ALJ hear ings can t ake a year to sched-ule, making th em less useful in situ ations where you needcare quickly.

Standard Medicare review:If you d o not qu alify for an expedited Medicare review, youma y use t he r egular Medicar e review process, as follows:

You must first appea l the decision th rough t he MCOsappeals pr ocedures. If you are a ppealing a denial of care,th e MCO must ma ke a decision with in 30 days; if you areappealing a denial of payment for care a lready r eceived,th e HMO must m ake a decision within 60 days. Then, if your MCO still denies th e benefit , referral or pa yment ,th e MCO must a ut omatically forward your complaint or

disagreement t o th e CHDR.CHDR will review the MCOs decision a nd iss ue a ru lingwithin th e same time frames listed above. If CHDRagrees with your MCO to deny the hea lth care or paymentfor t he care, you can a ppeal furt her by requesting a nAdministra tive Law Ju dge Hearin g (ALJ ). You mustrequest a hear ing within 60 da ys after you r eceive theCHDR decision. Usua lly, you m ust appear in person forth is hearing. ALJ s often t ake 1 year to schedule.

Medicar e ru les tak e precedence over New York S ta te law.Contact the organizations listed on pa ge 8 for possiblechanges t o the pr ocedur es described in th is Guide or if youhave other questions about Medicare and m ana ged care.

For people on M edicare, please rem ember, once

you join a n M CO, you can n o longer get your

health care through fee-for-service Medicare.

For the tim e being, you can di senroll (drop out

of) any M edicare MCO at an y tim e and return to

fee-for-service Medicare.

YOUR RIGHTS IF YOU RECEIVE

Medicaid New York Sta te law r equires m an y people who receiveMedicaid to enr oll in an MCO. In some a reas of the sta te,people on Medicaid will be requ ired t o join MCOs. Somepeople will not be requir ed to join MCOs.

For some people on Medicaid, joining a n MCO is volunt ar y:I You live in an a rea wher e there a re not at least 2

MCOs.I You are in a residential a lcohol/substa nce abuse tr eat-

men t facility.I Most people with m enta l reta rdat ion or development al

disabilities (conta ct your local ARC or U CP forspecifics).

I You are disabled and in a special home care waiver pr o-gram.

I You are a Nat ive American.I You r eceive both Medicaid an d Medicare.I You ha ve a chr onic medical condit ion a nd a re receiving

ongoing care from a specialist wh o is not in a nyMedicaid MCOs net work.

I You h ave H IV/AIDS.I You r eceive SSI.I You ar e homeless.I You are an adu lt or child with serious ment al illness.

I If plans cant pr ovide a P CP who speaks your language.I If ther e are no PCPs within 30 minut es tra vel from

your home.I For good cau se.

Some groups of Medicaid r ecipient s will not be able t o joinMCOs:I You receive car e th rough a Long-Term H ome Health

Care Program .I You a re in a sta te psychiatric facility or r esidential

facility for children .I You ar e in a nu rsin g home or h ospice facility.

I You ar e expected to be Medicaid eligible for less t ha nsix month s.

I Foster Children.

Conta ct the organ izat ions listed a t t he end of this sectionfor u p-to-da te informa tionth e categories of people whoeither m ay or ma y not join an MCO could chan ge over th enext year .

If you join a M edicaid MCO, h old on to your M edicaid

card. Y ou will need it to get prescription dru gs, medicalsup plies, over-the-count er med ications w hen a d octor pre-

scribes them an d certain other benefits which m ay include

family planning, transportation and dental care.

For people with HIV who receive Medicaid:Curr ently Medicaid recipients with H IV and t heir chil-dren a re not requ ired to enroll in MCOs. Soon th ere willbe Special Needs Plan s (SNPs) in some par ts of th e Sta tefor people with H IV. SNP s will have to provide compre -hen sive services for H IV. If ther e is an H IV SNP in yourpart of th e Stat e, you and your children will have tochoose between a n H IV Special Needs Pla n (SNP) an d aregular Medicaid MCO. If you live in a par t of the Sta tewhere t her e ar e no HIV SNPs, you wont h ave to join aMedicaid m ana ged care plan.



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If you do enroll in a Medicaid MCO SNP you ha ve the sa merights th at all consum ers ha ve as described in t his guide.

For More Informat ion about H IV S N Ps contact:

I NYS AIDS Coalition: 518-426-2396

I NYS Depar tmen t of Health AIDS Inst itut e: 518-486-1383.

P e op l e o n M e d i c a i d w h o a r e en r o l l e d i n M C O s h a v e

t h e s a m e r i g h t s a s a l l c on s u m e r s u n d e r t h eMan aged Ca re Consu m er s B i l l o f R igh t s descr ibed

i n t h i s gu i d e .

In a ddition, ther e are other ru les that apply to people onMedicaid enrolled in MCOs:I You have th e right t o cha nge your MCO.I The r ules for when an d how often you can switch from

one MCO to anoth er var y based on where you live andwheth er you picked a plan or were a ssigned to one.Cont act th e organizations listed at th e end of th is sec-tion to find out which t ime fram es apply to you.

You have th e right t o chan ge your PCP:I W i t h i n 3 0 d a y s of your first visit with tha t P CP.

However, most MCOs let you chan ge your PCP when-ever you wan t t o.

I After th at initial time per iod, only once every 6 month s.

You have t he right to see your HCP within 1 h our of yourscheduled appointment time.

Medicaid MCOs cannot discriminate against you becauseof your hea lth pr oblems or disabilities, or becau se you a reon Medicaid. Also, MCOs can not discrimina te a gainstyou for filing compla int s or grievan ces.

Your Righ t to Informa tion: Along with t he informa tiontha t MCOs must give al l consumers in the member h and-book or mem ber cont ra ct, MCOs th at serve people onMedicaid mus t a lso provide the following inform at ion toMedicaid recipients:I How the plan addresses t he n eeds of people who are

visually or hear ing impaired.I Notice of your right t o a Medicaid Fa ir Hear ing and to

Aid Continu ing whenever a hea lth ser vice or benefit isdenied.

I For women , notice of your r ight t o self-refer forwomens h ealth needs, at no additional cost to you, t oan y women s hea lth care pr ovider of your choicewheth er th at HCP is in your MCOs network or outsidetha t network.

Your right to a hea lth care p rovider who will meet yourneeds:The Commissioner of Hea lth h as est ablished specificstanda rds tha t Medicaid MCOs must m eet .These s tan -

dar ds ar e included in t he cont ra cts Medicaid MCOs signwith th e Departm ent of Social Services. These standa rdsspell out acceptable:I Ratios of HCPs t o patients.I Travel distances and tr avel times to HCPs.I Waiting times to get an appointm ent or a referra l to an

H C P .

Medicaid managed care consumer complaint rightPeople on Medicaid ha ve the sa me r ights as other con-sumer s as outlined in t he sections on GrievancePr ocedur es a nd Utilizat ion Review. In addition, peoplereceiving Medicaid have th e right t o ha ve their com-plaints r esolved thr ough the Medicaid Fair H earin gprocess which is externa l to all health insur an ce plans.When you request a Fa ir Hear ing you can r equest AidContin uing, that is, tha t ongoing car e continue dur ing thFa ir Hear ing process.

Here is h ow th e process works:I Your MCO n otifies you th at a Medicaid ser vice or ben

fit h as been den ied, suspen ded or discont inued.I You have 60 days to request a F air Hea ring, butI If you want Aid Contin uing you mu st requ est a F air

Hear ing within 10 da ys of the da te on th e notice fromyour MCO. If you do not get a writ ten notice, you canget Aid Continu ing at a ny time.

Request a Fair H earing even if you t hink t hat your MCOma de a mist ake. You can a lways can cel your request laterif your complaint is resolved t o your sat isfaction before thhear ing dat e. Most Medicaid notices say you can r equest conference or a hear ing. Always request a h earing,because you can only get Aid Cont inu ing if you r equest a

hearing.To ask for a Fair Hear ing contact:

NYS Dept. of Health ,PO Box 1930, Albany, N Y 12201,518-474-8781 or 212-417-6550.

If you are disa bled or t oo ill to att end a Fa ir Hea ring, youcan request a home hearing. The Depart ment of Heal th(DOH) will schedu le either :

I A hear ing that your represent ative atten ds, orI A telephone hear ing, orI A paper h earing.

You get to choose wh ich type of hea rin g.If you dont geteverything you a sked for from th at hear ing, DOH willau tomat ically schedu le a home hearin g in your h ome wiAid Cont inuing.

For More In form at ion About Medicaid & MCOs cont act:I Dept. of Hea lth Ma na ged Care H otline: 800-206-8125

I Legal Aid Societys H ealth Law Un it, 212-577-3575,TTY/TDD 212-577-3581, or u pst at e call t oll free: 888-500-2455

I New York Legal Assista nce Group: 212-750-0800, ext153

I NYC Mana ged Car e H elpline: 800-505-5678I Great er U psta te La w Pr oject: 800-724-0490I Commu nity Service Society H elpline: 212-614-5400I Legal Action Cent er (for quest ions a bout a lcohol an d

dru g t reat ment ): 800-299-4121.I Your local lega l ser vices or legal a id office.

10 G UI DE TO N E W YO RK S M AN AG E D C AR E B IL L O F R I GH T S


11/16

A WOMANS RIGHT TO

Womens Health Care

Services Applies to Managed Care Organizations only.

Any woma n enrolled in a n MCO can self-refer, th at is,make a ppointments without a referral f rom a PCP or the

MCO, 2 times a year t o any ob/gyn in t he MCO's network,for r outine womens hea lth car e. In addit ion, an enr olleecan self-refer for:I Any ob/gyn care relat ed to pregna ncyI Pr eventive and pr imar y ob/gyn services to deal with a

health problem found dur ing an ob/gyn visit .I Trea tm ent of an acut e gynecological condit ion.

The plan ma y not cha rge you a ny more for t hese ser vicestha n would be norma lly char ged if the plan m ade th ereferral.

For women in Medicaid MCOs:Your MCO must let you kn ow th at at no additiona l cost toyou, you h ave th e same r ights as a ll female consu mers inMCOs, plus you can go to an y women s hea lth careprovider you choose, even if th at provider is outside th eplan s n etwork, for:I All types of birt h contr ol.I Sterilization.I Testing and treat ment for sexually tr ansm itted dis-

eases(STDs).I Testing for womens h ealth problems including a nemia ,

cervical cancer, hypertension, breast disease, pregnan-cy and p elvic problems.

I Abortions.I Edu cation a nd coun seling relat ed to the list a bove.I HIV testing; pre-test a nd post-test couns eling when it

is part of a r egular women's health services visit .If your MCO cann ot provide you with a women s hea lthservice, they mu st t ell you where you can go to get th isservice at no extra cost to you.

YOUR RIGHT TO

Information From Your

Health Care Provider Applies to al l health plans.If you requ est it , a HCP m ust give you inform at ion abouther/his qua lificat ions, t ra ining an d experience.A health plan cannot pun ish or forbid a H CP from:I Fu lly inform ing you or your repr esenta tive of all the

treatm ents , therapies , consul tat ions or t ests tha t applyto your cond ition or diseas e, even if your pla n does notcover th em.

I Explaining how the plans requirement s and limita -tions a ffect you.

I Advocatin g on your beha lf.I Reporting t o the Stat e a plans pra ctices th at th e HCP

believes has affected t he qu ality of health car e.

YOUR RIGHT TO

A Doctor or Health Care

Provider Who Will meet

Your Needs Applies to Managed Care Organizations only.

Your Right t o an MCO With Enough Hea lth Car eProviders:

I MCOs mu st h ave enough HCPs within a r easonabledistan ce from wher e its members live to meet th e mem-bers needs .

I Every member m ust have a choice of at least t hree (3)PCPs, prima ry care providers.

The Hea lth Comm issioner mu st look a t t he following todecide if th e MCO can meet the needs of the people it sa ysi t wants to serve:I The requirem ents in t he American s with Disability Act,I Whether an MCO is able to meet the n eeds of people

who have tr ouble comm un icat ing in English or are

from different cultures, an dI Complaint s about waiting times t o get appointmen ts or

referra ls to HCPs.

Your right t o specialty care:I Out -o f -ne tw ork re f e r ra l s :

If your MCO, consulting with your prima ry care pr ovider,decides tha t t he MCO doesnt h ave a pr ovider in th eir net -work with t he tr aining and experience you n eed, the MCOmu st refer you out of th eir network at no extr a char ge toyou. This decision mu st be par t of a tr eatm ent pla napproved by the MCO.

I S t a n d i n g R e f er r a l s t o S p e c ia l i s t s :

If the MCO, consulting with your P CP a nd your specialist,decides tha t you need ongoing care from th at specialist,you can get a ser ies of referra ls at one t ime so you dontha ve to go back and get a new referra l from your PCPeach time you need to see the specialist. This is called astanding referral.

For peop le w i th l i f e-th r ea ten in g or d i sab l in g &

degenera t i ve d i seases or cond i t i ons :

If you n eed specialized medical care over a long per iod oftim e, you can, at n o extr a cost t o you:I Get a r eferra l to a specialist who will then act as your

PCP a nd coordinate your care.I Get a r eferra l to a specialty car e cent er (such as a can-

cer institut e).

Ei ther of these must be part of a t r eatment plan tha t yourMCO has ap proved after consultin g with you, your sp e-cialist , your PCP , and t he MCOs medical director.

Your right t o continue to see your current healthcare providerWhen you join an MCO, if you ar e gettin g ongoing trea t -ment from a provider who is not in t hat MCOs net work,the MCO must pay for you t o continue seeing yourprovider, as long as your provider meet s th e MCOsrequirements and a grees to their payment rat es , in thefollowing 2 cases only:

G UI DE TO N E W YO RK S M AN AG E D C AR E B IL L O F R IG H TS 11


12/16

I If you h ave a life threat ening or disabling & degenera-tive disease AND you ar e un dergoing a course of treat-men t for it, you can cont inu e to see your cur ren tprovider for u p t o 60 d a y s.

I If you are in t he second or th ird tr imester of pregna ncy,you can cont inue seeing your cur ren t HCP t hr oughyour delivery an d for a period of tim e after your deliv-ery, u s u a l l y 60 d a y s.

When your H CP leaves th e plan if you a re gettin g ongoingtr eatm ent from tha t provider, the MCO must pa y for you

to continue seeing th at provider, (except if the HCP ha sleft or been dismissed for frau d, imminent h arm topat ient care or St at e san ctions), as long as your providermeets t he MCOs requirement s an d agrees to th eir pay-ment r at es, for:I Up to 90 da ys after youve been notified th at your

provider is n o longer in th e planI If you are in t he second or th ird tr imester of pregna ncy,

th rough your delivery an d for a per iod of tim e afteryour delivery, u s u a l l y 60 d a y s.

YOUR RIGHT TO

Prevent ive Care

for Your Children Applies to all types of plans.

There are no co-payments allowed for im m un iza-

tions or any other preventive health services for

children und er 19 years old.

If your children have no health insurance, you m ay

be eligible for a New Y ork S tate program called

Child Health Plus wh ich provides health insur -ance coverage for child ren through age 18. For

m ore information call 1-800-698-4KIDS .

YOUR RIGHTS FOR 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 enr ollees or people thinking a bout enrolling in a nyplan, you ma y want to investigate th e following informa-tion a plan mu st give you if you r equest it:

I Whether the plan will pay for a certa in drug, and t heright to inspect th e list of drugs th e plan will pay for,known as th e form ular y.

I A descript ion of the pr ocedur es th e plan follows todecide whether dr ugs, devices or t reat ment s ar e expement al or investigational. Plans m ay not cover these syou m ay want to find out exactly what the plan willan d wont cover. But , even if a pla n d ecides n ot to cove

a ben efit , you m ay be able to get coverage th rough NewYork St at es extern al a ppeal pr ocess.Read th at sectionon pages 7-8 careful ly.

I The clinical r eview criteria for a par ticular condition ordisease and a description of how the plan uses th at criter ia to decide what ben efits a nd r eferr als ar e covered.The plan mu st a lso tell you wha t other types of clinicainformation th e plan might r eview in ma king a decisio

I The h ospital a ffiliations of part icular health careproviders.

I Benefit l imits and prior auth orization requirement s;th is informat ion m ust be given to you with out yourrequesting it .

Also, you can a sk a ny licensed HCP to provide you withinform ation on her or his qua lificat ions, tr aining a ndexperience, including par ticipation in continu ing educa-tion pr ogra ms. Th is inform at ion will help you decide if apar ticular HCP can meet your n eeds.

Read over the section in this Guid e called, You r Ri ght t o

an E xternal A ppeal on pages 7 and 8. If your plan denieyou n eeded care because the plan sa ys it is not medicallynecessary or becau se the plan says it isexperimen ta l/investigat iona l or a clinical tr ial, you canask t he Sta te for an exter na l appeal. These appeals willbe decided by independent , external r eviewers with m edical expert ise who may overtu rn your plan s decision.

Applies only to Managed Care Organizations.S ee pages 11-12 for an explanation of your right to:

I Out-of-network referrals;I Sta nding referra ls to specialists;I Having a specialist act as your PCP or getting a refer -

ral t o a specialty care center if you h ave a life-thr eatening or disabling an d degenera tive disease or condition

Your Right to Cont inue Seeing your Cu rr ent H CP:S ee pages 11 and 12 of this guid e for an explan ation of you

rights wh en you enroll in an MCO or when your providerleaves your M CO.



13/16

YOUR RIGHT TO

Purchase HealthCoverageIf you do not have health insurance you are guar-

anteed th e right to purchase health coverage in

New Y ork. N ew Y ork law requires HMOs to sell

every individ ual a h ealth insu rance policy.

The law provides importan t consu mer protections in th osepolicies, including:I You can not be charged m ore becau se you h ave a health

problem. Uniform pr emium r at es are set for each HMOin ea ch ar ea of New York .

I The ben efit pa ckage is compreh ensive so it will meetth e needs of most consumer s, including people whohave ser ious heal th problems.

I HMOs m ust offer individua l consu mer s th e choice of aPoint of Service (POS) plan . POS options ar e moreexpensive but they a llow you to go to HCPs outside t heHMOs net work a t h igher out -of-pocket cost s to you. Ifyou u se th e POS option, th e HMO will usu ally cha rge

you a dedu ctible and t hen t he HMO will pay a percent -age of th e usu al an d cust omar y cost of th e benefitwhich may be considerably less th an wh at a providercharges.

I Rules are set on when a H MO must cover a pre-existinghealt h condition. (S ee details on p age 14.)

I You are guar ant eed, by Federal law, the r ight to renewyour policy, as long as you pa y your prem ium s, dontmove out of th e plan s service area or comm it frau d.

Shop aroun d for coverage. The Stat e Insur an ceDepart ment publishes a book which lists all the HMOsth at sell individual coverage, including their ph one num -bers. To get th e book, ca ll 1-800-342-3736and a sk for t he

C on s u m e r s G u i d e f or S t a n d a r d I n d i v i d u a l H M Oa n d P o i n t o f S e r v i ce C ov e r a g e .

Health Insurance for Children through age 18:If your children ha ve no health insur ance, you m ay be eli-gible for a N ew York Sta te pr ogra m called Child HealthPlus which provides hea lth insur an ce coverage for chil-dren t hr ough age 18. For ma ny families, Child Healt hPlus policies are m uch less expensive tha n regula r HMOpolicies, since New York St at e pays pa rt of th e cost(depending on income). F or m o r e i n f o r m a t i o n a b o u t Ch i ld Hea l th P lu s ca l l 1 -800-698-4KIDS .

Health Insurance for Adults between the ages of 19

and 64:If you h ave no hea lth insu ra nce, you m ay be eligible for anew New York Stat e program called Fam ily Health Plus,which will provide health insu ra nce covera ge for adu lts.The pr ogra m is expected t o begin in October 2001. It willprovide free insu ra nce for adu lts who qua lify and is fun dedby both t he Stat e and the Federa l government s. F or m o r ei n f o r m a t i o n a b ou t F a m i l y H e a l t h P l u s , ca l l t h e N Y S

Depa rtm ent of H eal th tol l free: 877-934-7587.

YOUR RIGHT TO

Continue Your HealthCoverage if You Lose orChange Your J obApplies to all types of plans.A federal law kn own a s COBRA provides health insura nceprotection for people who lose th eir hea lth insur an ce for avariet y of rea sons. COBRA app lies to all plans, even self-insured plans th at a re normally exempt from state laws.

If you received your h ealth insura nce thr ough youremployer and your em ployer ha d 20 or m ore employees,your employer mu st cont inue t o offer group h ealth insur-ance to you a nd your depend ents after you lose yourinsu ra nce. You ha ve to pay th e full cost of the policy an dmay be charged an additional 2%, but th is may be lessexpensive tha n buying private insur ance. You shouldcompa re t he cost of cont inu ing covera ge und er COBRAwith buying an individua l HMO plan described above.

New York Sta te Law expan ds th is coverage t o includeemployers with as few as 2 employees.

Your r ight t o purchase coverage un der COBRA is limitedto 18 month s after you lose your insu ra nce (29 month s forpeople on Social Security Disability). COBRA covers:I Worker s who lost their jobs or ha d th eir hours sh ar ply

reduced.I These workers spouses and dependents.I Coverage is expanded to 36 month s for sp ouses a nd

dependent s who lose insura nce coverage because of aninsu red em ployees dea th , divorce, legal sepa ra tion or ifth e dependent s lose coverage because th ey reached th eage when coverage thr ough the par ent(s) ends.

G UI DE TO N E W YO RK S M AN AG E D C AR E B IL L O F R IG H TS 13


14/16

YOUR RIGHT TO

Coverage forPre-existing Conditions Applies to all types of plans.A m ajor nightm are for people who lose health

insu rance or chan ge health plan s is wh ether the

new p lan wi ll include coverage for pre-existingconditions.

Th e federal Health Insu rance Portability &

Accoun tability Act (HIPAA), backed up by N ew

York S tate law, provides important protections for

people with existing h ealth problem s wh o switch

health insurance plans. The federal law applies toall plans, even self-insured plans.

A pre-existing condit ion is a condit ion wh ich h as beendiagnosed or for wh ich you ha ve received tr eatm ent in thpast six months. These a re t he only conditions for which

an insu ra nce compa ny can im pose limit s. (If you receivedtrea tment earlier than t he last six months - but did notreceive any tr eatm ent or care dur ing the past six mont hsth e insur an ce compa ny can not impose any pre-existingcondition limits).I In order to qualify for the p rotections on pr e-existing

conditions you m ust not allow your health insur an cecoverage to lapse for more th an 63 days.

I If you ha ve had contin uous coverage for one-year befoswitching health plans t here is n o exclusion for pr e-existing condit ions.

I A plan m ust cover all condit ionsincluding pr e-exist-ing conditionsafter one year .

I You get a credit towards t ha t year for every month inth e previous year th at you h ad cont inuous coverage.For exam ple, if you work a t one job for 11 month s an dth en m ove to a new employer a nd t he new emp loyerha s a 12 month pre-existing condition limit - th en th enew plan m ust give you credit for t he 11 month s.


How to order more copies of this Consum ers Guide:

I The first copy of th e Guide is free.

I To ord er on e copy u se t his form or call: (518) 465-4600.I

For quan tity orders, please use th is form :The charge for qua nt ity orders is:

2-99 copies @ 25 cen ts a copy.*

100 or m ore copies @ 20 cent s a copy.*

*Add $5.00 for shipping an d ha ndlin g.I Please send me:

____ copies of the Con su me rs Gu ide .

$____ enclosed in a check t o PP EF .

Name: ___________________________________________

Organization: _____________________________________

Address: _________________________________________

Cit y: _____________________ Sta t e: ______ Zip: ________

P hone: ( ) _________________ F a x: _________________I Mail to: NY Guide, PP EF , 94 Cent ra l Avenue,

Albany, NY 12206.I Order s m ay a lso be placed by faxing (518)465-2890 or

by ema iling PP EF @citizena ctionn y.org.

Please include a VISA or Mast erCard n umber a nd

expira tion dat e with fax or ema il order s.

Ca rd Nu m ber : ______________________ E xpir es: ______

Managed Car e Consumer

Assistance Programs (MCCAP)

There ar e a nu mber of MCCAPs in New York St at e tha tprovide free help to New Yorkers with h ealth insur an ceproblems, including denials of care. MCCAPs are listedby the area each serves.

Broome & Tioga Counti es: Cit izen Acti on Binghamton:

607-723-1350 or call t oll free 8 77-706-2227 or em ail:MCCAP2@hotm ail.com. This pr ogram a lso provideseducation and t ra ining for consumers , advocates andproviders on consumer r ights in health care.

Nassau County: The Long Isl and Progressive Coali ti on:516-616-3345 or ema il: mccapli@hotm ail.com. This pr o-gram also provides education and t ra ining for con-sum ers, advocates an d providers on consu mer r ights inheal th care.

New York Cit y: The Community Service Societ y coordi-nat es a NYC program t ha t cont racts with commun ity-based organ izations to provide assistance with m an -aged care problems in a variety of langua ges. Call 212-

614-5400, TTY/TDD 212-505-5522 for assistance and/orreferral to th e MCCAP a gency tha t can h elp you.

S t a t e w i d e :

The Legal Aid Societ ys Healt h Law Unit provides freelegal advice to individua ls, providers a nd a dvocat eswho have problems with ma naged care plans. In NewYork City ca ll: 212-577-3575, TTY/TDD 212-577-3581or up sta te call toll free: 888-500-2455.

The Medicare Right s Center (MRC) opera tes astat ewide hotline for people with Medicar e an d t heircar egivers to get help with hea lth care quest ions a ndproblems. The hotline is open Monda y to Thu rsda y

from 9am to 2pm at toll-free: 800-333-4114.


15/16

GUIDE TO NEW YORKS MANAGED CARE BILL OF RIGHTS15

AS A CONSUMER OR A HEALTH CARE PROVIDER,

Wed like to hear from you!We need to know about your problem s with m anaged care and health in surance to m ake sure New Y orks

new m anaged care law is w orkingso please fill out the form below or call and tell us about an y prob-

lem s youve had with m anaged care or health insurance.

PLEASE NOTE: If you wish, your identifying information will be kept confi-

dent ial, but we would like to be able to cont act you, so please pr int your :

Name:

Da y phon e ( ) E ven in g ph on e ( )

Address:

Did this problem h appen t o you?

If this problem ha ppened to someone else, can we contact t ha t person a nd h ow do we do that ?

Can we use your na me with your story? (yes, no, ma ybe: call me)

WHAT HAPPEN ED? Briefly describe th e specific problem, an d, if you can, t he d at es.

Did you cont act your p lan to resolve th e problem? If so, what ha ppened?

Did you conta ct the St at e Dept. of Health, th e Insu ran ce Dept. or t he Attorney General? If so, who and wh at happen ed?

Did you t ur n t o anyone else for help? Who and wha t h appened?

How was th e problem resolved?

F ee l f r ee t o a t t a c h a d d i t i o n a l p a g e s

Return to:Mana ged Car e Problem Form

Pu blic Policy Education Fu nd94 Cent ra l Avenue, Albany NY 12206

(518) 465-4600

800-636-BILL (2455)


16/16

IT U SE D TO BE th at decisions a bout your health car e were betweenyou an d your doctor or other h ealth car e provider. Your h ealthinsura nce compa ny didn't int erfere; it just paid t he bills. But

th at s no longer t ru e. In the new world of hea lth car ecalled ma n-aged careyour insur an ce compa ny often ma kes h ealth car e deci-sions. Your health car e insur an ce compa ny decides whether to

approve th e health care procedures an d trea tm ents r ecomm endedby your doctor or other hea lth car e provider.

In 1996 New York Sta te passed a law which we call The ManagedCare Consum ers' Bill of Rights. This law, and oth er laws, providerights an d pr otections to consu mers to improve your access t ohealth car e and help you r esolve problems with your health insur -an ce company.

The Consu mer s Guide t o New York s Mana ged Car e Bill of Right sexplains key featu res of New Yorks laws in simple terms. TheGuide also describes other import an t r ights, including r ights forconsu mers who have chronic illnesses or disabilities, for women an dchildren , for consum ers wh o ar e covered by Medicar e an d Medicaid,

and rights for people seeking to purchase h ealth insura nce.

We need your h elp! We wan t t o un derst an d if th ese laws are work -ing. Please fill out th e form on page 15 of this booklet a nd t ell usabout your experience with m an aged care. By collectin g the expe-riences of New Yorker s th roughout our St at e, we can learn howwell the law is working-an d wha t else n eeds to be done t o impr oveconsu mer protections.

Sincerely,

Richa rd KirschResearch Director, PP EF

The Pu blic Policy and Education Fu nd

is a research and educat ion inst i tut e

th at focuses on a var iety of consu mer

issues including health care a nd cam-

paign fina nce reform. To mak e a t ax-

deductible contribution, mail to PPEF,

94 Cent ra l Ave., Albany, NY 12206.

Special than ks for th eir comments a nd

corr ections to: J oe Baker, E lisabeth

Benjam in, Doug Cooper, Su san Dooha ,

Helen F ar rell, Vickie Gott lick, Cath y

Hur wit , Suzanne Levin, Chris ty

Margelli, Gail Myers, J udith Ng, Brad

Plebani, Mark Scherzer, Ellen Yacknin

PP EF t ha nks t he following foundat ions

for t heir su pport of work t o strength en

consu mer p rotections: Robert St erling

Clark Foundation, J P Morgan, New

York Commu nity Trust , Altman

Founda tion, Public Welfar e Founda tion

Assistan ce for pr int ing this edition of th

Guide was provided by the Health care

Associat ion of New York St at e.

THE CONSUMERS GUIDE TO N EW YORKS

MANAGED CARE BI LL O F RIGHTS is a pub

licat ion of th e Pu blic Policy an d

Edu cation Fu nd of New York 2001.

The Guide was wri t ten by Laura Kapla

and edited by Richa rd Kirsch.

HERES THE

Consumers Guide to New Yorks

Managed Care Bill of RightsYOU REQUESTED!

Cit izen Action of New York

94 Centra l Avenue

Alban y, NY 12206

Non Pr ofit Org.

U.S. Postage P aid

Alban y, NY

Perm it #621

the consumers' guide to new york's managed care bill of rights

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