New York Managed Care Consumer Bill of Rights Compliance Survey - Report on HMOs Failing to Provide Coverage Information - March 2004

Sep 13, 2026

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Report analyzes results of the New York State Attorney General’s survey of health plan compliance with the Managed Care Consumer Bill of Rights requirement to provide clinical review criteria to consumers upon written request. Findings show most health plans violated the law by not disclosing requested criteria to surveyors posing as prospective enrollees. The survey tested five medical services—insulin pump, Crohn’s surgery, arthroscopic knee surgery, enteral formulas, and breast reduction surgery—and graded plan responses from A to F.

LanguageEnglish

CategoryLetters

FormatPDF

Pages31

Reading Time11 min

AccessFree to download

Executive Summary

The Survey

Our Findings

Enforcement Action and Legislative Proposal

I. Introduction

A. The Managed Care Consumer Bill of Rights

B. This Report

II. Methodology

III. Findings

A. Overall Results

B. Impact on Consumers

C. Results for Each Medical Service or Supply Surveyed

IV. Action by the Attorney General

A. Enforcement Action

B. Legislative Proposal

Appendix A: Survey Letters Sent to Health Plans

New York Managed Care Consumer Bill of Rights Compliance Survey: The Failure of New York HMOs to Provide Important Coverage Information to Consumers A REPORT FROM THE NEW YORK STATE DEPARTMENT OF LAW HEALTH CARE BUREAU ELIOT SPITZER ATTORNEY GENERAL March, 2004 Health Care Bureau The Health Care Bureau (HCB) is part of the Division of Public Advocacy in the Office of the New York State Attorney General. The HCB’s principal mandate is to protect and advocate for the rights of health care consumers statewide, through: " Operation of the Health Care Helpline. This toll-free telephone hotline provides assistance to New York health care consumers by employing staff who provide helpful information and referrals, investigate individual complaints, and attempt to reach aresolution that will help to ensure that each consumer obtains access to the health care to which the consumer is entitled. " Investigations and enforcement actions. These activities target health plans, providers, and other individuals and entities that engage in fraudulent, misleading, deceptive or illegal practices in the health care market. " Consumer Education. Through education initiatives, the HCB seeks to acquaint New Yorkers with their rights under the Managed Care Consumer Bill of Rights and other health and consumer protection laws. " Legislation and policy initiatives. Such projects are aimed at enhancing the rights of health care consumers and their ability to obtain good, affordable health care in New York State. Health Care Helpline Tel: (800) 771-7755—option 3 Fax: (518) 402-2163 New York Office Mailing address: 120 Broadway, 25th Floor, New York, NY 10271-0334 Albany Office Mailing address: The Capitol, Albany, NY 12224-0341 This report was primarily written by Paul Beyer, Assistant Attorney General, and the survey of health plans was primarily implemented by Heather Hussar, Assistant Attorney General. TABLE OF CONTENTS Page EXECUTIVE SUMMARY ................................................... ii The Survey ......................................................... ii Our Findings ........................................................ iii Enforcement Action and Legislative Proposal ............................... v I. INTRODUCTION ..................................................... 1 A. The Managed Care Consumer Bill of Rights .......................... 1 B. This Report .................................................... 3 II. METHODOLOGY .................................................... 4 III. FINDINGS .......................................................... 7 A. Overall Results ................................................. 7 B. Impact on Consumers ............................................ 9 C. Results for Each Medical Service or Supply Surveyed ................. 10 1. Insulin Pump ........................................... 10 2. Surgery for Crohn’s Disease ............................... 11 3. Arthroscopic Knee Surgery ................................. 12 4. Enteral Formulas ......................................... 13 5. Breast Reduction Surgery (Reduction Mammoplasty) ............ 15 IV. ACTION BY THE ATTORNEY GENERAL .............................. 16 A. Enforcement Action ............................................ 16 B. Legislative Proposal ............................................ 17 Appendix A: Survey Letters Sent to Health Plans ................................. 19 EXECUTIVE SUMMARY This report analyzes the results of the Attorney General’s survey of health plan compliance with the New York Managed Care Consumer Bill of Rights’ requirement to provide clinical review criteria to consumers upon their written request. Unfortunately, the Attorney General finds that the vast majority of health plans violated the law by failing to disclose the requested clinical review criteria to the surveyors. The Survey New York’s Managed Care Cons

FAQs

What compliance requirement did the report evaluate for New York health plans?

The survey evaluated whether health plans provided consumers, upon written request, with clinical review criteria required under the Managed Care Consumer Bill of Rights.

How did the Attorney General conduct the survey?

Surveyors posed as prospective enrollees with specific medical needs and sent letters to twenty-two health plans, requesting clinical review criteria for designated services.

What were the main findings about plan disclosure of clinical review criteria?

Most health plans violated the law by failing to disclose the requested clinical review criteria to the surveyors, as reflected in the A-to-F grading of responses.

Sep 13, 2026

Upload by Rowan