NY Ins L § 3217-A (2021)
2021 New York Laws ISC - Insurance Article 32 - Insurance Contracts - Life, Accident and Health, Annuities 3217-A - Disclosure of Information.

§  3217-a. Disclosure of information. The requirements of this section shall apply to all comprehensive,  expense-reimbursed  health  insurance contracts;  managed care health insurance contracts; or any other health insurance contract or product for which the  superintendent  deems  such disclosure appropriate.  (a)  Each  insurer  subject to this article shall supply each insured, and upon request each prospective insured prior to  enrollment,  written disclosure  information,  which  may  be incorporated into the insurance 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  insurance  contract  or  certificate,  the terms of the insurance contract or certificate shall be controlling. The information to be disclosed shall include at least the following:  (1)  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;  (2) a description of all prior authorization or other requirements for treatments and services;  (3) a description of utilization review policies and procedures,  used by the insurer, including:  (A)   the   circumstances  under  which  utilization  review  will  be undertaken;  (B) the toll-free telephone number of the utilization review agent;  (C) the time frames under which utilization review decisions  must  be made for prospective, retrospective and concurrent decisions;  (D) the right to reconsideration;  (E)  the  right  to  an  appeal,  including the expedited and standard appeals processes and the time frames for such appeals;  (F) the right to designate a representative;  (G) 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;  (H) a notice of the right  to  an  external  appeal  together  with  a description,   jointly   promulgated   by  the  superintendent  and  the commissioner of health as required pursuant to subsection (e) of section four thousand 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 time frames for such appeals; and  (I) further appeal rights, if any;  (4) a description prepared annually of the types of methodologies  the insurer  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 an insurer and a health care provider;  (5)  an  explanation  of  an  insured's  financial  responsibility for payment of premiums, coinsurance, co-payments, deductibles and any other charges, annual limits on an insured's financial responsibility, caps on payments  for  covered  services  and   financial   responsibility   for non-covered health care procedures, treatments or services;  (6)  an  explanation,  where  applicable,  of  an  insured's financial responsibility for payment when services are provided by a  health  care provider who is not part of the insurer's network of providers or by any provider  without required authorization, or when a procedure, treatment or service is not a covered benefit;  (7) a description of the grievance procedures to be  used  to  resolve disputes between an insurer and an insured, including: the right to file a grievance regarding any dispute between an insured and an insurer; the right  to file a grievance orally when the dispute is about referrals or covered  benefits; the toll-free telephone number which insureds 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;  (8) a description of the procedure for obtaining  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  insured's  financial  and  other  responsibilities regarding obtaining such  services  including  when  such  services  are received outside the insurer's service area, if any;  (9)  where  applicable,  a  description  of procedures for insureds to select and access the insurer's primary and  specialty  care  providers, including notice of how to determine whether a participating provider is accepting new patients;  (10)  where  applicable,  a description of the procedures for changing primary and specialty care providers within  the  insurer's  network  of providers;  (11)  where  applicable,  notice that an insured enrolled in a managed care product or in a comprehensive policy that  utilizes  a  network  of providers   offered   by   the   insurer   may   obtain  a  referral  or preauthorization for a health care provider  outside  of  the  insurer's network  or  panel when the insurer does not have a health care provider who is  geographically  accessible  to  the  insured  and  who  has  the appropriate  training and experience in the network or panel to meet the particular health care needs of the insured and the procedure  by  which the insured can obtain such referral or preauthorization;  (12)  where  applicable,  notice that an insured enrolled in a managed care product or a  comprehensive  policy  that  utilizes  a  network  of providers offered by the insurer 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;  (13)  where  applicable,  notice that an insured enrolled in a managed care product or a  comprehensive  policy  that  utilizes  a  network  of providers  offered  by the insurer with (A) a life-threatening condition or disease, or (B) 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 insured's medical care and the procedure for requesting and obtaining such a specialist;  (14)  where  applicable,  notice that an insured enrolled in a managed care product or a  comprehensive  policy  that  utilizes  a  network  of providers  offered  by the insurer with (A) a life-threatening condition or disease, or (B) 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;  (15)  a  description  of  how  the  insurer  addresses  the  needs  of non-English speaking insureds;  (16) notice of all appropriate mailing addresses and telephone numbers to be utilized by insureds seeking information or authorization;  (16-a)  where  applicable,  notice  that  an insured 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;  (17) where applicable, 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: (A) whether the provider is accepting new patients; (B) 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 (C) in the case of physicians, board certification,  languages spoken and any affiliations with participating hospitals. The listing shall also be posted on the insurer's website and the insurer shall update the website within fifteen days of the addition or termination of a provider from the insurer's network or a change in a physician's hospital affiliation;  (18) a description of the method by which  an  insured  may  submit  a claim for health care services;  (19) with respect to out-of-network coverage:  (A)  a  clear  description  of  the methodology used by the insurer to determine reimbursement for out-of-network health care services;  (B) the amount that the insurer 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; and  (C)  examples of anticipated out-of-pocket costs for frequently billed out-of-network health care services;  (20) information in writing  and  through  an  internet  website  that reasonably  permits  an  insured  or prospective insured 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 insurer will reimburse for out-of-network health care  services and  the  usual  and  customary  cost  for  out-of-network  health  care services; and  (21) the most recent comparative analysis performed by the insurer  to assess the provision of its covered services in accordance with the Paul Wellstone  and  Pete  Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. 18031(j), and  any  amendments  to,  and  federal guidance or regulations issued under those acts.  (b)  Each insurer subject to this article, upon request of an insured, or prospective insured, shall:  (1) provide a list of  the  names,  business  addresses  and  official positions  of  the  membership  of the board of directors, officers, and members of the insurer;  (2) provide a copy of  the  most  recent  annual  certified  financial statement  of  the  insurer,  including  a  balance sheet and summary of receipts and disbursements prepared by a certified public accountant;  (3)  provide  a  copy  of  the  most  recent  individual,  direct  pay subscriber contracts;  (4)  provide  information  relating  to  consumer  complaints compiled pursuant to section two hundred ten of this chapter;  (5) provide the  procedures  for  protecting  the  confidentiality  of medical records and other insured information;  (6)  where  applicable,  allow  insureds  and  prospective insureds to inspect drug formularies used by such  insurer;  and  provided  further, that  the  insurer  shall  also  disclose  whether  individual drugs are included or excluded from coverage to an insured or prospective  insured who requests this information;  (7)  provide  a written description of the organizational arrangements and ongoing procedures of the insurer's quality  assurance  program,  if any;  (8) provide a description of the procedures followed by the insurer in making  decisions  about  the  experimental or investigational nature of individual drugs, medical devices or treatments in clinical trials;  (9)  provide  individual   health   practitioner   affiliations   with participating hospitals, if any;  (10)  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  subsection  (c-1),  subsection  (c-2)   and subsection  (c-3)  of  section forty-nine hundred three of this chapter, and, where appropriate, other clinical  information  which  the  insurer might  consider  in  its  utilization review and the insurer 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 insurer, the  insured  or  prospective insured 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 subsection (f) of section forty-nine  hundred of this chapter, on behalf of an insured and upon written request;  (11)  where applicable, provide the written application procedures and minimum qualification requirements  for  health  care  providers  to  be considered by the insurer for participation in the insurer's network for a managed care product;  (12)   disclose   such   other   information   as   required   by  the superintendent, provided that such requirements are promulgated pursuant to the state administrative procedure act;  (13) disclose whether a health care provider scheduled  to  provide  a health care service is an in-network provider; and  (14) with respect to out-of-network coverage, disclose the approximate dollar  amount  that  the insurer will pay for a specific out-of-network health care service. The insurer shall also inform the  insured  through such  disclosure  that  such approximation is not binding on the insurer and that the approximate dollar amount that the insurer will pay  for  a specific out-of-network health care service may change.  (c)  Nothing in this section shall prevent an insurer from changing or updating the materials that are made available to insureds.  (d) As to any program where the insured must  select  a  primary  care provider,  if  a participating primary care provider becomes unavailable to provide services to an insured, the  insurer  shall  provide  written notice  within  fifteen  days from the time the insurer becomes aware of such unavailability to each insured who has chosen the provider as their primary care provider. If an insured enrolled in a managed care  product is  in  an  ongoing  course  of  treatment  with any other participating provider who becomes unavailable to continue to provide services to such insured, and the insurer is aware of such ongoing course  of  treatment, the  insurer  shall  provide written notice within fifteen days from the time that the insurer becomes  aware  of  such  unavailability  to  such insured.  Each  notice shall also describe the procedures for continuing  care pursuant to subsections (e) and (f) of section forty-eight  hundred four of this chapter and for choosing an alternative provider.  (e)  For purposes of this section, a "managed care product" shall mean a contract which requires that all medical or other health care services covered under the contract,  other  than  emergency  care  services,  be provided  by,  or  pursuant to a referral from, a designated health care provider chosen by the insured (i.e. a  primary  care  gatekeeper),  and that  services  provided  pursuant  to  such a referral be rendered by a health  care  provider  participating  in  the  insurer's  managed  care provider  network.  In addition, in the case of (i) an individual health insurance contract, or (ii) a group health insurance  contract  covering no  more  than three hundred lives, imposing a coinsurance obligation of more than twenty-five percent upon  services  received  outside  of  the insurer's managed care provider network, and which has been sold to five or  more groups, a managed care product shall also mean a contract which requires that all medical or other health care  services  covered  under the  contract,  other  than  emergency care services, be provided by, or pursuant to a referral from, a designated health care provider chosen by the insured (i.e. a primary care gatekeeper), and that services provided pursuant to such a referral  be  rendered  by  a  health  care  provider participating  in  the insurer's managed care provider network, in order for the insured to be entitled to the maximum  reimbursement  under  the contract.  (f)  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.  The nonprofit organization shall not be affiliated with an insurer,  a  corporation  subject  to  article  forty-three  of  this chapter,  a municipal cooperative health benefit plan certified pursuant to  article  forty-seven  of  this  chapter,  or  a  health  maintenance organization  certified  pursuant  to  article  forty-four of the public health law.