2006 New York Code - Disclosure Of Information.

 
    §  4408.  Disclosure  of  information.  1.  Each  subscriber, and upon
  request each  prospective  subscriber  prior  to  enrollment,  shall  be
  supplied  with  written disclosure information which may be incorporated
  into the member handbook  or  the  subscriber  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
  subscriber contract or certificate, the terms of the subscriber contract
  or certificate shall be controlling. The  information  to  be  disclosed
  shall include at least the following:
    (a)  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;
    (b) a description of all prior authorization or other requirements for
  treatments and services;
    (c) a description of utilization review policies and  procedures  used
  by the health maintenance organization, including:
    (i)   the   circumstances  under  which  utilization  review  will  be
  undertaken;
    (ii) the toll-free telephone number of the utilization review agent;
    (iii) the timeframes under which utilization review decisions must  be
  made for prospective, retrospective and concurrent decisions;
    (iv) the right to reconsideration;
    (v)  the  right  to  an  appeal,  including the expedited and standard
  appeals processes and the time frames for such appeals;
    (vi) the right to designate a representative;
    (vii) 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;
    (viii) a notice of the right to an external  appeal  together  with  a
  description,   jointly   promulgated   by   the   commissioner  and  the
  superintendent of insurance as required pursuant to subdivision five  of
  section  forty-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 timeframes for such appeals; and
    (ix) further appeal rights, if any;
    (d)  a description prepared annually of the types of methodologies the
  health maintenance organization 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  a  health maintenance
  organization and a health care provider;
    (e) an explanation of  a  subscriber's  financial  responsibility  for
  payment of premiums, coinsurance, co-payments, deductibles and any other
  charges,  annual limits on a subscriber's financial responsibility, caps
  on payments  for  covered  services  and  financial  responsibility  for
  non-covered  health  care  procedures,  treatments  or services provided
  within the health maintenance organization;
    (f) an explanation of  a  subscriber's  financial  responsibility  for
  payment  when services are provided by a health care provider who is not
  part of the health maintenance organization or by any  provider  without
  required  authorization or when a procedure, treatment or service is not
  a covered health care benefit;
    (g) a description of the grievance procedures to be  used  to  resolve
  disputes  between  a  health  maintenance  organization and an enrollee,
  including: the right to file a grievance regarding any  dispute  between
  an  enrollee  and a health maintenance organization; the right to file a
  grievance  orally  when  the  dispute  is  about  referrals  or  covered
  benefits; the toll-free telephone number which enrollees 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;
    (h) a description of the procedure for  providing  care  and  coverage
  twenty-four  hours  a day for 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
  enrollee's financial and other responsibilities regarding obtaining such
  services including when such services are received  outside  the  health
  maintenance organization's service area;
    (i) a description of procedures for enrollees to select and access the
  health  maintenance organization's primary and specialty care providers,
  including notice of how to determine whether a participating provider is
  accepting new patients;
    (j) a description of the procedures for changing primary and specialty
  care providers within the health maintenance organization;
    (k)  notice that an enrollee may obtain a referral to  a  health  care
  provider  outside  of  the  health maintenance organization's network or
  panel when the health maintenance organization 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 enrollee and the
  procedure by which the enrollee can obtain such referral;
    (l) notice that an enrollee 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;
    (m)  notice  that an enrollee 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 enrollee's  medical  care  and  the  procedure  for  requesting  and
  obtaining such a specialist;
    (n)    notice that an enrollee with a (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;
    (o) a description of the mechanisms by which enrollees may participate
  in   the   development   of  the  policies  of  the  health  maintenance
  organization;
    (p) a description of how the health maintenance organization addresses
  the needs of non-English speaking enrollees;
    (p-1) notice that an enrollee shall have direct access to primary  and
  preventive  obstetric and gynecologic services from a qualified provider
  of such services of her choice from within the plan for  no  fewer  than
  two  examinations  annually  for such services or to any care related to
  pregnancy and that additionally, the enrollee shall have  direct  access
  to primary and preventive obstetric and gynecologic services required as
  a  result  of  such  annual  examinations  or  as  a  result of an acute
  gynecologic condition;
    (q) notice of all appropriate mailing addresses and telephone  numbers
  to be utilized by enrollees seeking information or authorization; and
    (r)  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.
    2. Each health maintenance organization  shall,  upon  request  of  an
  enrollee or prospective enrollee:
    (a)  provide  a  list  of  the  names, business addresses and official
  positions of  the  membership  of  the  board  of  directors,  officers,
  controlling  persons,  owners  or  partners  of  the  health maintenance
  organization;
    (b) provide a copy of  the  most  recent  annual  certified  financial
  statement  of  the  health maintenance organization, including a balance
  sheet and summary of receipts and disbursements prepared by a  certified
  public accountant;
    (c)  provide  a  copy  of  the  most  recent  individual,  direct  pay
  subscriber contracts;
    (d) provide  information  relating  to  consumer  complaints  compiled
  pursuant to section two hundred ten of the insurance law;
    (e)  provide  the  procedures  for  protecting  the confidentiality of
  medical records and other enrollee information;
    (f)  allow  enrollees  and  prospective  enrollees  to  inspect   drug
  formularies  used  by such health maintenance organization; and provided
  further, that the health maintenance organization  shall  also  disclose
  whether  individual  drugs  are included or excluded from coverage to an
  enrollee or prospective enrollee who requests this information;
    (g) provide a written description of the  organizational  arrangements
  and  ongoing procedures of the health maintenance organization's quality
  assurance program;
    (h) provide a description of the procedures  followed  by  the  health
  maintenance  organization  in making decisions about the experimental or
  investigational  nature  of  individual  drugs,   medical   devices   or
  treatments in clinical trials;
    (i)   provide   individual   health   practitioner  affiliations  with
  participating hospitals, if any;
    (j) upon written request, provide  specific  written  clinical  review
  criteria  relating  to  a  particular  condition  or  disease and, where
  appropriate, other clinical information  which  the  organization  might
  consider in its utilization review and the organization 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 organization, the enrollee or prospective enrollee
  shall  only  use  the  information  for  the  purposes  of assisting the
  enrollee or prospective enrollee  in  evaluating  the  covered  services
  provided by the organization;
    (k)   provide   the   written   application   procedures  and  minimum
  qualification requirements for health care providers to be considered by
  the health maintenance organization; and
    (1) disclose  other  information  as  required  by  the  commissioner,
  provided  that  such  requirements are promulgated pursuant to the state
  administrative procedure act.
    3.  Nothing  in  this  section  shall  prevent  a  health  maintenance
  organization  from  changing  or  updating  the  materials that are made
  available to enrollees.
    4. If a primary care  provider  ceases  participation  in  the  health
  maintenance  organization, the organization shall provide written notice
  within fifteen days from the date that the organization becomes aware of
  such change in status to each enrollee who has chosen  the  provider  as
  their  primary  care provider. If an enrollee is in an ongoing course of
  treatment with any other participating provider who becomes  unavailable
  to  continue  to  provide  services  to  such  enrollee  and  the health
  maintenance organization is aware of such ongoing course  of  treatment,
  the  health maintenance organization shall provide written notice within
  fifteen days from the date  that  the  health  maintenance  organization
  becomes aware of such unavailability to such enrollee. Each notice shall
  also  describe the procedures for continuing care pursuant to paragraphs
  (e) and (f) of subdivision six of section  four  thousand  four  hundred
  three of this article and for choosing an alternative provider.
    5.  Every  health maintenance organization shall annually on or before
  April first, file a report with the commissioner and  superintendent  of
  insurance  showing  its  financial  condition  as of the last day of the
  preceding calendar year, in such form and providing such information  as
  the commissioner shall prescribe.
    6.   Every  health  maintenance  organization  offering  to  indemnify
  enrollees pursuant to subdivision nine  of  section  forty-four  hundred
  five  and  subdivision  two  of  section  forty-four hundred six of this
  article shall on a quarterly basis file a report with  the  commissioner
  and  the  superintendent of insurance showing the percentage utilization
  for the preceding quarter of non-participating provider services in such
  form and providing such other  information  as  the  commissioner  shall
  prescribe.