If you think there ought to be a law about access to specialists and specialty centers, there is! New York State healthcare consumers are protected by a law that gives them important rights in a managed care environment.
If you are enrolled in a managed care organization, you have a Right to Specialty Care, including information about the following:
- Out of network referrals: If your MCO, consulting with your PCP, decides that an MCO network doesn't include a PCP in their network with the training and experience you need, the MCO must refer you to a specialist out of the network at no charge to you. This decision must be part of a treatment plan approved by the MCO.
- Standing referral to specialists: If the MCO, consulting with your PCP and your specialist, decides that you need ongoing care from that specialist, you can get a series of referrals at one time so you don't have to go back and get a new referral each time you need to see the specialist.
- Specialist care coordinator: If you need specialized medical care over a long period of time, you can, at no extra cost, get a referral to a specialist who will then act as your PCP and coordinate your care.
- Specialty care center: If you need specialized medical care over a long period of time, your MCO must allow a referral to a specialty care center (such as a cancer institute), which can provide and/or coordinate your primary and specialty care.
A specialty care center is any "center accredited or designated by an agency of the state or federal government or by a voluntary national health organization as having special expertise in treating the condition or disease for which it has been accredited." Roswell Park Comprehensive Cancer Center is a National Cancer Institute-designated Comprehensive Cancer Center.
*Adapted from the Consumers' Guide to New York's Managed Care Bill of Rights, published by the Public Policy and Education Fund of New York.
Referral policy
If your health insurance plan informs you that you are not allowed to go to Roswell Park for any reason, you may want to consider taking the following steps to appeal their decision:
Work with your health insurance plan
- Health insurance plans have a member handbook which explains policies and procedures, and describes formal grievance or appeal processes. If you do not have a copy of this handbook, call your insurance carrier to request one.
- Remember to keep detailed written records of phone conversations, contacts and phone numbers, and copies of all papers and dated letters. You may be asked to provide this information during the grievance process.
Dealing with unresolved disputes
- If, after exhausting all avenues with your health care plan, you are still dissatisfied with the decision made regarding your grievance, you have the right to file a complaint with the New York State Insurance Department Consumer Services Bureau (800-342-3736) or the New York State Department of Health Managed Care Hotline (800-206-8125)
- The New York State Department of Health has regulatory oversight of the grievance and appeal processes under the New York State Managed Care Law.