NY Ins L § 4324 (2021)
2021 New York Laws ISC - Insurance Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations 4324 - Disclosure of Information.

§  4324.  Disclosure  of information. The requirements of this section shall apply to all comprehensive, expense-reimbursed contracts;  managed care   products;  or  any  other  contract  or  product  for  which  the superintendent deems such disclosure appropriate.  (a)  Each  health  service,  hospital  service,  or  medical   expense indemnity   corporation  subject  to  this  article  shall  supply  each subscriber, and  upon  request  each  prospective  subscriber  prior  to enrollment,  written  disclosure  information, which may be incorporated into 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:  (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 corporation, 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 corporation  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 corporation and a health care provider;  (5)  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;  (6) an explanation, where  applicable,  of  a  subscriber's  financial responsibility  for  payment when services are provided by a health care provider who is not part of the corporation's network of providers or by any provider without required authorization;  (7) a description of the grievance procedures to be  used  to  resolve disputes  between the corporation and a subscriber, including: the right to file a grievance regarding any dispute between the corporation and  a subscriber;  the  right  to  file a grievance orally when the dispute is about  referrals  or  covered  benefits;  the toll-free telephone number which subscribers 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  subscriber's  financial and other responsibilities regarding obtaining such  services  including  when  such  services  are received outside the corporation's service area, if any;  (9)  where  applicable, a description of procedures for subscribers to select  and  access  the  corporation'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 corporation's network of providers;  (11)  where applicable, notice that a subscriber enrolled in a managed care product or in a comprehensive contract that utilizes a  network  of providers   offered   by  the  corporation  may  obtain  a  referral  or preauthorization for a health care provider outside of the corporation's network or panel when the  corporation  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  subscriber  and  the  procedure  by which the subscriber can obtain such referral or preauthorization;  (12)  where applicable, notice that a subscriber enrolled in a managed care product or a comprehensive contract  that  utilizes  a  network  of providers  offered  by  the  corporation 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 a subscriber enrolled in a managed care product or a comprehensive contract  that  utilizes  a  network  of providers  offered  by  the  corporation  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  subscriber's  medical  care  and  the procedure for requesting and obtaining such a specialist;  (14) where applicable, notice that a subscriber enrolled in a  managed care  product  or  a  comprehensive  contract that utilizes a network of providers  offered  by  the  corporation  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  corporation  addresses  the  needs  of non-English speaking subscribers;  (16) notice of all appropriate mailing addresses and telephone numbers to be utilized by subscribers seeking information or authorization;  (16-a)  where  applicable,  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;  (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;  (C)  in the case of physicians, board certification, languages spoken and any affiliations with  participating hospitals. The listing shall also be posted on the corporation's website and  the corporation shall update the website within fifteen days of the addition or termination of a provider from the corporation's network  or a change in a physician's hospital affiliation;  (18)  a  description  of  the  mechanisms  by  which  subscribers  may participate in the development of the policies of the corporation;  (19) the method by which a subscriber may submit a  claim  for  health care services;  (20) with respect to out-of-network coverage:  (A)  a clear description of the methodology used by the corporation to determine reimbursement for out-of-network health care services;  (B) a description of the amount that the  corporation  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;  (21) information in writing  and  through  an  internet  website  that reasonably  permits  a  subscriber or prospective subscriber 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 corporation will reimburse  for  out-of-network  health care services and the usual and customary cost for out-of-network health care services; and  (22) the most recent comparative analysis performed by the corporation 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  health  service,  hospital  service,  or  medical   expense indemnity  corporation  subject  to  this  article,  upon  request  of a subscriber or prospective subscriber 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 corporation;  (2) provide a copy of  the  most  recent  annual  certified  financial statement  of  the corporation, 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 subscriber information;  (6) where applicable, to allow subscribers and prospective subscribers to inspect drug formularies  used  by  such  corporation;  and  provided further,  that  the  corporation  shall also disclose whether individual drugs are  included  or  excluded  from  coverage  to  a  subscriber  or prospective subscriber who requests this information;  (7)  provide  a written description of the organizational arrangements and ongoing procedures of the corporation's quality  assurance  program, if any;  (8)   provide   a  description  of  the  procedures  followed  by  the corporation   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 corporation might consider in its utilization review and the corporation 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  corporation,  the  subscriber  or prospective  subscriber  shall only use the information for the purposes of assisting the subscriber or prospective subscriber 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 corporation for  participation  in  the  corporation'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   corporation   will  pay  for  a  specific out-of-network health care service. The corporation  shall  also  inform the  insured  through  such  disclosure  that  such approximation is not binding on the corporation and that the approximate dollar  amount  that the  corporation  will  pay  for  a  specific out-of-network health care service may change.  (c) Nothing in this section shall prevent a corporation from  changing or updating the materials that are made available to subscribers.  (d)  As to any program where the subscriber must select a primary care provider, if a participating primary care provider  becomes  unavailable to  provide  services  to  a  subscriber,  the corporation shall provide written notice within fifteen days from the time the corporation becomes aware of such unavailability to  each  subscriber  who  has  chosen  the  provider  as their primary care provider. If a subscriber is enrolled in a managed care product and is in an ongoing course of treatment with any other participating provider who  becomes  unavailable  to  continue  to provide  services  to  such  subscriber, and the corporation is aware of such ongoing course of treatment, the corporation shall provide  written notice  within  fifteen days from the time the corporation becomes aware of such unavailability  to  such  subscriber.  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 subscriber (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  corporation'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 corporation'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  subscriber  (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  corporation's  managed  care  provider network, in order for the subscriber  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  this  article,  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.