Dear Friend,
Millions of New Yorkers are currently enrolled in managed care health programs, also known as Health Maintenance Organizations or HMOs.
To ensure cost-effective managed care programs don’t hurt the quality of care, the State Legislature passed the Consumer Managed Care Reform Act, providing HMO members in New York State with more protections than anywhere else in the nation.
HMO consumers also have a new protection — the External Appeal Law. This law guarantees consumers the opportunity to a review by an independent panel of medical experts if they are denied services or treatments by HMOs.
As always, if you have any questions or comments, please feel free to contact my office.
Sincerely,
Nelson L. Castro
Assemblyman
Residents of New York State have been joining Health Maintenance Organizations (HMOs) with increasing frequency. Enrollment in HMOs now exceeds six million members statewide.
HMOs provide a different system of health care than the traditional indemnity or “fee-for-service” plans that are familiar to many New Yorkers. Typically, HMOs offer benefits at a lower cost, but require members to have greater awareness of his or her obligation to access care effectively.
The Managed Care Reform Act provides consumers with the most far-reaching protections in the nation. The following are explanations of these new protections available to consumers in New York State. Greater details are provided in each member’s contract and handbook.
Sources: NY Health Plan Association, NYS Health Insurance Program
Every HMO must provide written disclosure to subscribers in their contracts or handbooks and (upon request) to potential subscribers of the following:
Plan benefits and coverage
Definition of “medical necessity”
Prior authorization requirements
Methods used for provider reimburse-ment
Member’s financial responsibilities
Grievance procedures and appeals
Member’s ability to access provider not on HMO’s network
Procedures to select and change primary care and specialty care physician
List of participating providers and facilities in an HMO’s network
Upon request, a plan must:
Provide consumer complaint informa-tion
List procedures for protection of confidential information
Allow members to inspect their HMO’s prescription drug formulary
Describe procedures used to evaluate requests for experimental procedures
Provide individual physician hospital affiliations
Provide specific written treatment protocols for a particular disease or condition
Every plan must have a grievance and appeals procedure to handle non-medical issues. This includes complaints related to billing problems, coverage issues and issues regarding dissatisfaction with providers or quality of care provided. Every plan’s grievance procedure must include:
Accessible toll-free phone line
Standard form for filing grievances and appeals
Written description of appropriate appeal procedures if coverage is denied
Time frame for responding to members after receiving all necessary information:
48 hours when delay would significantly increase the risk to an enrollee’s health
30 days in cases regarding referrals or determinations regarding coverage
45 days in all other instances
Designation of qualified reviewers, including at least one medical professional for each grievance
Appeal of grievance determination:
Members have 60 business days to appeal a grievance decision
Clinical determinations must be made by qualified personnel
Non-clinical matters require qualified personnel at a higher level than those who made the initial determination
Formal notice of an appeal determination detailing reasons for the determination and the clinical rationale
Utilization Review (UR) is done by the HMO to assess the medical necessity or appropriateness of health care treatments. These reviews can be done before, during or after treatment. All plans performing UR must:
Allow members or their physicians to appeal adverse decisions
Provide toll-free access to reviewers
Establish UR time frames for member notification and appeals
Have duly licensed and trained personnel conducting UR
Provide notice of adverse determination in writing, including reasons, and how to appeal
Have a minimum of 45 days to file an appeal
Provide standard appeal decision within 60 days
Health care consumers are entitled to an independent external review if services are denied for certain reasons. Every health plan must provide an external review application whenever they issue such denials. Consumers can also request copies of external review applications from their health plans or call the New York State Insurance Department’s External Review Information Line at 1-800-400-8882.
Appeal
A formal request by a member or provider for reconsideration of a
determination issued as part of a filed grievance or a Utilization
Review recommendation.
Drug Formulary
A listing of prescription medication preferred by the health plan.
Medical Necessity
An evaluation of health services to determine if they are medically appropriate
and necessary.
Participating Provider
Health care provider who has contracted with a health plan to deliver medical
services to members.
Point-of-Service (POS)
Known as open-ended HMOs or PPOs, these plans encourage using network providers,
but allow members to choose providers outside the plan.
Preferred Provider Organization (PPO)
A health plan that contracts with medical care providers for a discounted fee.
Prior Authorization
Obtaining prior approval as to the appropriateness of a certain service or medication.
Quality Assurance
A formal set of activities to review and positively affect the quality of services
provided by a plan.
Utilization Review
A formal assessment of the medical necessity, efficiency and/or appropriateness of
health care services and treatment plans on a prospective, concurrent or retrospective
basis.
Department of Health
Managed Care Hotline
1-800-206-8125
Department of Insurance
Consumer Services Bureau
1-800-342-3736
External Review Information Line
1-800-400-8882