2006 New York Code - 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 offered by the insurer may obtain a referral  to  a  health
  care provider outside of the insurer's network or panel when the insurer
  does  not  have  a  health  care  provider with 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;
    (12) where applicable, notice that an insured enrolled  in  a  managed
  care  product  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  offered  by  the  insurer  with  (i)  a  life-threatening
  condition  or disease, or (ii) 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  offered  by  the  insurer  with  (i)  a  life-threatening
  condition  or disease, or (ii) 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; and
    (17)  where  applicable,  a  listing  by  specialty, which may be in a
  separate document that is updated annually, of the  name,  address,  and
  telephone  number  of all participating providers, including facilities,
  and in addition, in the case of physicians, board certification.
    (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  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;
    (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; and
    (12)   disclose   such   other   information   as   required   by  the
  superintendent, provided that such requirements are promulgated pursuant
  to the state administrative procedure act.
    (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.