2023 New York Laws › CVS - Civil Service › Article 11 - Health Benefits for State and Retired State Employees › 162 - Contract for Health Benefits.

§ 162.  Contract  for  health  benefits.  1.  The  president is hereby
authorized and directed to purchase a contract or contracts  to  provide
the  benefits  under  the  plan  of  health  benefits determined upon in
accordance with  the  provisions  of  this  article.  Such  contract  or
contracts  shall  be purchased from one or more corporations licensed to
transact accident and health insurance business in this state or subject
to article forty-three of the insurance law.
(a) Alternatively, the president may provide health benefits  directly
to  plan  participants, in which case the president is hereby authorized
to purchase a contract or contracts with one or more firms qualified  to
administer,  on New York state health benefit plan's behalf, the plan of
benefits required under this article.
(b) In the event the  president  elects  to  provide  health  benefits
directly  to  plan participants in accordance with paragraph (a) of this
subdivision:
(i) Any and all health insurance coverage mandated by any law, rule or
regulation, including but not limited to coverage mandated  pursuant  to
article  forty-three  of  the insurance law, applicable to contracts for
health insurance entered into under this section shall be provided in  a
manner  assuring  uninterrupted  continuance of coverage for all covered
persons. For the purposes of this paragraph "coverage" shall include but
shall not be limited to all benefits, services, rights,  privileges  and
guarantees allowed by law;
(ii)  Plan  participants  shall  be afforded all internal and external
review and appeal rights as  described  in  article  forty-nine  of  the
insurance law;
(iii)  A  plan  participant  receiving  covered services rendered by a
health care provider prior to the date upon which the  president  elects
to  provide  health benefits directly to plan participants in accordance
with paragraph (a) of this subdivision shall be  permitted  to  continue
receiving  services  from  such health care provider after the effective
date of the  election  at  the  discretion  of  such  plan  participant.
Services  provided by such health care provider after the effective date
of the election as described in this paragraph shall  be  covered  in  a
manner  consistent  with  covered  services  provided  directly  to plan
participants in accordance with paragraph (a) of this subdivision; and
(iv)  Notwithstanding  the  provisions  of   this   subdivision,   the
president's  election  to  provide  health  benefits  directly  to  plan
participants shall not constitute the doing of insurance business within
the meaning of article eleven of the insurance  law;  provided  however,
the  provision  of  direct  benefits  as  per  this subdivision shall be
subject to review by the superintendent of financial  services  for  the
purposes  of  ensuring  compliance with applicable insurance law and any
and all associated insurance rules and  regulations  as  noted  in  this
subdivision.
(c)  All  of  the  benefits  to  be provided under this article may be
included in one or more  similar  contracts,  or  the  benefits  may  be
classified  into  different  types  with each type included under one or
more similar contracts issued by the same or different companies.
2. A reasonable time before entering into any  insurance  contract  or
contract   with   an  administrator  or  administrators  hereunder,  the
president  shall  invite  proposals  from  such  qualified  insurers  or
administrators  as in his or her opinion would desire to accept any part
of the insurance coverage or administrative services authorized by  this
article.
3. The president may arrange with any corporation licensed to transact
accident  and  health  insurance  business  in  this state or subject to
article forty-three of the insurance law issuing any  such  contract  to

reinsure portions of such contract with any other such corporation which
elects  to  be  a  reinsurer  and  is  legally competent to enter into a
reinsurance agreement.
4. The president may designate one or more of such corporations as the
administering corporation or corporations.
5.  Each  employee who is covered under any such contract or contracts
shall receive a certificate setting forth  the  benefits  to  which  the
employee  and  his  dependents  are  entitled  thereunder,  to whom such
benefits shall be payable, to  whom  claims  should  be  submitted,  and
summarizing  the  provisions  of  the contract principally affecting the
employee and his dependents. Such certificate shall be in  lieu  of  the
certificate  which the corporation or corporations issuing such contract
or contracts would otherwise issue.
6. The corporations eligible to participate  as  reinsurers,  and  the
amount  of  coverage  under the contract or contracts to be allocated to
each issuing corporation  or  reinsurer,  may  be  redetermined  by  the
president  for  and in advance of any contract year after the first year
on a basis consistent with subdivision three of this section,  and  with
any  modifications  thereof he deems appropriate to carry out the intent
of such subdivision.
7. The president shall not purchase any contract or contracts for  any
period except upon the prior approval of the director of the budget.
8.   The  president  may,  on  March  thirty-first,  nineteen  hundred
fifty-seven or at the end of any fiscal year thereafter, discontinue any
contract  or  contracts  he  has  purchased  from  any  corporation   or
corporations  and replace it or them with a contract or contracts in any
other corporation or  corporations  meeting  the  requirements  of  this
section.
9.  (a)  (i) As soon as is practicable, but no later than the first of
September, two thousand fourteen, the department  shall,  upon  request,
but  no more frequently than semi-annually, provide to any participating
employer a standard report which contains data relating to  the  use  of
benefits by persons covered under the plan by such employer. Such report
shall  include:  premiums  paid  by  month for each month covered in the
report and  paid  claims  by  month  for  the  following  categories  of
services:  inpatient  hospital, outpatient hospital, in network medical,
out of network medical, prescription drugs, and treatment of  behavioral
conditions, each reported separately. To the extent allowed by state and
federal  privacy laws, such report shall also contain claims information
for individual claimants for claims in excess of fifty thousand  dollars
that were paid in any of the months covered by the report.
(ii)  The  department  shall provide such reports to any participating
employer, upon request submitted on or after the first of April for data
from the first of January through the thirty-first of  December  of  the
prior  year,  and  on  or after the first of September for data from the
first of June of the prior year through the thirty-first of May  of  the
current  year,  within  thirty days of receipt of said request. However,
requests submitted in the two thousand fourteen calendar year  shall  be
provided  as  soon  as  practicable,  but  no  later  than  the first of
September, two thousand fourteen,  or  within  thirty  days  after  said
request  if  request  is  submitted on or after the first of August, two
thousand fourteen.
(b) (i) As soon as practicable, but not later than December  first  of
each  year,  the department shall collect and analyze health care claims
data from the Empire Plan,  or  its  successor,  to  develop,  and  make
publicly  available,  a  New  York  state  health  benefit plan hospital
pricing report. Such report shall exclude optional benefit  plan  health
care claims data and claims for Medicare primary individuals. The report

shall  include,  but not be limited to, a comparative analysis of actual
hospital in-network allowed amounts and out-of-network  allowed  amounts
for  each  hospital facility located in the state of New York identified
by  name  and  CMS  certification  number (CCN) or successor identifier,
based on the following service categories: (A) inpatient  hospital,  (B)
outpatient  hospital,  (C)  emergency  room  services, and (D) physician
services provided (1) during an inpatient hospital admission and (2)  as
part  of  an  outpatient  visit  or  in connection with the provision of
emergency room services,  except  to  the  extent  that  the  department
determines  that  the  analysis of physician services is not technically
feasible and explains the basis for such determination.
(ii) The report shall also include the in-network allowed  amount  and
out-of-network  allowed  amount per service per hospital facility on the
top twenty services by volume  within  each  of  the  following  service
categories:  (A) inpatient, (B) outpatient, (C) emergency room services,
and (D) physician services provided (1)  during  an  inpatient  hospital
admission  and  (2) as part of an outpatient visit or in connection with
the provision of emergency room services, except to the extent that  the
department  determines  that  the  analysis of physician services is not
technically feasible and explains the basis for  such  determination  at
each  hospital  located  in  the  state  of  New  York. The report shall
compare, to the best of the department's ability, the in-network allowed
amounts  and  out-of-network  allowed  amounts  for   similar   services
reimbursed  under title eighteen of the social security act. Such report
shall also include a comprehensive analysis of the prior  two  years  of
hospital  in-network  allowed amounts and out-of-network allowed amounts
for such services to illustrate trends in hospital  prices.  The  report
shall also include an all-plan aggregated total yearly spend by hospital
facility  identified  by  name  and  CMS  certification  number (CCN) or
successor identifier. In preparing the report, the president shall  take
appropriate  steps  to ensure that individual insurer's or health plan's
confidential  proprietary   pricing   information   is   maintained   as
confidential  to  the  extent  permissible  by law. Such report shall be
delivered to the  legislative  fiscal  committees,  the  chairs  of  the
legislative  health  care  committees,  the  chair  of  the senate civil
service and pensions committee, and the chair of the assembly  committee
on  governmental  employees,  on or before December thirty-first of each
year, and such report shall be posted on  the  department's  website  no
later than January first of the following calendar year. For purposes of
this  subdivision,  "health  care claims data" means any hospital claims
paid by the health benefit  plan,  or  its  designee,  for  the  service
categories  listed in this subdivision on form UB-04 or successor forms,
with UB-04 being the billing form identified by the Centers for Medicare
and Medicaid Services.