The State of New Jersey
NJ Department of Banking and Insurance
Home > Insurance Division > Life and Health > Life & Health Actuarial > HMO Performance Report
2008 New Jersey HMO Performance Report
Consumer Bill of Rights

Persons covered under HMO and HMO/POS Products have important consumer rights:

The Right to Information about Your Coverage and How it Works

  • The right to information on what health care services are covered and any limitations on that coverage
  • The right to obtain a current directory of doctors within the network
  • The right to know how your carrier pays its doctors so you know if financial incentives or disincentives are tied to medical decisions

The Right to Ask Questions and to File Complaints, Appeals and Lawsuits

  • The right to no “gag rules”—doctors are allowed to discuss all treatment options even if they are not covered services
  • The right to know the reason your carrier denied a covered service requested by you or your doctor
  • The right to file appeals with the carrier concerning denials or limitations of a covered service
  • The right to file complaints with the carrier regarding any aspect of the carrier’s network and delivery of health care services, including quality of care, choice, accessibility of providers and network adequacy
  • The right to file complaints and appeals or have them filed on your behalf by your health care provider without fear of retaliation against you or your health care provider
  • The right to independent review of the carrier’s decision to deny or limit covered services; if you have exhausted the carrier’s internal appeal process, you have the right to appeal that decision through the Independent Health Care Appeals Program (see Appeals and Complaints for more details)
  • The right to sue your carrier for losses if you or a covered member of your family sustains serious injury or death that you believe is the result of the carrier’s denial or delay of approval of medically necessary covered services

The Right to Appropriate Treatment

  • The right to have a doctor — not an administrator — make the decision to deny or limit coverage of services
  • The right to change primary care providers without having to wait more than two weeks
  • The right to access a primary care provider 24 hours a day, 365 days a year for urgent care
  • The right to call 911 in a potentially life threatening situation without prior approval
  • The right to go to an emergency room without first contacting the carrier when it appears to a person that serious harm could result from not obtaining immediate medical treatment
  • The right to coverage of a medical screening exam in a hospital emergency room to determine whether an emergency medical condition exists
  • The right to a choice of participating specialists when getting an authorized referral
  • The right to be referred to an experienced specialist when a member is addressing a chronic disability
  • The right to receive coverage for treatment by a doctor for up to four months after the doctor stops being part of the carriers network (and for longer periods for certain medical conditions)

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New Jersey Department of Banking and Insurance