2023 New York Laws › PBH - Public Health › Article 44 - Health Maintenance Organizations › 4409 - Health Maintenance Organizations; Examinations.

§ 4409. Health maintenance organizations; examinations. 1. In order to
carry  out the provisions of this article, the commissioner, pursuant to
his authority under section two  hundred  six  of  this  chapter,  shall
examine  not  less  than once every three years, each health maintenance
organization and all participating entities through  which  such  health
maintenance  organization  offers  health  services as to the quality of
health  care  services  offered,  and  the  adequacy  of  its   provider
arrangements.
2. (a) The superintendent shall examine not less than once every three
years   into   the   financial   affairs   of  each  health  maintenance
organization,  and  transmit  his  findings  to  the  commissioner.   In
connection  with  any  such  examination,  the superintendent shall have
convenient access at all reasonable hours to all books,  records,  files
and  other documents relating to the affairs of such organization, which
are relevant to the examination. The  superintendent  may  exercise  the
powers  set forth in sections three hundred six and three hundred ten of
the insurance law in connection with such  examinations,  and  may  also
require  special  reports  from such health maintenance organizations as
specified in section three hundred eight of the insurance law.  As  part
of  an  examination,  the  superintendent shall review determinations of
coverage for substance use disorder treatment and shall ensure that such
determinations are issued in compliance with section four thousand three
hundred three of the insurance law and title one of  article  forty-nine
of this chapter.
(b)  The department is authorized to address to any health maintenance
organization, and managed long term care  plan  with  a  certificate  of
authority  pursuant  to  section  forty-four  hundred  three-f  of  this
article, or officers thereof, any inquiry in relation to  its  contracts
with  providers  and  other  entities  providing covered services to the
health maintenance organization's  or  managed  long  term  care  plan's
enrollees, including but not limited to the rates of payment and payment
terms  and conditions therein. Every entity or person so addressed shall
reply in writing to such inquiry promptly and truthfully, and such reply
shall be, if required by the department, signed by such  individual,  or
by  such  officer  or officers of a corporation, as the department shall
designate, and affirmed by  them  as  true  under  penalty  of  perjury.
Failure to comply with the requirements of this section shall be subject
to  civil penalties under section twelve of this chapter. Each day after
the deadline established by the department for  reply  until  such  time
that  the  provider  submits a good faith response shall be considered a
separate and  subsequent  violation.  In  accordance  with  the  process
outlined  in  this  paragraph,  employers shall provide any documents or
materials in the employer's possession, custody,  or  control  that  are
requested  by  the  department  as  needed  to  support  or  verify  the
employer's reply.
(c) Any report, information, documents, or other  materials  furnished
to  the department under this subdivision shall be deemed a confidential
communication and shall not be subject to inspection  or  disclosure  in
any  manner,  including  article  six  of  the  public  officers  law or
department regulations in conformance therewith, except as  provided  in
this section, pursuant to a judicial subpoena issued in a pending action
or  proceeding,  or  upon  formal  written  request by the department of
labor, the office of attorney  general,  or  a  duly  authorized  public
agency.
(d) The department shall no less than annually provide a report to the
governor, temporary president of the senate, and speaker of the assembly
summarizing  the  information obtained by the department under paragraph

(b) of this subdivision. Such  report  shall  not  contain  individually
identifiable data.
3. The superintendent and the commissioner are authorized to share and
exchange   information  obtained  by  them  in  the  exercise  of  their
respective responsibilities under the insurance law and this chapter.
4. Nothing contained in this section shall be deemed  to  require  the
public disclosure of privileged patient information.