2023 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,
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; 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.
(g) (1) As used in this subsection:
(A) "Pharmacy benefit manager" shall have the meanings  set  forth  in
section two hundred eighty-a of the public health law.
(B) "Cost-sharing information" means the amount an insured is required
to  pay  to receive a drug that is covered under the insured's insurance
policy.
(C) "Covered/coverage" means those health care services  to  which  an
insured is entitled under the terms of the insurance policy.
(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"  means  an  electronic  prescription  as
defined 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)  An  insurer  subject  to this article or pharmacy benefit manager
shall, upon request of the insured, the insured's health care  provider,
or  an  authorized  third  party  on  the  insured's behalf, made to the
insurer or pharmacy benefit manager,  furnish  the  cost,  benefit,  and
coverage  data required by this subsection to the insured, the insured'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  an  RTBT  when the request is made by the insured'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  insurer  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; or
(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 insurer or pharmacy benefit manager  shall  provide  the
following  data  for  any  drug  covered  under  the insured's insurance
policy:
(A) insured-specific eligibility information;
(B) insured-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)  insured-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)  Any insurer 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. An insurer or pharmacy benefit manager
shall not deny or unreasonably delay processing a request.
(8) An insurer 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
an insurer or pharmacy benefit manager penalize a health  care  provider
for  disclosing  such  information to an insured 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  insured-specific  eligibility or insured-specific
prescription cost and benefit data by the insurer  or  pharmacy  benefit
manager.
(10)  Nothing  in  this subsection shall interfere with insured choice
and a health care  provider's  ability  to  convey  the  full  range  of
prescription  drug  cost  options  to  an insured. Insurers and pharmacy
benefit  managers  shall  not  restrict  a  health  care  provider  from
communicating to the insured prescription cost options.