2013 New York Consolidated Laws
ISC - Insurance
Article 43 - (4301 - 4328) NON-PROFIT MEDICAL AND DENTAL INDEMNITY, OR HEALTH AND HOSPITAL SERVICE CORPORATIONS
4324 - Disclosure of information.

 
    §  4324.  Disclosure  of information. The requirements of this section
  shall apply to all comprehensive, expense-reimbursed contracts;  managed
  care   products;  or  any  other  contract  or  product  for  which  the
  superintendent deems such disclosure appropriate.
    (a)  Each  health  service,  hospital  service,  or  medical   expense
  indemnity   corporation  subject  to  this  article  shall  supply  each
  subscriber, and  upon  request  each  prospective  subscriber  prior  to
  enrollment,  written  disclosure  information, which may be incorporated
  into 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:
    (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 corporation, 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
  corporation  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 corporation and a health care provider;
    (5)  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;
    (6) an explanation, where  applicable,  of  a  subscriber's  financial
  responsibility  for  payment when services are provided by a health care
  provider who is not part of the corporation's network of providers or by
  any provider without required authorization;

    (7) a description of the grievance procedures to be  used  to  resolve
  disputes  between the corporation and a subscriber, including: the right
  to file a grievance regarding any dispute between the corporation and  a
  subscriber;  the  right  to  file a grievance orally when the dispute is
  about  referrals  or  covered  benefits;  the toll-free telephone number
  which subscribers 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  subscriber's  financial and other responsibilities
  regarding obtaining such  services  including  when  such  services  are
  received outside the corporation's service area, if any;
    (9)  where  applicable, a description of procedures for subscribers to
  select  and  access  the  corporation'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 corporation's network of
  providers;
    (11)  where applicable, notice that a subscriber enrolled in a managed
  care  product  offered  by  the  corporation  may obtain a referral to a
  health care provider outside of the corporation's network or panel  when
  the  corporation  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  subscriber  and the procedure by which the
  subscriber can obtain such referral;
    (12) where applicable, notice that a subscriber enrolled in a  managed
  care  product offered by the corporation 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 a subscriber enrolled in a managed
  care product offered by the  corporation  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  subscriber's  medical  care  and   the
  procedure for requesting and obtaining such a specialist;
    (14)  where applicable, notice that a subscriber enrolled in a managed
  care product offered by the  corporation  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  corporation  addresses  the  needs  of
  non-English speaking subscribers;
    (16) notice of all appropriate mailing addresses and telephone numbers
  to be utilized by subscribers seeking information or authorization;
    (16-a)  where  applicable,  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;
    (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; and
    (18)  a  description  of  the  mechanisms  by  which  subscribers  may
  participate in the development of the policies of the corporation.
    (b)   Each  health  service,  hospital  service,  or  medical  expense
  indemnity corporation  subject  to  this  article,  upon  request  of  a
  subscriber or prospective subscriber 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 corporation;
    (2)  provide  a  copy  of  the  most recent annual certified financial
  statement of the corporation, 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 subscriber information;
    (6) where applicable, to allow subscribers and prospective subscribers
  to inspect drug formularies  used  by  such  corporation;  and  provided
  further,  that  the  corporation  shall also disclose whether individual
  drugs are  included  or  excluded  from  coverage  to  a  subscriber  or
  prospective subscriber who requests this information;
    (7)  provide  a written description of the organizational arrangements
  and ongoing procedures of the corporation's quality  assurance  program,
  if any;
    (8)   provide   a  description  of  the  procedures  followed  by  the
  corporation   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 corporation might
  consider in its utilization review and the corporation 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  corporation,  the  subscriber  or  prospective
  subscriber shall only use the information for the purposes of  assisting
  the  subscriber  or  prospective  subscriber  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 corporation for  participation  in  the  corporation'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 a corporation from  changing
  or updating the materials that are made available to subscribers.
    (d)  As to any program where the subscriber must select a primary care
  provider, if a participating primary care provider  becomes  unavailable
  to  provide  services  to  a  subscriber,  the corporation shall provide
  written notice within fifteen days from the time the corporation becomes
  aware of such unavailability to  each  subscriber  who  has  chosen  the
  provider  as their primary care provider. If a subscriber is enrolled in
  a managed care product and is in an ongoing course of treatment with any
  other participating provider who  becomes  unavailable  to  continue  to
  provide  services  to  such  subscriber, and the corporation is aware of
  such ongoing course of treatment, the corporation shall provide  written
  notice  within  fifteen days from the time the corporation becomes aware
  of such unavailability  to  such  subscriber.  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 subscriber (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  corporation'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
  corporation'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  subscriber  (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  corporation's  managed  care  provider
  network, in order for the subscriber  to  be  entitled  to  the  maximum
  reimbursement under the contract.