§ 4324 — Disclosure of information

§ 4324. Disclosure of information. The requirements of this section\nshall apply to all comprehensive, expense-reimbursed contracts; managed\ncare products; or any other contract or product for which the\nsuperintendent deems such disclosure appropriate.\n (a) Each health service, hospital service, or medical expense\nindemnity corporation subject to this article shall supply each\nsubscriber, and upon request each prospective subscriber prior to\nenrollment, written disclosure information, which may be incorporated\ninto the subscriber contract or certificate, containing at least the\ninformation set forth below. In the event of any inconsistency between\nany separate written disclosure statement and the subscriber contract or\ncertificate, the terms of the subscriber contract or certificate shall\nbe controlling. The information to be disclosed shall include at least\nthe 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 corporation, 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\ncorporation uses to reimburse providers, specifying the type of\nmethodology that is used to reimburse particular types of providers or\nreimburse for the provision of particular types of services; provided,\nhowever, that nothing in this paragraph should be construed to require\ndisclosure of individual contracts or the specific details of any\nfinancial arrangement between a corporation and a health care provider;\n (5) an explanation of a subscriber's financial responsibility for\npayment of premiums, coinsurance, co-payments, deductibles and any other\ncharges, annual limits on a subscriber's financial responsibility, caps\non payments for covered services and financial responsibility for\nnon-covered health care procedures, treatments or services;\n (6) an explanation, where applicable, of a subscriber's financial\nresponsibility for payment when services are provided by a health care\nprovider who is not part of the corporation's network of providers or by\nany provider without required authorization;\n (7) a description of the grievance procedures to be used to resolve\ndisputes between the corporation and a subscriber, including: the right\nto file a grievance regarding any dispute between the corporation and a\nsubscriber; the right to file a grievance orally when the dispute is\nabout referrals or covered benefits; the toll-free telephone number\nwhich subscribers may use to file an oral grievance; the timeframes and\ncircumstances for expedited and standard grievances; the right to appeal\na grievance determination and the procedures for filing such an appeal;\nthe timeframes 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 subscriber's financial and other responsibilities\nregarding obtaining such services including when such services are\nreceived outside the corporation's service area, if any;\n (9) where applicable, a description of procedures for subscribers to\nselect and access the corporation's primary and specialty care\nproviders, including notice of how to determine whether a participating\nprovider is accepting new patients;\n (10) where applicable, a description of the procedures for changing\nprimary and specialty care providers within the corporation's network of\nproviders;\n (11) where applicable, notice that a subscriber enrolled in a managed\ncare product or in a comprehensive contract that utilizes a network of\nproviders offered by the corporation may obtain a referral or\npreauthorization for a health care provider outside of the corporation's\nnetwork or panel when the corporation does not have a health care\nprovider who 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 subscriber and the procedure by\nwhich the subscriber can obtain such referral or preauthorization;\n (12) where applicable, notice that a subscriber enrolled in a managed\ncare product or a comprehensive contract that utilizes a network of\nproviders offered by the corporation with a condition which requires\nongoing care 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 a subscriber enrolled in a managed\ncare product or a comprehensive contract that utilizes a network of\nproviders offered by the corporation with (i) a life-threatening\ncondition or disease, or (ii) a degenerative and disabling condition or\ndisease, either of which requires specialized medical care over a\nprolonged period of time may request a specialist responsible for\nproviding or coordinating the subscriber's medical care and the\nprocedure for requesting and obtaining such a specialist;\n (14) where applicable, notice that a subscriber enrolled in a managed\ncare product or a comprehensive contract that utilizes a network of\nproviders offered by the corporation with (A) a life-threatening\ncondition or disease, or (B) a degenerative and disabling condition or\ndisease, either of which requires specialized medical care over a\nprolonged period of time may request access to a specialty care center\nand the procedure by which such access may be obtained;\n (15) a description of how the corporation addresses the needs of\nnon-English speaking subscribers;\n (16) notice of all appropriate mailing addresses and telephone numbers\nto be utilized by subscribers seeking information or authorization;\n (16-a) where applicable, notice that an enrollee 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; (C) in\nthe case of physicians, board certification, languages spoken and any\naffiliations with participating hospitals. The listing shall also be\nposted on the corporation's website and the corporation shall update the\nwebsite within fifteen days of the addition or termination of a provider\nfrom the corporation's network or a change in a physician's hospital\naffiliation;\n (18) a description of the mechanisms by which subscribers may\nparticipate in the development of the policies of the corporation;\n (19) the method by which a subscriber may submit a claim for health\ncare services;\n (20) with respect to out-of-network coverage:\n (A) a clear description of the methodology used by the corporation to\ndetermine reimbursement for out-of-network health care services;\n (B) a description of the amount that the corporation will reimburse\nunder the methodology for out-of-network health care services set forth\nas a percentage of the usual and customary cost for out-of-network\nhealth care services; and\n (C) examples of anticipated out-of-pocket costs for frequently billed\nout-of-network health care services;\n (21) information in writing and through an internet website that\nreasonably permits a subscriber or prospective subscriber to estimate\nthe anticipated out-of-pocket cost for out-of-network health care\nservices in a geographical area or zip code based upon the difference\nbetween what the corporation will reimburse for out-of-network health\ncare services and the usual and customary cost for out-of-network health\ncare services; and\n (22) the most recent comparative analysis performed by the corporation\nto assess the provision of its covered services in accordance with the\nPaul Wellstone and Pete Domenici Mental Health Parity and Addiction\nEquity Act of 2008, 42 U.S.C. 18031 (j), and any amendments to, and\nfederal guidance or regulations issued under, those Acts.\n (b) Each health service, hospital service, or medical expense\nindemnity corporation subject to this article, upon request of a\nsubscriber or prospective subscriber 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 corporation;\n (2) provide a copy of the most recent annual certified financial\nstatement of the corporation, 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 subscriber information;\n (6) where applicable, to allow subscribers and prospective subscribers\nto inspect drug formularies used by such corporation; and provided\nfurther, that the corporation shall also disclose whether individual\ndrugs are included or excluded from coverage to a subscriber or\nprospective subscriber who requests this information;\n (7) provide a written description of the organizational arrangements\nand ongoing procedures of the corporation's quality assurance program,\nif any;\n (8) provide a description of the procedures followed by the\ncorporation in making decisions about the experimental or\ninvestigational nature of individual drugs, medical devices or\ntreatments 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 corporation\nmight consider in its utilization review and the corporation 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 corporation, the subscriber or\nprospective subscriber shall only use the information for the purposes\nof assisting the subscriber or prospective subscriber in evaluating the\ncovered services provided by the organization. Such clinical review\ncriteria, and other clinical information shall also be made available to\na health care professional as defined in subsection (f) of section\nforty-nine hundred of this chapter, on behalf of an insured and upon\nwritten request;\n (11) where applicable, provide the written application procedures and\nminimum qualification requirements for health care providers to be\nconsidered by the corporation for participation in the corporation's\nnetwork for a 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 corporation will pay for a specific\nout-of-network health care service. The corporation shall also inform\nthe insured through such disclosure that such approximation is not\nbinding on the corporation and that the approximate dollar amount that\nthe corporation will pay for a specific out-of-network health care\nservice may change.\n (c) Nothing in this section shall prevent a corporation from changing\nor updating the materials that are made available to subscribers.\n (d) As to any program where the subscriber must select a primary care\nprovider, if a participating primary care provider becomes unavailable\nto provide services to a subscriber, the corporation shall provide\nwritten notice within fifteen days from the time the corporation becomes\naware of such unavailability to each subscriber who has chosen the\nprovider as their primary care provider. If a subscriber is enrolled in\na managed care product and is in an ongoing course of treatment with any\nother participating provider who becomes unavailable to continue to\nprovide services to such subscriber, and the corporation is aware of\nsuch ongoing course of treatment, the corporation shall provide written\nnotice within fifteen days from the time the corporation becomes aware\nof such unavailability to such subscriber. Each notice shall also\ndescribe the procedures for continuing care pursuant to subsections (e)\nand (f) of section forty-eight hundred four of this chapter and for\nchoosing 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 subscriber (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 corporation'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\ncorporation's managed care provider network, and which has been sold to\nfive or more groups, a managed care product shall also mean a contract\nwhich requires that all medical or other health care services covered\nunder the contract, other than emergency care services, be provided by,\nor pursuant to a referral from, a designated health care provider chosen\nby the subscriber (i.e. a primary care gatekeeper), and that services\nprovided pursuant to such a referral be rendered by a health care\nprovider participating in the corporation's managed care provider\nnetwork, in order for the subscriber to be entitled to the maximum\nreimbursement under the contract.\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 this article, a municipal\ncooperative health benefit plan certified pursuant to article\nforty-seven of this chapter, or a health maintenance organization\ncertified pursuant to article forty-four of the public health law.\n (g) (1) As used in this subsection:\n (A) "Pharmacy benefit manager" shall have the meaning set forth in\nsection two hundred eighty-a of the public health law.\n (B) "Cost-sharing information" means the amount a subscriber is\nrequired to pay to receive a drug that is covered under the subscriber's\ninsurance contract.\n (C) "Covered/coverage" means those health care services to which a\nsubscriber is entitled under the terms of the insurance contract.\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" shall have the meaning set forth in\nsection 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) A health service, hospital service, or medical expense indemnity\ncorporation subject to this article or pharmacy benefit manager shall,\nupon request of the subscriber, the subscriber's health care provider,\nor an authorized third party on the subscriber's behalf, made to the\nhealth service, hospital service, or medical expense indemnity\ncorporation or pharmacy benefit manager, furnish the cost, benefit, and\ncoverage data required by this subsection to the subscriber, the\nsubscriber's health care provider, or the authorized third party and\nshall ensure that such data is: (A) current no later than one business\nday after any change to the cost, benefit, or coverage data is made; (B)\nprovided through a RTBT when the request is made by the subscriber's\nhealth care provider; and (C) in a format that is easily accessible to\nthe requestor.\n (4) When providing the data required by paragraph three of this\nsubsection, the health service, hospital service, or medical expense\nindemnity corporation or pharmacy benefit manager shall use established\nindustry 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.\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 health service, hospital service, or medical expense\nindemnity corporation or pharmacy benefit manager shall provide the\nfollowing data for any drug covered under the subscriber's insurance\ncontract:\n (A) subscriber-specific eligibility information;\n (B) subscriber-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) subscriber-specific cost-sharing information that describes\nvariance in cost-sharing based on the pharmacy dispensing the prescribed\ndrug or its alternatives, and in relation to the insured's benefit; and\n (D) applicable utilization management requirements.\n (7) A health service, hospital service, or medical expense indemnity\ncorporation 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. A health service, hospital service, or\nmedical expense indemnity corporation or pharmacy benefit manager shall\nnot deny or unreasonably delay processing a request.\n (8) A health service, hospital service, or medical expense indemnity\ncorporation and pharmacy benefit manager shall not, except as may be\nrequired or authorized by law, interfere with, prevent, or materially\ndiscourage access, exchange, or use of the data as required; nor shall a\nhealth service, hospital service, or medical expense indemnity\ncorporation or pharmacy benefit manager penalize a health care provider\nfor disclosing such information to a subscriber 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 subscriber-specific eligibility or\nsubscriber-specific prescription cost and benefit data by the health\nservice, hospital service, or medical expense indemnity corporation or\npharmacy benefit manager.\n (10) Nothing in this subsection shall interfere with subscriber choice\nand a health care provider's ability to convey the full range of\nprescription drug cost options to a subscriber. Health service, hospital\nservice, or medical expense indemnity corporations and pharmacy benefit\nmanagers shall not restrict a health care provider from communicating to\nthe subscriber prescription cost options.\n