§ 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\ncertified pursuant to article forty-four of the public health law.\n (a) The superintendent shall annually publish on or before September\nfirst, nineteen hundred ninety-nine, and annually thereafter, a consumer\nguide to insurers providing managed care products, individual accident\nand health insurance or group or blanket accident and health insurance\nand entities licensed pursuant to article forty-four of the public\nhealth law providing comprehensive health service plans which includes,\nin detail, a ranking from best to worst based upon each company's claim\nprocessing or medical payments record during the preceding calendar year\nusing criteria available to the department, adjusted for volume of\ncoverage provided. Such ranking shall also take into consideration the\ncorresponding total number or percentage of claims denied which were\nreversed or compromised after intervention by the department and the\ndepartment of health, consumer complaints to the department and the\ndepartment of health, violations of section three thousand two hundred\ntwenty-four-a of this chapter and other pertinent data which would\npermit the department to objectively determine a company's performance.\nThe department in publishing such consumer guide shall publish one\nstate-wide guide or no more than five regional guides so as to\nfacilitate comparisons among individual insurers and entities within a\nservice market area. Such rankings shall be printed in a format which\nranks all health insurers and all entities certified pursuant to article\nforty-four of the public health law in one combined list.\n (b) Beginning September first, nineteen hundred ninety-nine and\nannually thereafter, the superintendent shall include in such guide, and\ninsurers and entities certified pursuant to article forty-four of the\npublic health law shall provide to the superintendent the information\nrequired for such guide in a timely fashion, the following information:\n (1) The number of grievances filed pursuant to section forty-four\nhundred eight-a of the public health law or article forty-eight of this\nchapter and the number of such grievances in which an adverse\ndetermination of the insurer or entity was reversed in whole or in part\nversus the number of such determinations which were upheld; and\n (2) The number of appeals to utilization review determinations which\nwere filed pursuant to article forty-nine of the public health law or\narticle forty-nine of this chapter and the number of such determinations\nwhich were reversed versus the number of such determinations which were\nupheld.\n (c) Beginning September first, nineteen hundred ninety-nine and\nannually thereafter, in addition to the information required in\nsubsections (a) and (b) of this section, the superintendent, in\nconjunction with the commissioner of health, in consultation with the\nNational Committee on Quality Assurance or a similar national\norganization, shall include in such guide the following additional\ninformation, for the most recent year in which such information is\navailable and where applicable, for health insurers, health insurers\nproviding managed care products and entities certified under article\nforty-four of the public health law providing comprehensive health\nservice plans pursuant to such article:\n (1) the percentage of physicians who are either board certified or\nboard eligible;\n (2) the percentage of primary care physicians who remained\nparticipating providers, provided however, that such percentage shall\nexclude voluntary terminations due to physician retirement, relocation\nor other similar reasons;\n (3) the percentage of enrollees aged twenty-three to thirty-nine and\nforty to sixty-four who had one or more visits to a health plan\npractitioner during the three years of their continual enrollment.\n (4) the methods used to compensate primary care physicians and other\nproviders, provided however, that nothing in this section shall be\nconstrued to require disclosure of the specific details of any financial\narrangement between the insurer or entity and an individual provider or\npractice;\n (5) the national accreditation status of insurers and entities, where\napplicable;\n (6) indices of the quality of care provided, such as the rates of\nmammography, prostate, and cervical cancer screening, prenatal care,\nwell-child care, immunization and such other information collected by\nthe commissioner of health through the health plan employer data and\ninformation set (HEDIS); or through the quality assurance reporting\nrequirements for entities not otherwise required to collect and report\nhealth plan employer data and information set (HEDIS) data;\n (7) the results of a consumer satisfaction survey among enrollees of\nthe various health insurers and entities, which shall be conducted by\nthe superintendent and commissioner of health, in consultation with the\nNational Committee on Quality Assurance or a similar national\norganization;\n (8) a toll-free telephone number for each health insurer or plan;\n (9) toll-free telephone numbers at the department and the department\nof health to which consumers can make complaints about insurers or\nentities; and\n (10) except as required in paragraph seven of this subsection, health\ninsurers and entities certified pursuant to article forty-four of the\npublic health law shall report the information required under this\nsubdivision to the commissioner of health, and the commissioner shall\nprovide such information to the superintendent for inclusion in the\nannual consumer guide.\n (d) Health insurers and entities certified pursuant to article\nforty-four of the public health law shall provide annually to the\nsuperintendent and the commissioner of health, and the commissioner of\nhealth shall provide to the superintendent, all of the information\nnecessary for the superintendent to produce the annual consumer guide.\nIn compiling the guide, the superintendent shall make every effort to\nensure that the information is presented in a clear, understandable\nfashion which facilitates comparisons among individual insurers and\nentities, and in a format which lends itself to the widest possible\ndistribution to consumers. The superintendent shall either include the\ninformation from the annual consumer guide in the consumer shopping\nguide required by subsection (a) of section four thousand three hundred\ntwenty-three of this chapter or combine the two guides as long as\nconsumers in the individual market are provided with the information\nrequired by subsection (a) of section four thousand three hundred\ntwenty-three of this chapter.\n (e) The superintendent shall contract with a national organization for\nthe purposes of drafting and designing the guide, including the\npreparation of relevant explanatory material. Such organization shall\nhave actual experience in preparing a similar guide for at least one\nother state. The superintendent, in consultation with the commissioner\nof health, may also contract with one or more national organizations to\nassist such commissioner in the collection of data and the analysis and\nauditing of the clinical measurers. Such organizations shall consult\nperiodically with associations representing health insurers and health\nmaintenance organizations as well as with consumer representatives in\nNew York in preparing the consumer guide.\n