N.Y.
Insurance Law Section 4306-C
Grievance procedure and access to specialty care
Mentioned in
Your Rights as a Health Insurance Consumer
NY State Dept. of Financial Services, August 16, 2023
“You have many rights and protections if you have health insurance coverage through an HMO or insurer…”
Bibliographic info
(a)
A corporation, including a municipal cooperative health benefits plan certified pursuant to article 47 (Municipal Cooperative Health Benefit Plans)article forty-seven of this chapter, that issues a comprehensive contract that utilizes a network of providers and is not a managed care health insurance contract as defined in subsection (c) of § 4801 (Application)section four thousand eight hundred one of this chapter shall establish and maintain a grievance procedure consistent with the requirements of § 4802 (Grievance procedure)section four thousand eight hundred two of this chapter.(b)
A corporation, including a municipal cooperative health benefits plan certified pursuant to article 47 (Municipal Cooperative Health Benefit Plans)article forty-seven of this chapter, that issues a comprehensive contract that utilizes a network of providers and is not a managed care health insurance contract as defined in subsection (c) of § 4801 (Application)section four thousand eight hundred one of this chapter and requires that specialty care be provided pursuant to a referral from a primary care provider shall provide access to such specialty care consistent with the requirements of subsections (b), (c) and (d) of § 4804 (Access to specialty care)section four thousand eight hundred four of this chapter; provided however, that nothing in this section shall be construed to require that a corporation, or a primary care provider on behalf of the corporation, make a referral to a provider that is not in the corporation’s network.(c)
A corporation, including a municipal cooperative health benefits plan certified pursuant to article 47 (Municipal Cooperative Health Benefit Plans)article forty-seven of this chapter, that issues a comprehensive contract that utilizes a network of providers and is not a managed care health insurance contract as defined in subsection (c) of § 4801 (Application)section four thousand eight hundred one of this chapter shall provide access to transitional care consistent with the requirements of subsections (e) and (f) of § 4804 (Access to specialty care)section four thousand eight hundred four of this chapter.(d)
A corporation, including a municipal cooperative health benefit plan certified pursuant to article 47 (Municipal Cooperative Health Benefit Plans)article forty-seven of this chapter and a student health plan established or maintained pursuant to § 1124 (Institutions of higher education exempt)section one thousand one hundred twenty-four of this chapter, that issues a comprehensive policy that utilizes a network of providers and is not a managed care health insurance contract as defined in subsection (c) of § 4801 (Application)section four thousand eight hundred one of this chapter, shall provide access to out-of-network services consistent with the requirements of subsection (a) of § 4804 (Access to specialty care)section four thousand eight hundred four of this chapter, subsections (g-6) and (g-7) of § 4900 (Definitions)section four thousand nine hundred of this chapter, subsections (a-1) and (a-2) of § 4904 (Appeal of adverse determinations by utilization review agents)section four thousand nine hundred four of this chapter, paragraphs three and four of subsection (b) of § 4910 (Right to external appeal established)section four thousand nine hundred ten of this chapter, and subparagraphs (C) and (D) of paragraph four of subsection (b) of § 4914 (Procedures for external appeals of adverse determinations)section four thousand nine hundred fourteen of this chapter.(e)
A corporation, including a municipal cooperative health benefit plan certified pursuant to article 47 (Municipal Cooperative Health Benefit Plans)article forty-seven of this chapter and a student health plan established or maintained pursuant to § 1124 (Institutions of higher education exempt)section one thousand one hundred twenty-four of this chapter as added by chapter 246 of the laws of 2012, that issues a comprehensive policy that uses a network of providers and is not a managed care health insurance contract, as defined in subsection (c) of § 4801 (Application)section four thousand eight hundred one of this chapter, shall establish and maintain procedures for health care professional applications and terminations consistent with the requirements of § 4803 (Health care professional applications and terminations)section four thousand eight hundred three of this chapter and procedures for health care facility applications consistent with § 4806 (Health care facility applications)section four thousand eight hundred six of this chapter.
Source:
Section 4306-C — Grievance procedure and access to specialty care, https://www.nysenate.gov/legislation/laws/ISC/4306-C (updated Apr. 22, 2022; accessed Oct. 26, 2024).
