Health plan members have always had many consumer rights. But New York State also has some specific laws designed to provide managed care consumers even greater protection.
Managed Care Reform Act
The Managed Care Reform Act, in effect since April of 1997, is the most far-reaching legislation to regulate health plans in the country. The law established utilization review standards for all managed care plans, standardized grievance and appeals procedures, and requirements for providing all enrollees and potential enrollees with detailed descriptions of a managed care plan’s benefits and coverage.
Independent External Appeal
New York’s external appeal law gives health care consumers broader protection by giving them the right to have an external appeal agent (an independent panel of medical experts) review certain health plan decisions. Consumers can seek an external appeal in cases where a health plan denies coverage for care it determines is not medically necessary or when a health plan denies a treatment or service because it is experimental or investigational in nature.