2023 New York Laws › ISC - Insurance › Article 2 - Organization of the Department of Financial Services › 210 - Annual Consumer Guide of Health Insurers, and Entities Certified Pursuant to Article Forty-Four of the Public Health Law.

§  210.  Annual  consumer  guide  of  health  insurers,  and  entities
certified pursuant to article forty-four of the public health law.
(a) The superintendent shall annually publish on or  before  September
first, nineteen hundred ninety-nine, and annually thereafter, a consumer
guide  to  insurers providing managed care products, individual accident
and health insurance or group or blanket accident and  health  insurance
and  entities  licensed  pursuant  to  article  forty-four of the public
health law providing comprehensive health service plans which  includes,
in  detail, a ranking from best to worst based upon each company's claim
processing or medical payments record during the preceding calendar year
using criteria available to  the  department,  adjusted  for  volume  of
coverage  provided.  Such ranking shall also take into consideration the
corresponding total number or percentage of  claims  denied  which  were
reversed  or  compromised  after  intervention by the department and the
department of health, consumer complaints  to  the  department  and  the
department  of  health, violations of section three thousand two hundred
twenty-four-a of this chapter  and  other  pertinent  data  which  would
permit  the department to objectively determine a company's performance.
The department in publishing  such  consumer  guide  shall  publish  one
state-wide  guide  or  no  more  than  five  regional  guides  so  as to
facilitate comparisons among individual insurers and entities  within  a
service  market  area.  Such rankings shall be printed in a format which
ranks all health insurers and all entities certified pursuant to article
forty-four of the public health law in one combined list.
(b)  Beginning  September  first,  nineteen  hundred  ninety-nine  and
annually thereafter, the superintendent shall include in such guide, and
insurers  and  entities  certified pursuant to article forty-four of the
public health law shall provide to the  superintendent  the  information
required for such guide in a timely fashion, the following information:
(1)  The  number  of  grievances  filed pursuant to section forty-four
hundred eight-a of the public health law or article forty-eight of  this
chapter   and  the  number  of  such  grievances  in  which  an  adverse
determination of the insurer or entity was reversed in whole or in  part
versus the number of such determinations which were upheld; and
(2)  The  number of appeals to utilization review determinations which
were filed pursuant to article forty-nine of the public  health  law  or
article forty-nine of this chapter and the number of such determinations
which  were reversed versus the number of such determinations which were
upheld.
(c)  Beginning  September  first,  nineteen  hundred  ninety-nine  and
annually   thereafter,  in  addition  to  the  information  required  in
subsections  (a)  and  (b)  of  this  section,  the  superintendent,  in
conjunction  with  the  commissioner of health, in consultation with the
National  Committee  on  Quality  Assurance  or   a   similar   national
organization,  shall  include  in  such  guide  the following additional
information, for the most recent  year  in  which  such  information  is
available  and  where  applicable,  for health insurers, health insurers
providing managed care products and  entities  certified  under  article
forty-four  of  the  public  health  law  providing comprehensive health
service plans pursuant to such article:
(1) the percentage of physicians who are  either  board  certified  or
board eligible;
(2)   the   percentage   of   primary  care  physicians  who  remained
participating providers, provided however, that  such  percentage  shall
exclude  voluntary  terminations due to physician retirement, relocation
or other similar reasons;
(3) the percentage of enrollees aged twenty-three to  thirty-nine  and
forty  to  sixty-four  who  had  one  or  more  visits  to a health plan
practitioner during the three years of their continual enrollment.
(4)  the  methods used to compensate primary care physicians and other
providers, provided however, that  nothing  in  this  section  shall  be
construed to require disclosure of the specific details of any financial
arrangement  between the insurer or entity and an individual provider or
practice;
(5) the national accreditation status of insurers and entities,  where
applicable;
(6)  indices  of  the  quality  of care provided, such as the rates of
mammography, prostate, and cervical  cancer  screening,  prenatal  care,
well-child  care,  immunization  and such other information collected by
the commissioner of health through the health  plan  employer  data  and
information  set  (HEDIS);  or  through  the quality assurance reporting
requirements for entities not otherwise required to collect  and  report
health plan employer data and information set (HEDIS) data;
(7)  the  results of a consumer satisfaction survey among enrollees of
the various health insurers and entities, which shall  be  conducted  by
the  superintendent and commissioner of health, in consultation with the
National  Committee  on  Quality  Assurance  or   a   similar   national
organization;
(8) a toll-free telephone number for each health insurer or plan;
(9)  toll-free  telephone numbers at the department and the department
of health to which consumers  can  make  complaints  about  insurers  or
entities; and
(10)  except as required in paragraph seven of this subsection, health
insurers and entities certified pursuant to article  forty-four  of  the
public  health  law  shall  report  the  information required under this
subdivision to the commissioner of health, and  the  commissioner  shall
provide  such  information  to  the  superintendent for inclusion in the
annual consumer guide.
(d)  Health  insurers  and  entities  certified  pursuant  to  article
forty-four  of  the  public  health  law  shall  provide annually to the
superintendent and the commissioner of health, and the  commissioner  of
health  shall  provide  to  the  superintendent,  all of the information
necessary for the superintendent to produce the annual  consumer  guide.
In  compiling  the  guide, the superintendent shall make every effort to
ensure that the information is  presented  in  a  clear,  understandable
fashion  which  facilitates  comparisons  among  individual insurers and
entities, and in a format which lends  itself  to  the  widest  possible
distribution  to  consumers. The superintendent shall either include the
information from the annual consumer  guide  in  the  consumer  shopping
guide  required by subsection (a) of section four thousand three hundred
twenty-three of this chapter or  combine  the  two  guides  as  long  as
consumers  in  the  individual  market are provided with the information
required by subsection  (a)  of  section  four  thousand  three  hundred
twenty-three of this chapter.
(e) The superintendent shall contract with a national organization for
the  purposes  of  drafting  and  designing  the  guide,  including  the
preparation of relevant explanatory material.  Such  organization  shall
have  actual  experience  in  preparing a similar guide for at least one
other state. The superintendent, in consultation with  the  commissioner
of  health, may also contract with one or more national organizations to
assist such commissioner in the collection of data and the analysis  and
auditing  of  the  clinical  measurers. Such organizations shall consult
periodically with associations representing health insurers  and  health

maintenance  organizations  as  well as with consumer representatives in
New York in preparing the consumer guide.