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Resources > HMO Member Rights | Your Right to Appeal | Who to Contact | Additional HMO Information

HMO Member Rights

  • To a full, honest and confidential discussion with their physician about their medical needs.

  • Receive a "standing referral" to a specialist if ongoing care is required.

  • Receive care for any emergency condition at an emergency room without getting prior approval from their HMO.

  • A second medical opinion for the diagnosis of cancer.

  • See an out-of-network provider without additional cost if their HMO does not have an in-network provider for their condition.

  • If a person switches to a new HMO, the person can continue to see their current provider for 60 days if they have a life-threatening, degenerative or disabling condition or disease and their provider agrees to the new HMO's terms.

  • File a grievance if they disagree with any HMO determination other than those involving medical necessity or experimental or investigational treatment.

    • Have any grievance decided within 48 hours when a delay would increase the risk to their health.

  • Appeal through the HMO's own internal appeal process any determination that a procedure, service or treatment is not covered because it is considered experimental, investigational or not medically necessary.

    • An expedited appeal through the HMO's utilization review process if they are undergoing a course of treatment or if their doctor believes an immediate appeal is warranted.

  • An external review by an external review organization for any final adverse determination denying coverage because a procedure, service or treatment is considered experimental, investigational or not medically necessary.

  • Women are entitled to:

    • Direct access to primary and preventative OB/GYN services at least twice a year,

    • Coverage for bone mineral density measurements and testing,

    • Coverage for contraception under most group health insurance contracts.

    • Remain in the hospital for 48 hours after a natural delivery of a child and at least 96 hours after a Cesarean section delivery.

    • Continue to see their current provider for the duration of postpartum care related to delivery if they switch to a new HMO during their second or third trimester of pregnancy. The provider must agree to the new HMO's terms.

For more information go to the Your Rights as Health Insurance Consumer page.


State of New York
David A. Paterson
State of New York
Department of Insurance
Eric R. Dinallo
Superintendent of Insurance
State of New York
Department of Health
Richard F. Daines, M.D.
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