§ 162 — Contract for health benefits

§ 162. Contract for health benefits. 1. The president is hereby\nauthorized and directed to purchase a contract or contracts to provide\nthe benefits under the plan of health benefits determined upon in\naccordance with the provisions of this article. Such contract or\ncontracts shall be purchased from one or more corporations licensed to\ntransact accident and health insurance business in this state or subject\nto article forty-three of the insurance law.\n (a) Alternatively, the president may provide health benefits directly\nto plan participants, in which case the president is hereby authorized\nto purchase a contract or contracts with one or more firms qualified to\nadminister, on New York state health benefit plan's behalf, the plan of\nbenefits required under this article.\n (b) In the event the president elects to provide health benefits\ndirectly to plan participants in accordance with paragraph (a) of this\nsubdivision:\n (i) Any and all health insurance coverage mandated by any law, rule or\nregulation, including but not limited to coverage mandated pursuant to\narticle forty-three of the insurance law, applicable to contracts for\nhealth insurance entered into under this section shall be provided in a\nmanner assuring uninterrupted continuance of coverage for all covered\npersons. For the purposes of this paragraph "coverage" shall include but\nshall not be limited to all benefits, services, rights, privileges and\nguarantees allowed by law;\n (ii) Plan participants shall be afforded all internal and external\nreview and appeal rights as described in article forty-nine of the\ninsurance law;\n (iii) A plan participant receiving covered services rendered by a\nhealth care provider prior to the date upon which the president elects\nto provide health benefits directly to plan participants in accordance\nwith paragraph (a) of this subdivision shall be permitted to continue\nreceiving services from such health care provider after the effective\ndate of the election at the discretion of such plan participant.\nServices provided by such health care provider after the effective date\nof the election as described in this paragraph shall be covered in a\nmanner consistent with covered services provided directly to plan\nparticipants in accordance with paragraph (a) of this subdivision; and\n (iv) Notwithstanding the provisions of this subdivision, the\npresident's election to provide health benefits directly to plan\nparticipants shall not constitute the doing of insurance business within\nthe meaning of article eleven of the insurance law; provided however,\nthe provision of direct benefits as per this subdivision shall be\nsubject to review by the superintendent of financial services for the\npurposes of ensuring compliance with applicable insurance law and any\nand all associated insurance rules and regulations as noted in this\nsubdivision.\n (c) All of the benefits to be provided under this article may be\nincluded in one or more similar contracts, or the benefits may be\nclassified into different types with each type included under one or\nmore similar contracts issued by the same or different companies.\n 2. A reasonable time before entering into any insurance contract or\ncontract with an administrator or administrators hereunder, the\npresident shall invite proposals from such qualified insurers or\nadministrators as in his or her opinion would desire to accept any part\nof the insurance coverage or administrative services authorized by this\narticle.\n 3. The president may arrange with any corporation licensed to transact\naccident and health insurance business in this state or subject to\narticle forty-three of the insurance law issuing any such contract to\nreinsure portions of such contract with any other such corporation which\nelects to be a reinsurer and is legally competent to enter into a\nreinsurance agreement.\n 4. The president may designate one or more of such corporations as the\nadministering corporation or corporations.\n 5. Each employee who is covered under any such contract or contracts\nshall receive a certificate setting forth the benefits to which the\nemployee and his dependents are entitled thereunder, to whom such\nbenefits shall be payable, to whom claims should be submitted, and\nsummarizing the provisions of the contract principally affecting the\nemployee and his dependents. Such certificate shall be in lieu of the\ncertificate which the corporation or corporations issuing such contract\nor contracts would otherwise issue.\n 6. The corporations eligible to participate as reinsurers, and the\namount of coverage under the contract or contracts to be allocated to\neach issuing corporation or reinsurer, may be redetermined by the\npresident for and in advance of any contract year after the first year\non a basis consistent with subdivision three of this section, and with\nany modifications thereof he deems appropriate to carry out the intent\nof such subdivision.\n 7. The president shall not purchase any contract or contracts for any\nperiod except upon the prior approval of the director of the budget.\n 8. The president may, on March thirty-first, nineteen hundred\nfifty-seven or at the end of any fiscal year thereafter, discontinue any\ncontract or contracts he has purchased from any corporation or\ncorporations and replace it or them with a contract or contracts in any\nother corporation or corporations meeting the requirements of this\nsection.\n 9. (a) (i) As soon as is practicable, but no later than the first of\nSeptember, two thousand fourteen, the department shall, upon request,\nbut no more frequently than semi-annually, provide to any participating\nemployer a standard report which contains data relating to the use of\nbenefits by persons covered under the plan by such employer. Such report\nshall include: premiums paid by month for each month covered in the\nreport and paid claims by month for the following categories of\nservices: inpatient hospital, outpatient hospital, in network medical,\nout of network medical, prescription drugs, and treatment of behavioral\nconditions, each reported separately. To the extent allowed by state and\nfederal privacy laws, such report shall also contain claims information\nfor individual claimants for claims in excess of fifty thousand dollars\nthat were paid in any of the months covered by the report.\n (ii) The department shall provide such reports to any participating\nemployer, upon request submitted on or after the first of April for data\nfrom the first of January through the thirty-first of December of the\nprior year, and on or after the first of September for data from the\nfirst of June of the prior year through the thirty-first of May of the\ncurrent year, within thirty days of receipt of said request. However,\nrequests submitted in the two thousand fourteen calendar year shall be\nprovided as soon as practicable, but no later than the first of\nSeptember, two thousand fourteen, or within thirty days after said\nrequest if request is submitted on or after the first of August, two\nthousand fourteen.\n (b) (i) As soon as practicable, but not later than December first of\neach year, the department shall collect and analyze health care claims\ndata from the Empire Plan, or its successor, to develop, and make\npublicly available, a New York state health benefit plan hospital\npricing report. Such report shall exclude optional benefit plan health\ncare claims data and claims for Medicare primary individuals. The report\nshall include, but not be limited to, a comparative analysis of actual\nhospital in-network allowed amounts and out-of-network allowed amounts\nfor each hospital facility located in the state of New York identified\nby name and CMS certification number (CCN) or successor identifier,\nbased on the following service categories: (A) inpatient hospital, (B)\noutpatient hospital, (C) emergency room services, and (D) physician\nservices provided (1) during an inpatient hospital admission and (2) as\npart of an outpatient visit or in connection with the provision of\nemergency room services, except to the extent that the department\ndetermines that the analysis of physician services is not technically\nfeasible and explains the basis for such determination.\n (ii) The report shall also include the in-network allowed amount and\nout-of-network allowed amount per service per hospital facility on the\ntop twenty services by volume within each of the following service\ncategories: (A) inpatient, (B) outpatient, (C) emergency room services,\nand (D) physician services provided (1) during an inpatient hospital\nadmission and (2) as part of an outpatient visit or in connection with\nthe provision of emergency room services, except to the extent that the\ndepartment determines that the analysis of physician services is not\ntechnically feasible and explains the basis for such determination at\neach hospital located in the state of New York. The report shall\ncompare, to the best of the department's ability, the in-network allowed\namounts and out-of-network allowed amounts for similar services\nreimbursed under title eighteen of the social security act. Such report\nshall also include a comprehensive analysis of the prior two years of\nhospital in-network allowed amounts and out-of-network allowed amounts\nfor such services to illustrate trends in hospital prices. The report\nshall also include an all-plan aggregated total yearly spend by hospital\nfacility identified by name and CMS certification number (CCN) or\nsuccessor identifier. In preparing the report, the president shall take\nappropriate steps to ensure that individual insurer's or health plan's\nconfidential proprietary pricing information is maintained as\nconfidential to the extent permissible by law. Such report shall be\ndelivered to the legislative fiscal committees, the chairs of the\nlegislative health care committees, the chair of the senate civil\nservice and pensions committee, and the chair of the assembly committee\non governmental employees, on or before December thirty-first of each\nyear, and such report shall be posted on the department's website no\nlater than January first of the following calendar year. For purposes of\nthis subdivision, "health care claims data" means any hospital claims\npaid by the health benefit plan, or its designee, for the service\ncategories listed in this subdivision on form UB-04 or successor forms,\nwith UB-04 being the billing form identified by the Centers for Medicare\nand Medicaid Services.\n