Health insurance can be confusing for most consumers — both those who have purchased it before and those who are brand new to buying coverage. In fact, many people do not even know that an HMO is a type of insurance plan. With an HMO plan, individuals have little say in the management of their care, a prospect that both frightens and relieves many consumers. Some do not like the thought of having a single doctor responsible for managing all of their care. Others like being able to take their hands off. Regardless, state health insurance regulations provide standard healthcare insurance companies with guidelines they must follow, guidelines that give patients rights when using an HMO. Some of those rights include the right to certain types of coverage and the right to appeal decisions.

First, a number of states offer HMO patients the right to certain types of coverage. Although what coverage is mandated differs dramatically by state, most states have at least some regulations for what conditions and care HMO providers must cover under the law. Some of these conditions/situations include pregnancy and other women's health and reproductive health issues, children's health, and autism spectrum disorders. When a consumer knows his or her rights to treatment for specific illnesses under the law, he or she can better discuss issues of denied claims with his or her insurance company.

Second, some states require HMOs to cover people who have pre-existing conditions. In some states, insurance companies cannot consider a person's health record when determining whether they can obtain coverage. People who have been trying to get coverage and are continually denied because of a health-related issue may need to know their rights in order to appeal the decision or discuss the decision with the insurance company.

Finally, some state health insurance regulations govern the rights patients have to appeal decisions made by standard healthcare companies. The federal law ERISA, which applies to almost all private healthcare plans, requires the company to allow patients to appeal decisions made regarding care or the denial of a claim. States may have more specific regulations about the appeal process. California, for example, is rather vocal about the patient's right to appeal, with local non-profits distributing handbooks that explain to HMO patients their rights.

HMO patients who want to know what rights they have in their state should contact their state insurance regulator, as well as non-profit groups in the state that can help them understand and take advantage of their rights. Because each state is different, each HMO patient needs to take a careful look at the state and federal laws that affect him or her.