§ 3217-A — Disclosure of information

§ 3217-a. Disclosure of information. The requirements of this section\nshall apply to all comprehensive, expense-reimbursed health insurance\ncontracts; managed care health insurance contracts; or any other health\ninsurance contract or product for which the superintendent deems such\ndisclosure appropriate.\n (a) Each insurer subject to this article shall supply each insured,\nand upon request each prospective insured prior to enrollment, written\ndisclosure information, which may be incorporated into the insurance\ncontract or certificate, containing at least the information set forth\nbelow. In the event of any inconsistency between any separate written\ndisclosure statement and the insurance contract or certificate, the\nterms of the insurance contract or certificate shall be controlling. The\ninformation to be disclosed shall include at least the following:\n (1) a description of coverage provisions; health care benefits;\nbenefit maximums, including benefit limitations; and exclusions of\ncoverage, including the definition of medical necessity used in\ndetermining whether benefits will be covered;\n (2) a description of all prior authorization or other requirements for\ntreatments and services;\n (3) a description of utilization review policies and procedures, used\nby the insurer, including:\n (A) the circumstances under which utilization review will be\nundertaken;\n (B) the toll-free telephone number of the utilization review agent;\n (C) the time frames under which utilization review decisions must be\nmade for prospective, retrospective and concurrent decisions;\n (D) the right to reconsideration;\n (E) the right to an appeal, including the expedited and standard\nappeals processes and the time frames for such appeals;\n (F) the right to designate a representative;\n (G) a notice that all denials of claims will be made by qualified\nclinical personnel and that all notices of denials will include\ninformation about the basis of the decision;\n (H) a notice of the right to an external appeal together with a\ndescription, jointly promulgated by the superintendent and the\ncommissioner of health as required pursuant to subsection (e) of section\nfour thousand nine hundred fourteen of this chapter, of the external\nappeal process established pursuant to title two of article forty-nine\nof this chapter and the time frames for such appeals; and\n (I) further appeal rights, if any;\n (4) a description prepared annually of the types of methodologies the\ninsurer uses to reimburse providers specifying the type of methodology\nthat is used to reimburse particular types of providers or reimburse for\nthe provision of particular types of services; provided, however, that\nnothing in this paragraph should be construed to require disclosure of\nindividual contracts or the specific details of any financial\narrangement between an insurer and a health care provider;\n (5) an explanation of an insured's financial responsibility for\npayment of premiums, coinsurance, co-payments, deductibles and any other\ncharges, annual limits on an insured's financial responsibility, caps on\npayments for covered services and financial responsibility for\nnon-covered health care procedures, treatments or services;\n (6) an explanation, where applicable, of an insured's financial\nresponsibility for payment when services are provided by a health care\nprovider who is not part of the insurer's network of providers or by any\nprovider without required authorization, or when a procedure, treatment\nor service is not a covered benefit;\n (7) a description of the grievance procedures to be used to resolve\ndisputes between an insurer and an insured, including: the right to file\na grievance regarding any dispute between an insured and an insurer; the\nright to file a grievance orally when the dispute is about referrals or\ncovered benefits; the toll-free telephone number which insureds may use\nto file an oral grievance; the timeframes and circumstances for\nexpedited and standard grievances; the right to appeal a grievance\ndetermination and the procedures for filing such an appeal; the\ntimeframes and circumstances for expedited and standard appeals; the\nright to designate a representative; a notice that all disputes\ninvolving clinical decisions will be made by qualified clinical\npersonnel and that all notices of determination will include information\nabout the basis of the decision and further appeal rights, if any;\n (8) a description of the procedure for obtaining emergency services.\nSuch description shall include a definition of emergency services,\nnotice that emergency services are not subject to prior approval, and\nshall describe the insured's financial and other responsibilities\nregarding obtaining such services including when such services are\nreceived outside the insurer's service area, if any;\n (9) where applicable, a description of procedures for insureds to\nselect and access the insurer's primary and specialty care providers,\nincluding notice of how to determine whether a participating provider is\naccepting new patients;\n (10) where applicable, a description of the procedures for changing\nprimary and specialty care providers within the insurer's network of\nproviders;\n (11) where applicable, notice that an insured enrolled in a managed\ncare product or in a comprehensive policy that utilizes a network of\nproviders offered by the insurer may obtain a referral or\npreauthorization for a health care provider outside of the insurer's\nnetwork or panel when the insurer does not have a health care provider\nwho is geographically accessible to the insured and who has the\nappropriate training and experience in the network or panel to meet the\nparticular health care needs of the insured and the procedure by which\nthe insured can obtain such referral or preauthorization;\n (12) where applicable, notice that an insured enrolled in a managed\ncare product or a comprehensive policy that utilizes a network of\nproviders offered by the insurer with a condition which requires ongoing\ncare from a specialist may request a standing referral to such a\nspecialist and the procedure for requesting and obtaining such a\nstanding referral;\n (13) where applicable, notice that an insured enrolled in a managed\ncare product or a comprehensive policy that utilizes a network of\nproviders offered by the insurer with (A) a life-threatening condition\nor disease, or (B) a degenerative and disabling condition or disease,\neither of which requires specialized medical care over a prolonged\nperiod of time may request a specialist responsible for providing or\ncoordinating the insured's medical care and the procedure for requesting\nand obtaining such a specialist;\n (14) where applicable, notice that an insured enrolled in a managed\ncare product or a comprehensive policy that utilizes a network of\nproviders offered by the insurer with (A) a life-threatening condition\nor disease, or (B) a degenerative and disabling condition or disease,\neither of which requires specialized medical care over a prolonged\nperiod of time, may request access to a specialty care center and the\nprocedure by which such access may be obtained;\n (15) a description of how the insurer addresses the needs of\nnon-English speaking insureds;\n (16) notice of all appropriate mailing addresses and telephone numbers\nto be utilized by insureds seeking information or authorization;\n (16-a) where applicable, notice that an insured shall have direct\naccess to primary and preventive obstetric and gynecologic services,\nincluding annual examinations, care resulting from such annual\nexaminations, and treatment of acute gynecologic conditions, from a\nqualified provider of such services of her choice from within the plan\nor for any care related to a pregnancy;\n (17) where applicable, a listing by specialty, which may be in a\nseparate document that is updated annually, of the name, address,\ntelephone number, and digital contact information of all participating\nproviders, including facilities, and: (A) whether the provider is\naccepting new patients; (B) in the case of mental health or substance\nuse disorder services providers, any affiliations with participating\nfacilities certified or authorized by the office of mental health or the\noffice of addiction services and supports, and any restrictions\nregarding the availability of the individual provider's services; and\n(C) in the case of physicians, board certification, languages spoken and\nany affiliations with participating hospitals. The listing shall also be\nposted on the insurer's website and the insurer shall update the website\nwithin fifteen days of the addition or termination of a provider from\nthe insurer's network or a change in a physician's hospital affiliation;\n (18) a description of the method by which an insured may submit a\nclaim for health care services;\n (19) with respect to out-of-network coverage:\n (A) a clear description of the methodology used by the insurer to\ndetermine reimbursement for out-of-network health care services;\n (B) the amount that the insurer will reimburse under the methodology\nfor out-of-network health care services set forth as a percentage of the\nusual and customary cost for out-of-network health care services; and\n (C) examples of anticipated out-of-pocket costs for frequently billed\nout-of-network health care services;\n (20) information in writing and through an internet website that\nreasonably permits an insured or prospective insured to estimate the\nanticipated out-of-pocket cost for out-of-network health care services\nin a geographical area or zip code based upon the difference between\nwhat the insurer will reimburse for out-of-network health care services\nand the usual and customary cost for out-of-network health care\nservices; and\n (21) the most recent comparative analysis performed by the insurer to\nassess the provision of its covered services in accordance with the Paul\nWellstone and Pete Domenici Mental Health Parity and Addiction Equity\nAct of 2008, 42 U.S.C. 18031(j), and any amendments to, and federal\nguidance or regulations issued under those acts.\n (b) Each insurer subject to this article, upon request of an insured,\nor prospective insured, shall:\n (1) provide a list of the names, business addresses and official\npositions of the membership of the board of directors, officers, and\nmembers of the insurer;\n (2) provide a copy of the most recent annual certified financial\nstatement of the insurer, including a balance sheet and summary of\nreceipts and disbursements prepared by a certified public accountant;\n (3) provide a copy of the most recent individual, direct pay\nsubscriber contracts;\n (4) provide information relating to consumer complaints compiled\npursuant to section two hundred ten of this chapter;\n (5) provide the procedures for protecting the confidentiality of\nmedical records and other insured information;\n (6) where applicable, allow insureds and prospective insureds to\ninspect drug formularies used by such insurer; and provided further,\nthat the insurer shall also disclose whether individual drugs are\nincluded or excluded from coverage to an insured or prospective insured\nwho requests this information;\n (7) provide a written description of the organizational arrangements\nand ongoing procedures of the insurer's quality assurance program, if\nany;\n (8) provide a description of the procedures followed by the insurer in\nmaking decisions about the experimental or investigational nature of\nindividual drugs, medical devices or treatments in clinical trials;\n (9) provide individual health practitioner affiliations with\nparticipating hospitals, if any;\n (10) upon written request, provide specific written clinical review\ncriteria relating to a particular condition or disease including\nclinical review criteria relating to a step therapy protocol override\ndetermination pursuant to subsection (c-1), subsection (c-2) and\nsubsection (c-3) of section forty-nine hundred three of this chapter,\nand, where appropriate, other clinical information which the insurer\nmight consider in its utilization review and the insurer may include\nwith the information a description of how it will be used in the\nutilization review process; provided, however, that to the extent such\ninformation is proprietary to the insurer, the insured or prospective\ninsured shall only use the information for the purposes of assisting the\nenrollee or prospective enrollee in evaluating the covered services\nprovided by the organization. Such clinical review criteria, and other\nclinical information shall also be made available to a health care\nprofessional as defined in subsection (f) of section forty-nine hundred\nof this chapter, on behalf of an insured and upon written request;\n (11) where applicable, provide the written application procedures and\nminimum qualification requirements for health care providers to be\nconsidered by the insurer for participation in the insurer's network for\na managed care product;\n (12) disclose such other information as required by the\nsuperintendent, provided that such requirements are promulgated pursuant\nto the state administrative procedure act;\n (13) disclose whether a health care provider scheduled to provide a\nhealth care service is an in-network provider; and\n (14) with respect to out-of-network coverage, disclose the approximate\ndollar amount that the insurer will pay for a specific out-of-network\nhealth care service. The insurer shall also inform the insured through\nsuch disclosure that such approximation is not binding on the insurer\nand that the approximate dollar amount that the insurer will pay for a\nspecific out-of-network health care service may change.\n (c) Nothing in this section shall prevent an insurer from changing or\nupdating the materials that are made available to insureds.\n (d) As to any program where the insured must select a primary care\nprovider, if a participating primary care provider becomes unavailable\nto provide services to an insured, the insurer shall provide written\nnotice within fifteen days from the time the insurer becomes aware of\nsuch unavailability to each insured who has chosen the provider as their\nprimary care provider. If an insured enrolled in a managed care product\nis in an ongoing course of treatment with any other participating\nprovider who becomes unavailable to continue to provide services to such\ninsured, and the insurer is aware of such ongoing course of treatment,\nthe insurer shall provide written notice within fifteen days from the\ntime that the insurer becomes aware of such unavailability to such\ninsured. Each notice shall also describe the procedures for continuing\ncare pursuant to subsections (e) and (f) of section forty-eight hundred\nfour of this chapter and for choosing an alternative provider.\n (e) For purposes of this section, a "managed care product" shall mean\na contract which requires that all medical or other health care services\ncovered under the contract, other than emergency care services, be\nprovided by, or pursuant to a referral from, a designated health care\nprovider chosen by the insured (i.e. a primary care gatekeeper), and\nthat services provided pursuant to such a referral be rendered by a\nhealth care provider participating in the insurer's managed care\nprovider network. In addition, in the case of (i) an individual health\ninsurance contract, or (ii) a group health insurance contract covering\nno more than three hundred lives, imposing a coinsurance obligation of\nmore than twenty-five percent upon services received outside of the\ninsurer's managed care provider network, and which has been sold to five\nor more groups, a managed care product shall also mean a contract which\nrequires that all medical or other health care services covered under\nthe contract, other than emergency care services, be provided by, or\npursuant to a referral from, a designated health care provider chosen by\nthe insured (i.e. a primary care gatekeeper), and that services provided\npursuant to such a referral be rendered by a health care provider\nparticipating in the insurer's managed care provider network, in order\nfor the insured to be entitled to the maximum reimbursement under the\ncontract.\n (f) For purposes of this section, "usual and customary cost" shall\nmean the eightieth percentile of all charges for the particular health\ncare service performed by a provider in the same or similar specialty\nand provided in the same geographical area as reported in a benchmarking\ndatabase maintained by a nonprofit organization specified by the\nsuperintendent. The nonprofit organization shall not be affiliated with\nan insurer, a corporation subject to article forty-three of this\nchapter, a municipal cooperative health benefit plan certified pursuant\nto article forty-seven of this chapter, or a health maintenance\norganization certified pursuant to article forty-four of the public\nhealth law.\n (g) (1) As used in this subsection:\n (A) "Pharmacy benefit manager" shall have the meanings set forth in\nsection two hundred eighty-a of the public health law.\n (B) "Cost-sharing information" means the amount an insured is required\nto pay to receive a drug that is covered under the insured's insurance\npolicy.\n (C) "Covered/coverage" means those health care services to which an\ninsured is entitled under the terms of the insurance policy.\n (D) "Electronic health record" means a digital version of a patient's\npaper chart and medical history that makes information available\ninstantly and securely to authorized users.\n (E) "Electronic prescribing system" means a system that enables\nprescribers to enter prescription information into a computer\nprescription device and securely transmit the prescription to pharmacies\nusing a special software program and connectivity to a transmission\nnetwork.\n (F) "Electronic prescription" means an electronic prescription as\ndefined in section thirty-three hundred two of the public health law.\n (G) "Prescriber" means a health care provider licensed to prescribe\nmedication or medical devices in this state.\n (H) "Real-time benefit tool" or "RTBT" means an electronic\nprescription decision support tool that: (i) is capable of integrating\nwith prescribers' electronic prescribing system and, if feasible,\nelectronic health record systems; and (ii) complies with the technical\nstandards adopted by an American National Standards Institute (ANSI)\naccredited standards development organization.\n (I) "Authorized third party" shall include a third party legally\nauthorized under state or federal law subject to a Health Insurance\nPortability and Accountability Act (HIPAA) business associate agreement.\n (2) The provisions of this section shall not apply to any health plan\nthat exclusively serves individuals enrolled pursuant to a federal or\nstate insurance affordability program, including the medical assistance\nprogram under title eleven of article five of the social services law,\nchild health plus under section twenty-five hundred eleven of the public\nhealth law, the basic health program under section three hundred\nsixty-nine-gg of the social services law, or a plan providing services\nunder title XVIII of the federal social security act.\n (3) An insurer subject to this article or pharmacy benefit manager\nshall, upon request of the insured, the insured's health care provider,\nor an authorized third party on the insured's behalf, made to the\ninsurer or pharmacy benefit manager, furnish the cost, benefit, and\ncoverage data required by this subsection to the insured, the insured's\nhealth care provider, or the authorized third party and shall ensure\nthat such data is: (A) current no later than one business day after any\nchange to the cost, benefit, or coverage data is made; (B) provided\nthrough an RTBT when the request is made by the insured's health care\nprovider; and (C) in a format that is easily accessible to the\nrequestor.\n (4) When providing the data required by paragraph three of this\nsubsection, the insurer or pharmacy benefit manager shall use\nestablished industry content and transport standards published by:\n (A) a standards developing organization accredited by the American\nNational Standards Institute (ANSI), including, the National Council for\nPrescription Drug Programs (NCPDP), ASC X12, Health Level 7; or\n (B) a relevant federal or state governing body, including the Center\nfor Medicare & Medicaid Services or the Office of the National\nCoordinator for Health Information Technology; or\n (C) another format deemed acceptable to the department which provides\nthe data prescribed in paragraph three of this subsection and in the\nsame timeliness as required by this section.\n (5) A facsimile shall not be considered an acceptable electronic\nformat pursuant to this subsection.\n (6) Upon a request made pursuant to paragraph three of this\nsubsection, the insurer or pharmacy benefit manager shall provide the\nfollowing data for any drug covered under the insured's insurance\npolicy:\n (A) insured-specific eligibility information;\n (B) insured-specific prescription cost and benefit data, such as\napplicable formulary, benefit, coverage and cost-sharing data for the\nprescribed drug and clinically-appropriate alternatives, when\nappropriate;\n (C) insured-specific cost-sharing information that describes variance\nin cost-sharing based on the pharmacy dispensing the prescribed drug or\nits alternatives, and in relation to the insured's benefit; and\n (D) applicable utilization management requirements.\n (7) Any insurer or pharmacy benefit manager shall furnish the data as\nrequired whether the request is made using the drug's unique billing\ncode, such as a National Drug Code or Healthcare Common Procedure Coding\nSystem code or descriptive term. An insurer or pharmacy benefit manager\nshall not deny or unreasonably delay processing a request.\n (8) An insurer and pharmacy benefit manager shall not, except as may\nbe required or authorized by law, interfere with, prevent, or materially\ndiscourage access, exchange, or use of the data as required; nor shall\nan insurer or pharmacy benefit manager penalize a health care provider\nfor disclosing such information to an insured or legally prescribing,\nadministering, or ordering a lower cost clinically appropriate\nalternative.\n (9) Nothing in this subsection shall be construed to limit access to\nthe most up-to-date insured-specific eligibility or insured-specific\nprescription cost and benefit data by the insurer or pharmacy benefit\nmanager.\n (10) Nothing in this subsection shall interfere with insured choice\nand a health care provider's ability to convey the full range of\nprescription drug cost options to an insured. Insurers and pharmacy\nbenefit managers shall not restrict a health care provider from\ncommunicating to the insured prescription cost options.\n