NY Pub Health L § 4408 (2021)
2021 New York Laws PBH - Public Health Article 44 - Health Maintenance Organizations 4408 - Disclosure of Information.

§  4408.  Disclosure  of  information.  1.  Each  subscriber, and upon request each  prospective  subscriber  prior  to  enrollment,  shall  be supplied  with  written disclosure information which may be incorporated into the member handbook  or  the  subscriber  contract  or  certificate containing at least the information set forth below. In the event of any inconsistency  between any separate written disclosure statement and the subscriber contract or certificate, the terms of the subscriber contract or certificate shall be controlling. The  information  to  be  disclosed shall include at least the following:  (a)  a  description  of  coverage  provisions;  health  care benefits; benefit maximums,  including  benefit  limitations;  and  exclusions  of coverage,   including  the  definition  of  medical  necessity  used  in determining whether benefits will be covered;  (b) a description of all prior authorization or other requirements for treatments and services;  (c) a description of utilization review policies and  procedures  used by the health maintenance organization, including:  (i)   the   circumstances  under  which  utilization  review  will  be undertaken;  (ii) the toll-free telephone number of the utilization review agent;  (iii) the timeframes under which utilization review decisions must  be made for prospective, retrospective and concurrent decisions;  (iv) the right to reconsideration;  (v)  the  right  to  an  appeal,  including the expedited and standard appeals processes and the time frames for such appeals;  (vi) the right to designate a representative;  (vii) a notice that all denials of claims will be  made  by  qualified clinical  personnel  and  that  all  notices  of  denials  will  include information about the basis of the decision;  (viii) a notice of the right to an external  appeal  together  with  a description,   jointly   promulgated   by   the   commissioner  and  the superintendent of financial services as required pursuant to subdivision five of section forty-nine hundred fourteen  of  this  chapter,  of  the external  appeal  process  established  pursuant to title two of article forty-nine of this chapter and the timeframes for such appeals; and  (ix) further appeal rights, if any;  (d) a description prepared annually of the types of methodologies  the health  maintenance  organization uses to reimburse providers specifying the type of methodology that is used to reimburse  particular  types  of providers  or  reimburse  for  the  provision  of  particular  types  of services; provided, however, that nothing in this  paragraph  should  be construed  to require disclosure of individual contracts or the specific details of  any  financial  arrangement  between  a  health  maintenance organization and a health care provider;  (e)  an  explanation  of  a  subscriber's financial responsibility for payment of premiums, coinsurance, co-payments, deductibles and any other charges, annual limits on a subscriber's financial responsibility,  caps on  payments  for  covered  services  and  financial  responsibility for non-covered health care  procedures,  treatments  or  services  provided within the health maintenance organization;  (f)  an  explanation  of  a  subscriber's financial responsibility for payment when services are provided by a health care provider who is  not part  of  the health maintenance organization or by any provider without required authorization or when a procedure, treatment or service is  not a covered health care benefit;  (g)  a  description  of the grievance procedures to be used to resolve disputes between a health  maintenance  organization  and  an  enrollee, including:  the  right to file a grievance regarding any dispute between  an enrollee and a health maintenance organization; the right to  file  a grievance  orally  when  the  dispute  is  about  referrals  or  covered benefits; the toll-free telephone number which enrollees may use to file an  oral  grievance;  the timeframes and circumstances for expedited and standard grievances; the right to appeal a grievance  determination  and the   procedures   for   filing  such  an  appeal;  the  timeframes  and circumstances for expedited and standard appeals; the right to designate a  representative;  a  notice  that  all  disputes  involving   clinical decisions  will  be  made  by qualified clinical personnel; and that all notices of determination will include information about the basis of the decision and further appeal rights, if any;  (h) a description of the procedure for  providing  care  and  coverage twenty-four  hours  a day for emergency services. Such description shall include a  definition  of  emergency  services;  notice  that  emergency services  are  not  subject  to  prior  approval; and shall describe the enrollee's financial and other responsibilities regarding obtaining such services including when such services are received  outside  the  health maintenance organization's service area;  (i) a description of procedures for enrollees to select and access the health  maintenance organization's primary and specialty care providers, including notice of how to determine whether a participating provider is accepting new patients;  (j) a description of the procedures for changing primary and specialty care providers within the health maintenance organization;  (k) notice that an enrollee may obtain a referral  to  a  health  care provider  outside  of  the  health maintenance organization's network or panel when the health maintenance organization does not  have  a  health care  provider  who is geographically accessible to the enrollee and who has appropriate training and experience in the network or panel to  meet the  particular  health  care needs of the enrollee and the procedure by which the enrollee can obtain such referral;  (l) notice that an enrollee with a condition  which  requires  ongoing care  from  a  specialist  may  request  a  standing  referral to such a specialist and  the  procedure  for  requesting  and  obtaining  such  a standing referral;  (m)  notice  that an enrollee with (i) a life-threatening condition or disease or (ii) a degenerative and disabling condition or disease either of which requires specialized medical care over a  prolonged  period  of time  may request a specialist responsible for providing or coordinating the enrollee's  medical  care  and  the  procedure  for  requesting  and obtaining such a specialist;  (n) notice that an enrollee with a (i) a life-threatening condition or disease or (ii) a degenerative and disabling condition or disease either of  which  requires  specialized medical care over a prolonged period of time may request access to a specialty care center and the procedure  by which such access may be obtained;  (o) a description of the mechanisms by which enrollees may participate in   the   development   of  the  policies  of  the  health  maintenance organization;  (p) a description of how the health maintenance organization addresses the needs of non-English speaking enrollees;  (p-1) notice that an enrollee shall have direct access to primary  and preventive   obstetric   and   gynecologic  services,  including  annual examinations,  care  resulting  from  such  annual   examinations,   and treatment  of acute gynecologic conditions, from a qualified provider of such services of her choice from within the plan or for any care related to a pregnancy;  (q) notice of all appropriate mailing addresses and telephone  numbers to be utilized by enrollees seeking information or authorization;  (r)  a  listing by specialty, which may be in a separate document that is updated annually, of the name, address and telephone  number  of  all participating  providers,  including  facilities,  and:  (i) whether the provider is accepting new patients; (ii) in the case of mental health or substance  use  disorder  services  providers,  any  affiliations   with participating facilities certified or authorized by the office of mental health or the office of alcoholism and substance abuse services, and any restrictions  regarding  the  availability  of the individual provider's services; and (iii) in the  case  of  physicians,  board  certification, languages  spoken and any affiliations with participating hospitals. The listing shall also be posted on the  health  maintenance  organization's website and the health maintenance organization shall update the website within  fifteen  days  of the addition or termination of a provider from the  health  maintenance  organization's  network  or  a  change  in   a physician's hospital affiliation;  (s) where applicable, a description of the method by which an enrollee may submit a claim for health care services;  (t) with respect to out-of-network coverage:  (i)  a  clear  description  of  the  methodology  used  by  the health maintenance organization to determine reimbursement  for  out-of-network health care services;  (ii)   the  amount  that  the  health  maintenance  organization  will reimburse under the methodology for out-of-network health care  services set  forth  as  a  percentage  of  the  usual  and  customary  cost  for out-of-network health care services;  (iii) examples  of  anticipated  out-of-pocket  costs  for  frequently billed out-of-network health care services;  (u)  information  in  writing  and  through  an  internet website that reasonably permits an enrollee or prospective enrollee to  estimate  the anticipated  out-of-pocket  cost for out-of-network health care services in a geographical area or zip code based  upon  the  difference  between what   the   health   maintenance   organization   will   reimburse  for out-of-network health care services and the usual and customary cost for out-of-network health care services; and  (v) the most recent  comparative  analysis  performed  by  the  health maintenance organization to assess the provision of its covered services in  accordance  with  the Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity Act of 2008,  42  U.S.C.  18031(j)  and  any amendments  to, and federal guidance and regulations issued under, those Acts.   2. Each health maintenance organization  shall,  upon  request  of  an enrollee or prospective enrollee:  (a)  provide  a  list  of  the  names, business addresses and official positions of  the  membership  of  the  board  of  directors,  officers, controlling  persons,  owners  or  partners  of  the  health maintenance organization;  (b) provide a copy of  the  most  recent  annual  certified  financial statement  of  the  health maintenance organization, including a balance sheet and summary of receipts and disbursements prepared by a  certified public accountant;  (c)  provide  a  copy  of  the  most  recent  individual,  direct  pay subscriber contracts;  (d) provide  information  relating  to  consumer  complaints  compiled pursuant to section two hundred ten of the insurance law;  (e)  provide  the  procedures  for  protecting  the confidentiality of medical records and other enrollee information;  (f)  allow  enrollees  and  prospective  enrollees  to  inspect   drug formularies  used  by such health maintenance organization; and provided further, that the health maintenance organization  shall  also  disclose whether  individual  drugs  are included or excluded from coverage to an enrollee or prospective enrollee who requests this information;  (g)  provide  a written description of the organizational arrangements and ongoing procedures of the health maintenance organization's  quality assurance program;  (h)  provide  a  description  of the procedures followed by the health maintenance organization in making decisions about the  experimental  or investigational   nature   of   individual  drugs,  medical  devices  or treatments in clinical trials;  (i)  provide  individual   health   practitioner   affiliations   with participating hospitals, if any;  (j)  upon  written  request,  provide specific written clinical review criteria  relating  to  a  particular  condition  or  disease  including clinical  review  criteria  relating to a step therapy protocol override determination pursuant to subdivisions three-a, three-b and  three-c  of section   forty-nine   hundred   three   of  this  chapter,  and,  where appropriate, other clinical information  which  the  organization  might consider in its utilization review and the organization may include with the  information a description of how it will be used in the utilization review process; provided, however, that to the extent  such  information is proprietary to the organization, the enrollee or prospective enrollee shall  only  use  the  information  for  the  purposes  of assisting the enrollee or prospective enrollee  in  evaluating  the  covered  services provided  by  the organization. Such clinical review criteria, and other clinical information shall also be  made  available  to  a  health  care professional as defined in subdivision six of section forty-nine hundred of this chapter, on behalf of an enrollee and upon written request;  (k)   provide   the   written   application   procedures  and  minimum qualification requirements for health care providers to be considered by the health maintenance organization;  (l) disclose  other  information  as  required  by  the  commissioner, provided  that  such  requirements are promulgated pursuant to the state administrative procedure act;  (m) disclose whether a health care provider  scheduled  to  provide  a health care service is an in-network provider; and  (n)  with respect to out-of-network coverage, disclose the approximate dollar amount that the health maintenance organization will  pay  for  a specific  out-of-network  health  care  service.  The health maintenance organization shall also inform an enrollee through such disclosure  that such approximation is not binding on the health maintenance organization and  that  the  approximate  dollar  amount  that the health maintenance organization will pay for a specific out-of-network health care  service may change.   3.  Nothing  in  this  section  shall  prevent  a  health  maintenance organization from changing or  updating  the  materials  that  are  made available to enrollees.   4.  If  a  primary  care  provider  ceases participation in the health maintenance organization, the organization shall provide written  notice within fifteen days from the date that the organization becomes aware of such  change  in  status to each enrollee who has chosen the provider as their primary care provider. If an enrollee is in an ongoing  course  of treatment  with any other participating provider who becomes unavailable to continue  to  provide  services  to  such  enrollee  and  the  health maintenance  organization  is aware of such ongoing course of treatment, the health maintenance organization shall provide written notice  within  fifteen  days  from  the  date  that the health maintenance organization becomes aware of such unavailability to such enrollee. Each notice shall also describe the procedures for continuing care pursuant to  paragraphs (e)  and  (f)  of  subdivision six of section four thousand four hundred three of this article and for choosing an alternative provider.   5. Every health maintenance organization shall annually on  or  before April  first,  file a report with the commissioner and superintendent of financial services showing its financial condition as of the last day of the preceding calendar year, in such form and providing such information as the commissioner shall prescribe.   6.  Every  health  maintenance  organization  offering  to   indemnify enrollees  pursuant  to  subdivision  nine of section forty-four hundred five and subdivision two of  section  forty-four  hundred  six  of  this article  shall  on a quarterly basis file a report with the commissioner and the superintendent of  financial  services  showing  the  percentage utilization  for  the  preceding  quarter  of non-participating provider services in such form  and  providing  such  other  information  as  the commissioner shall prescribe.   7. For purposes of this section, "usual and customary cost" shall mean the  eightieth  percentile of all charges for the particular health care service performed by a provider in the same  or  similar  specialty  and provided  in  the  same  geographical area as reported in a benchmarking database  maintained  by  a  nonprofit  organization  specified  by  the superintendent  of  financial services. The nonprofit organization shall not be affiliated with an insurer,  a  corporation  subject  to  article forty-three of the insurance law, a municipal cooperative health benefit plan  certified pursuant to article forty-seven of the insurance law, or a health maintenance organization certified pursuant to this article.