NY Managed Care Act
New York’s Managed Care Reform Act, enacted in 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.
Information You Should Know
Every health plan must disclose specific information to consumers—members of a health plan and those people considering joining a plan.
This consumer information will be provided in the plan’s member handbook, subscriber contract and member newsletters. Other information must also be provided at the request of a consumer. A partial list of the information that must be provided to all health plan members or those people thinking of joining a plan includes descriptions of:
- Plan benefits and coverage—the services the health plan will pay for and any limitations, such as dollar amounts, number of visits allowed, or any other limits.
- How the plan defines “medical necessity.”
- Prior authorization requirements. The plan will probably have provisions relating to when you must get approval for some services before receiving those services.
- How the health plan pays health care providers for the services given to patients that are members of the plan.
- Member’s financial responsibilities—or what your costs are—including co-payments or deductibles, payments for charges that are above what the plan considers “usual and customary” and paying for services not covered by the plan or services received from a provider outside the plan’s network.
- Grievance procedures and appeals rights, including the plan’s toll-free number, the process for filing a complaint and how long it will take to receive an answer. (See the section on “grievances and appeals” for more details.)
- Procedures to select and change your primary care physician (PCP).
- List of providers in network, listed by specialty.
- Coverage for emergency services (see the section on Specialty and Emergency Care Needs for more information).
Upon request, a plan must provide members or those people thinking of joining a plan with the following (partial list):
- Information on consumer complaints.
- Confidentiality procedures.
- The ability to inspect the health plan’s prescription drug formulary.
- Description of procedures used to evaluate requests for experimental and investigational treatments.
- Hospital affiliations of individual physicians.
- Specific written treatment protocols for a particular disease or condition.
Questions about Coverage and Care
Specialty and Emergency Care Needs
Independent External Appeal
There is much discussion focused on the rights that consumers have as members of managed care health plans.
However, consumers also have certain responsibilities. Knowing and accepting your role as a health plan member will help ensure the system works for you.
- To become informed about the benefits provided by your plan and procedures for receiving health care services.
- To provide, to the extent possible, information that your doctor and the plan’s professional staff need to know to care for you.
- To work with your doctor(s) in the coordination of your care and follow the treatment plans of all health professionals involved in your care.
- To keep your plan informed of any changes in your personal status, including name changes, changes in who is covered (a change in marital status or number of dependents) or change of address.