2023 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,
telephone number, and digital contact information 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  addiction  services  and  supports,  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.
(g) (1) As used in this subsection:
(A) "Pharmacy benefit manager" shall have the  meaning  set  forth  in
section two hundred eighty-a of the public health law.
(B)  "Cost-sharing  information"  means  the  amount  a  subscriber is
required to pay to receive a drug that is covered under the subscriber's
insurance contract.
(C) "Covered/coverage" means those health care  services  to  which  a
subscriber is entitled under the terms of the insurance contract.
(D)  "Electronic health record" means a digital version of a patient's
paper  chart  and  medical  history  that  makes  information  available
instantly and securely to authorized users.
(E)  "Electronic  prescribing  system"  means  a  system  that enables
prescribers  to  enter  prescription   information   into   a   computer
prescription device and securely transmit the prescription to pharmacies

using  a  special  software  program  and connectivity to a transmission
network.
(F)  "Electronic  prescription"  shall  have  the meaning set forth in
section thirty-three hundred two of the public health law.
(G) "Prescriber" means a health care provider  licensed  to  prescribe
medication or medical devices in this state.
(H)   "Real-time   benefit   tool"   or  "RTBT"  means  an  electronic
prescription decision support tool that: (i) is capable  of  integrating
with  prescribers'  electronic  prescribing  system  and,  if  feasible,
electronic health record systems; and (ii) complies with  the  technical
standards  adopted  by  an  American National Standards Institute (ANSI)
accredited standards development organization.
(I) "Authorized third party"  shall  include  a  third  party  legally
authorized  under  state  or  federal  law subject to a Health Insurance
Portability and Accountability Act (HIPAA) business associate agreement.
(2) The provisions of this section shall not apply to any health  plan
that  exclusively  serves  individuals enrolled pursuant to a federal or
state insurance affordability program, including the medical  assistance
program  under  title eleven of article five of the social services law,
child health plus under section twenty-five hundred eleven of the public
health law,  the  basic  health  program  under  section  three  hundred
sixty-nine-gg  of  the social services law, or a plan providing services
under title XVIII of the federal social security act.
(3) A health service, hospital service, or medical  expense  indemnity
corporation  subject  to this article or pharmacy benefit manager shall,
upon request of the subscriber, the subscriber's health  care  provider,
or  an  authorized  third  party on the subscriber's behalf, made to the
health  service,  hospital  service,  or   medical   expense   indemnity
corporation  or pharmacy benefit manager, furnish the cost, benefit, and
coverage data  required  by  this  subsection  to  the  subscriber,  the
subscriber's  health  care  provider,  or the authorized third party and
shall ensure that such data is: (A) current no later than  one  business
day after any change to the cost, benefit, or coverage data is made; (B)
provided  through  a  RTBT  when the request is made by the subscriber's
health care provider; and (C) in a format that is easily  accessible  to
the requestor.
(4)  When  providing  the  data  required  by  paragraph three of this
subsection, the health service, hospital  service,  or  medical  expense
indemnity  corporation or pharmacy benefit manager shall use established
industry content and transport standards published by:
(A) a standards developing organization  accredited  by  the  American
National Standards Institute (ANSI), including, the National Council for
Prescription Drug Programs (NCPDP), ASC X12, Health Level 7; or
(B)  a  relevant federal or state governing body, including the Center
for  Medicare  &  Medicaid  Services  or  the  Office  of  the  National
Coordinator for Health Information Technology.
(C)  another format deemed acceptable to the department which provides
the data prescribed in paragraph three of this  subsection  and  in  the
same timeliness as required by this section.
(5)  A  facsimile  shall  not  be  considered an acceptable electronic
format pursuant to this subsection.
(6)  Upon  a  request  made  pursuant  to  paragraph  three  of   this
subsection,  the  health  service,  hospital service, or medical expense
indemnity corporation or pharmacy  benefit  manager  shall  provide  the
following  data  for  any  drug covered under the subscriber's insurance
contract:
(A) subscriber-specific eligibility information;
(B) subscriber-specific prescription cost and benefit  data,  such  as
applicable  formulary,  benefit, coverage, and cost-sharing data for the
prescribed   drug   and   clinically-appropriate   alternatives,    when
appropriate;
(C)   subscriber-specific   cost-sharing  information  that  describes
variance in cost-sharing based on the pharmacy dispensing the prescribed
drug or its alternatives, and in relation to the insured's benefit; and
(D) applicable utilization management requirements.
(7) A health service, hospital service, or medical  expense  indemnity
corporation  or  pharmacy  benefit  manager  shall  furnish  the data as
required whether the request is made using  the  drug's  unique  billing
code, such as a National Drug Code or Healthcare Common Procedure Coding
System  code or descriptive term. A health service, hospital service, or
medical expense indemnity corporation or pharmacy benefit manager  shall
not deny or unreasonably delay processing a request.
(8)  A  health service, hospital service, or medical expense indemnity
corporation and pharmacy benefit manager shall not,  except  as  may  be
required  or  authorized  by law, interfere with, prevent, or materially
discourage access, exchange, or use of the data as required; nor shall a
health  service,  hospital  service,  or   medical   expense   indemnity
corporation  or pharmacy benefit manager penalize a health care provider
for disclosing such information to a subscriber or legally  prescribing,
administering,   or   ordering  a  lower  cost,  clinically  appropriate
alternative.
(9) Nothing in this subsection shall be construed to limit  access  to
the     most     up-to-date     subscriber-specific    eligibility    or
subscriber-specific prescription cost and benefit  data  by  the  health
service,  hospital  service, or medical expense indemnity corporation or
pharmacy benefit manager.
(10) Nothing in this subsection shall interfere with subscriber choice
and a health care  provider's  ability  to  convey  the  full  range  of
prescription drug cost options to a subscriber. Health service, hospital
service,  or medical expense indemnity corporations and pharmacy benefit
managers shall not restrict a health care provider from communicating to
the subscriber prescription cost options.