§ 3235 — Explanation of benefits forms relating to claims under medicare supplemental insurance policies and limited benefits health insurance pol...

§ 3235. Explanation of benefits forms relating to claims under\nmedicare supplemental insurance policies and limited benefits health\ninsurance policies or certificates designed primarily to supplement\nmedicare benefits. (a) Every insurer issuing medicare supplement\ninsurance policies or certificates and limited benefits health insurance\npolicies or certificates designed primarily to supplement medicare\nbenefits, including health maintenance organizations operating under\narticle forty-four of the public health law or article forty-three of\nthis chapter and any other corporation operating under article\nforty-three of this chapter, is required to provide the insured or\nsubscriber with an explanation of benefits form in response to the\nfiling of any claim under such policy or certificate.\n (b) The explanation of benefits form must include at least the\nfollowing:\n (1) the name of the provider of service and the admission or financial\ncontrol number, to the extent that they are included in the information\nreceived on the medicare claim from the medicare carrier or intermediary\nor from the beneficiary;\n (2) a statement that the name and address of the provider of service,\nan identification of the service, the amount charged for the service,\nand the medicare approved amount are specified on the medicare\nexplanation of benefits form to which the claim corresponds;\n (3) the date of service;\n (4) the amount of the benefit payable under the policy or certificate,\nincluding, if applicable, any amount exceeding medicare's approved\ncharge;\n (5) when payment under the policy or certificate is based upon the\nmedicare approved charge and does not include any part of a charge which\nexceeds the medicare approved charge, a statement that the policy or\ncertificate only provides reimbursement for the difference between the\nmedicare approved charge and the medicare payment, that charges in\nexcess of the medicare approved charge may be subject to limitations\npursuant to section nineteen of the public health law, that the insured\nor subscriber has a right to appeal the medicare approved charge by\nwriting to medicare's carrier or fiscal intermediary, and that the\ninsured or subscriber may be responsible for the amount by which the\ncharge exceeds the medicare approved charge; and\n (6) a telephone number or address where an insured or subscriber may\nobtain clarification of the explanation of benefits, as well as a\ndescription of the time limit, place and manner in which an appeal of a\ndenial of benefits must be brought under the policy or certificate and a\nnotification that failure to comply with such requirements may lead to\nforfeiture of a consumer's right to challenge a denial or rejection,\neven when a request for clarification has been made.\n (c) Except on demand by the insured or subscriber, insurers, including\nhealth maintenance organizations operating under article forty-four of\nthe public health law or article forty-three of this chapter and any\nother corporation operating under article forty-three of this chapter,\nissuing medicare supplement insurance policies or limited benefits\nhealth insurance policies or certificates designed primarily to\nsupplement medicare benefits shall not be required to provide the\ninsured or subscriber with an explanation of benefits form in any case\nwhere the service is provided by a facility or provider on an assignment\nbasis and the insurer's reimbursement is paid directly to the facility\nor provider.\n