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

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.

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.

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 Financial Services (DFS), 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 DFS at 1-800-342-3736. DFS assures that an insurer’s actions are in accordance with NYS Insurance Law; DFS 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.

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 Department of Financial Services web site.

How do I find out whether a service or item is covered under
my plan?

Answer: General benefit information is in the plan’s benefit booklet or member handbook. To obtain more specific benefit information, the plan’s member or customer service department should be contacted. Empire Plan enrollees who want to know beforehand how much United HealthCare (UHC) will pay for a medical service or item may submit a Pre-determination Request form.

How can I find out which doctors participate in the Empire

Answer: Members may call UHC at 1-800-942-4640. UHC’s representatives can provide the information over the telephone or a printed listing can be generated upon request. The par provider directory is also available on the NYS Department of Civil Service web site . On the Civil Service home page select Benefit Programs, then select NYSHIP Online and, if prompted, choose your group and Empire Plan. Then select Find a Provider. Enrollees should always confirm a provider’s participation status at the time they schedule an appointment.

What benefits are available if I go to a non-par provider?

Answer: Services received from a non-par provider are eligible for consideration under the Basic Medical Expense Program. The member is responsible for paying the provider and filing a claim with UHC. S/he will then be reimbursed for eligible expenses less any deductible and coinsurance amounts applied on the claim.

Are there any limitations on the number of copayments I have
to pay an Empire Plan par provider for services received during any single office visit?

Answer: There are two instances where the number of copayments is limited. First, if a par provider bills for both an office visit charge and an office surgery charge in any single visit, only one copayment will be charged for these services. Second, when outpatient radiology services and diagnostic laboratory services are performed by the same par provider during a single visit, only one copayment will be charged. However, if the par provider sends a sample/specimen to another par provider because s/he can’t perform the necessary lab services, another copayment will be charged.

UHC’s Reasonable and Customary (R&C) Charge is lower than
what my provider charged me. How do they determine their R&C Charges and how often are they updated?

ANSWER: Since 7/1/11, UHC has been using the FAIR Health, Inc. database to determine R&C Charges. FAIR Health is an independent, nonprofit organization selected by the Attorney General of the State of New York. The FAIR Health database is made up of charge data from billions of healthcare claims submitted to health insurers across the nation. The information in the database is updated by FAIR Health at scheduled times each year. The R&C Charge for The Empire Plan is set at the 90th percentile. An R&C Charge set at the 90th percentile is the amount equal to or greater than 90 percent of the charges in the database for the procedure billed in the geographic area where the provider is located (based on zip codes).

To help members estimate their out-of-pocket expenses for out-of-network care, FAIR Health has developed an online consumer cost look-up tool, available for free at www.fairhealthconsumer.org. Members can also find user-friendly educational materials at this site.

What can I do if I disagree with UHC’s R&C Charge?

ANSWER: Members enrolled in the New York State Health Insurance Program (NYSHIP) have a right to an external appeal when their HMO or The Empire Plan denies health care services as not medically necessary (including appropriateness, health care setting, level of care, or effectiveness of a covered benefit), or experimental / investigational (including a clinical trial or rare disease treatment).

You must send an external appeal application to the Department of Financial Services (DFS) within 4 months from the date of the final adverse determination from the first level of appeal with the health plan OR the health plan agrees to waive the internal appeal process. Health plans may charge you a $25.00 fee, not to exceed $75.00 in a single plan year. The fee will be returned to you if the external appeal agent overturns the health plan’s denial.

Randomly assigned external appeal agents certified by DFS will do the external reviews. These agents are required to notify you of the outcome within 72 hours for expedited appeals or 30 days for standard appeals. Your health plan is required to notify you of your right to an external appeal. For more detailed information, see the DFS web site at http://www.dfs.ny.gov/insurance/extapp/extappqa.htm

I received an Explanation Of Benefits form indicating my claim was denied because UHC can’t establish the medical necessity of my care. What should I do?

ANSWER: The member should contact UHC’s Customer Service Department to ask what additional documentation is needed to reconsider the claim. Once s/he knows what documentation is needed, the provider should be asked to either submit the documentation to UHC, or give the documentation to the member so s/he can submit it to UHC.