2023 New York Laws › ISC - Insurance › Article 32 - Insurance Contracts - Life, Accident and Health, Annuities › 3235 - Explanation of Benefits Forms Relating to Claims Under Medicare Supplemental Insurance Policies and Limited Benefits Health Insurance Policies or Cert

§  3235.  Explanation  of  benefits  forms  relating  to  claims under
medicare supplemental insurance policies  and  limited  benefits  health
insurance  policies  or  certificates  designed  primarily to supplement
medicare  benefits.  (a)  Every  insurer  issuing  medicare   supplement
insurance policies or certificates and limited benefits health insurance
policies  or  certificates  designed  primarily  to  supplement medicare
benefits, including health  maintenance  organizations  operating  under
article  forty-four  of  the public health law or article forty-three of
this  chapter  and  any  other  corporation  operating   under   article
forty-three  of  this  chapter,  is  required  to provide the insured or
subscriber with an explanation of  benefits  form  in  response  to  the
filing of any claim under such policy or certificate.
(b)  The  explanation  of  benefits  form  must  include  at least the
following:
(1) the name of the provider of service and the admission or financial
control number, to the extent that they are included in the  information
received on the medicare claim from the medicare carrier or intermediary
or from the beneficiary;
(2)  a statement that the name and address of the provider of service,
an identification of the service, the amount charged  for  the  service,
and   the  medicare  approved  amount  are  specified  on  the  medicare
explanation of benefits form to which the claim corresponds;
(3) the date of service;
(4) the amount of the benefit payable under the policy or certificate,
including, if  applicable,  any  amount  exceeding  medicare's  approved
charge;
(5)  when  payment  under  the policy or certificate is based upon the
medicare approved charge and does not include any part of a charge which
exceeds the medicare approved charge, a statement  that  the  policy  or
certificate  only  provides reimbursement for the difference between the
medicare approved charge and  the  medicare  payment,  that  charges  in
excess  of  the  medicare  approved charge may be subject to limitations
pursuant to section nineteen of the public health law, that the  insured
or  subscriber  has  a  right  to appeal the medicare approved charge by
writing to medicare's carrier  or  fiscal  intermediary,  and  that  the
insured  or  subscriber  may  be responsible for the amount by which the
charge exceeds the medicare approved charge; and
(6) a telephone number or address where an insured or  subscriber  may
obtain  clarification  of  the  explanation  of  benefits,  as well as a
description of the time limit, place and manner in which an appeal of  a
denial of benefits must be brought under the policy or certificate and a
notification  that  failure to comply with such requirements may lead to
forfeiture of a consumer's right to challenge  a  denial  or  rejection,
even when a request for clarification has been made.
(c) Except on demand by the insured or subscriber, insurers, including
health  maintenance  organizations operating under article forty-four of
the public health law or article forty-three of  this  chapter  and  any
other  corporation  operating under article forty-three of this chapter,
issuing medicare  supplement  insurance  policies  or  limited  benefits
health   insurance   policies  or  certificates  designed  primarily  to
supplement medicare benefits  shall  not  be  required  to  provide  the
insured  or  subscriber with an explanation of benefits form in any case
where the service is provided by a facility or provider on an assignment
basis and the insurer's reimbursement is paid directly to  the  facility
or provider.