Health Benefits...Any Questions?

HealthBenefits Updated February 12, 2002 - Health Benefits Homepage
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Frequently Asked Questions

Health Benefits...Any Questions?
According to Lorraine Simpkins, PEF Health Benefits Specialist, members frequently ask the following questions about their health insurance coverage.

QUESTION: What recourse do I have if I disagree with a determination made by my HMO or Empire Plan insurer?

ANSWER: Each health care plan offered to PEF members has an appeal procedure. When an HMO or Empire Plan insurer has determined a medical service or item isn't covered, in whole or in part, a review of the determination may be requested using this procedure. Details on how to file an appeal are in the plan's benefit booklet or member handbook.

QUESTION: What can I do if I'm not satisfied with the outcome achieved through the plan's appeal procedure?

ANSWER: Members who wish to pursue their appeal further should contact the PEF Joint Committee on Health Benefits (JCHB), through Simpkins. Simpkins will conduct an investigation of the complaint that includes contacting the HMO or Empire Plan insurer to obtain an explanation of the determination. She will then report her findings to the PEF JCHB. If the PEF JCHB decides the response is inconsistent with their understanding of Article 9 of the PEF/NYS contract, or the health plan's contract with the State, they will present the appeal to management for resolution. If management upholds the plan's determination, the PEF JCHB, in consultation with PEF's Contract Administration Department, will determine whether or not to file a contract grievance.

QUESTION: What can I do if I'm not satisfied with the outcome achieved through the JCHB's appeal process?

ANSWER: The member can file an external appeal, which is described in the following Q&A. In addition, at any point a member may contact one of the three state agencies that oversee health insurers and HMOs. These agencies are the NYS Department of Insurance (DOI), the NYS Department of Health (DOH), and the Office of the Attorney General.

For problems related to the payment of benefits, members may contact the Consumer Services Bureau of the NYS DOI at 1-800-342-3736. DOI assures that an insurer's actions are in accordance with NYS Insurance Law; Insurance Department rules and regulations; and contractual provisions.

HMO enrollees who are unable to get the care they need, or who are dissatisfied with the quality of care they are receiving, may contact the DOH Managed Care Hotline at 1-800-206-8125. DOH is responsible for the authorization and regulation of HMOs in the state, and assures the delivery, continuity, accessibility and quality of health care services are satisfactory.

For problems where you think a law has been broken or fraud might be involved, members may contact the Attorney General's Health Care Bureau at 1-800-771-7755.

Finally, a member may wish to file a lawsuit against the HMO or insurer when all other attempts to resolve the matter have failed.

QUESTION: How does the external appeals process work?

ANSWER: The external appeals process is for all health-care services denied on the grounds that the service is not medically necessary. There is also an external review process for patients with life-threatening or disabling conditions who want to participate in clinical trials, use off-label drugs, or use experimental or investigational procedures or treatments when such services are denied on the basis that they are experimental or investigative.

To be eligible for an external appeal, you must first exhaust the health plan's internal review process. The law permits plans to charge patients up to $50 for an external appeal, but they must give the money back to you if you win the appeal.

Randomly assigned agents certified by the state will do the external reviews. These agents are required to make a determination on an appeal within 30 days or three days for emergency cases.

Your health plan will send you more information on the external appeals process. You can find a summary of the law through the NYS Insurance Department web site by clicking on Health Related Insurance Laws.

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