Managed Care Bill of Rights

Article 44 of the New York State Public Health Law gives these rights to enrollees of managed care organizations. You may also ask the health plan for this information before you join the plan.

• You have a right to know what health care must be given to you by the plan, as well as any limits on care, and which types of health care are not covered.
• You have a right to know about any treatments or health care which your plan needs to approve in advance.
• You have a right to know what steps you can take if the plan will not cover a service. This includes the toll-free phone number of the person who will review the plan's action, how long it will take until the review is done, how to appeal the plan's action, and how to file an independent external appeal with the State. You also have a right to have someone speak for you in any disputes with the plan.
• You have a right to know, each year, how the plan decides on how much it will pay to doctors and health providers who belong to the plan.
• You have a right to know about any fees you will have to pay, any amount you have to pay yourself before the plan will start paying, and any caps (maximums) or yearly limits on plan payments. You also have a right to know what you will have to pay for health care not covered by the plan.
• You have a right to know about what you will have to pay if you go to a doctor who is not part of the plan, or if you get care that the plan has not approved in advance.
• You have a right to file a grievance about any dispute between you and the plan, and you have a right to know just how a grievance should be made.
• You have a right to go to the emergency room 24 hours a day for any health problem that threatens your life. You do not need the plan to approve this in advance.
• You have a right to a list of the plan's doctors, as well as to learn which doctors are taking new patients.
• You have a right to know how you can change to a new doctor within the plan.
• You have a right to a see a doctor outside the plan if the plan does not have a doctor who can meet your health needs, but your primary doctor must set this up for you.
• If you need to keep on seeing a special doctor (specialist), you can ask to be allowed to see that doctor as needed, without going through your primary doctor. Your plan must explain to you how you can do this.
• If you have a very bad health problem that requires you to be seen by a special doctor for a long time, you can ask to have your special doctor be your primary doctor. The plan must tell you how to make such a request.
• If you have a very bad health problem that requires you to be seen by a special health care center (for example, a hemodialysis center) for a long time, you can ask to go there when you need to, without going through your primary doctor. The plan must tell you how to make such a request.
• You have a right to know how you can have input in how the plan makes its rules.
• You have a right to know how the plan meets the needs of plan members who don't speak or read English.
• You have a right to know the correct mailing address and phone number to be used by plan members who need to know something or who need the plan to approve a health service.
• You have a right, as a female enrollee, to see a plan gynecologist or obstetrician for at least two exams per year and for all pregnancy care, without a referral from your primary doctor.
• You have a right to a list that the plan updates once a year, of the name, address and phone number of each health care provider who belongs to the plan. This includes special doctors (specialists). You also have a right to know the level of training that the plan's doctors have, and which ones have advanced training so they can practice in special health areas (board certification).