Health Plan

Healthcare Needs

1. What are your family's specific Healthcare needs?

  • What are your present and future needs?
  • Where do you want to go for your Healthcare - a clinic, a medical center, a private practice?
  • What Healthcare centers are conveniently located for you?
  • Will you need evening or weekend appointments?

Covered/Excluded Services

2. Will the plan's benefits and services meet your specific needs?

  • Ask for a list of covered and excluded benefits and services.
  • Review that list and compare it to your specific needs.
  • Do you have existing medical conditions that require specialized medical care?
  • Ask if medical conditions that you have now are covered by the plan.
  • Do you have specific needs such as eyeglasses, mental health, prescriptions, or well baby care?
  • When does the plan's coverage take effect?


3. Is your choice of doctors limited by the plan?

  • Ask for a list of participating physicians.
  • Does the plan require you to have one physician coordinate all your care?
  • Is the physician of your choice accepting patients under the plan?
  • Will you be seen by the same physician or care giver every time?

4. Is your choice of hospitals limited?

  • Ask for a list of participating hospitals.
  • Can your physician admit you to the hospital you want to use?


5. What is the monthly premium?

  • Find out how much the plan requires you to contribute to the cost of health insurance each month.
  • Compare the monthly cost of the plan to the monthly cost of other comparable plans.

6. What is a reasonable estimate of the out-of-pocket costs per year?

  • Are there co-payments, deductibles or other out- of-pocket costs?
  • Is there a limit on the total amount of out-of - pocket costs per year?
  • Are there dollar amount limits on the total amount of coverage the plan will provide each year?


7. Does the plan provide quality Healthcare?

  • Ask your physician their opinion of the plan.
  • If you know someone who belongs to the plan, ask them what they think about the care they have received.
  • Are the physicians who belong to the plan given financial incentives to limit care?
  • What is the plan's grievance procedure?
  • What is the plan's procedure for reviewing decisions on whether care is medically necessary?
  • Are there guidelines on length of stay after surgery and childbirth?

Procedures and Questions

8. Will you need the plan's approval before seeking care?

  • What are the plan's rules on seeking care and seeing specialists?
  • Does the plan cover visits to out of network doctors?
  • Does the plan require you to be responsible for referral forms, claim forms or other paper work?

9. What should you do if you need medical care and you are outside of the plan's service area?

  • Will the plan refer you to a doctor in the area in which you are located?
  • Will the plan cover the cost of services rendered by a doctor outside of the plan's network or service area?

10. Who do you call if you have a question?

  • Is there a 24 hour toll free telephone number?

For More Information Call The Attorney General's
Healthcare Bureau At 1-800-428-9071 option #3 (NYAGHCB)