§ 4408 — Disclosure of information

New York § 4408

• Jurisdiction: New York
• Law PBH: Public Health
• Art. 44: Health Maintenance Organizations

Text

§ 4408. Disclosure of information. 1. Each subscriber, and upon\nrequest each prospective subscriber prior to enrollment, shall be\nsupplied with written disclosure information which may be incorporated\ninto the member handbook or the subscriber contract or certificate\ncontaining at least the information set forth below. In the event of any\ninconsistency between any separate written disclosure statement and the\nsubscriber contract or certificate, the terms of the subscriber contract\nor certificate shall be controlling. The information to be disclosed\nshall include at least the following:\n (a) 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 (b) a description of all prior authorization or other requirements for\ntreatments and services;\n (c) a description of utilization review policies and procedures used\nby the health maintenance organization, including:\n (i) the circumstances under which utilization review will be\nundertaken;\n (ii) the toll-free telephone number of the utilization review agent;\n (iii) the timeframes under which utilization review decisions must be\nmade for prospective, retrospective and concurrent decisions;\n (iv) the right to reconsideration;\n (v) the right to an appeal, including the expedited and standard\nappeals processes and the time frames for such appeals;\n (vi) the right to designate a representative;\n (vii) 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 (viii) a notice of the right to an external appeal together with a\ndescription, jointly promulgated by the commissioner and the\nsuperintendent of financial services as required pursuant to subdivision\nfive of section forty-nine hundred fourteen of this chapter, of the\nexternal appeal process established pursuant to title two of article\nforty-nine of this chapter and the timeframes for such appeals; and\n (ix) further appeal rights, if any;\n (d) a description prepared annually of the types of methodologies the\nhealth maintenance organization uses to reimburse providers specifying\nthe type of methodology that is used to reimburse particular types of\nproviders or reimburse for the provision of particular types of\nservices; provided, however, that nothing in this paragraph should be\nconstrued to require disclosure of individual contracts or the specific\ndetails of any financial arrangement between a health maintenance\norganization and a health care provider;\n (e) 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 provided\nwithin the health maintenance organization;\n (f) an explanation of a subscriber's financial responsibility for\npayment when services are provided by a health care provider who is not\npart of the health maintenance organization or by any provider without\nrequired authorization or when a procedure, treatment or service is not\na covered health care benefit;\n (g) a description of the grievance procedures to be used to resolve\ndisputes between a health maintenance organization and an enrollee,\nincluding: the right to file a grievance regarding any dispute between\nan enrollee and a health maintenance organization; the right to file a\ngrievance orally when the dispute is about referrals or covered\nbenefits; the toll-free telephone number which enrollees may use to file\nan oral grievance; the timeframes and circumstances for expedited and\nstandard grievances; the right to appeal a grievance determination and\nthe procedures for filing such an appeal; the timeframes and\ncircumstances for expedited and standard appeals; the right to designate\na representative; a notice that all disputes involving clinical\ndecisions will be made by qualified clinical personnel; and that all\nnotices of determination will include information about the basis of the\ndecision and further appeal rights, if any;\n (h) a description of the procedure for providing care and coverage\ntwenty-four hours a day for emergency services. Such description shall\ninclude a definition of emergency services; notice that emergency\nservices are not subject to prior approval; and shall describe the\nenrollee's financial and other responsibilities regarding obtaining such\nservices including when such services are received outside the health\nmaintenance organization's service area;\n (i) a description of procedures for enrollees to select and access the\nhealth maintenance organization's primary and specialty care providers,\nincluding notice of how to determine whether a participating provider is\naccepting new patients;\n (j) a description of the procedures for changing primary and specialty\ncare providers within the health maintenance organization;\n (k) notice that an enrollee may obtain a referral to a health care\nprovider outside of the health maintenance organization's network or\npanel when the health maintenance organization does not have a health\ncare provider who is geographically accessible to the enrollee and who\nhas appropriate training and experience in the network or panel to meet\nthe particular health care needs of the enrollee and the procedure by\nwhich the enrollee can obtain such referral;\n (l) notice that an enrollee 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 (m) notice that an enrollee with (i) a life-threatening condition or\ndisease or (ii) a degenerative and disabling condition or disease either\nof which requires specialized medical care over a prolonged period of\ntime may request a specialist responsible for providing or coordinating\nthe enrollee's medical care and the procedure for requesting and\nobtaining such a specialist;\n (n) notice that an enrollee with a (i) a life-threatening condition or\ndisease or (ii) a degenerative and disabling condition or disease either\nof which requires specialized medical care over a prolonged period of\ntime may request access to a specialty care center and the procedure by\nwhich such access may be obtained;\n (o) a description of the mechanisms by which enrollees may participate\nin the development of the policies of the health maintenance\norganization;\n (p) a description of how the health maintenance organization addresses\nthe needs of non-English speaking enrollees;\n (p-1) notice that an enrollee shall have direct access to primary and\npreventive obstetric and gynecologic services, including annual\nexaminations, care resulting from such annual examinations, and\ntreatment of acute gynecologic conditions, from a qualified provider of\nsuch services of her choice from within the plan or for any care related\nto a pregnancy;\n (q) notice of all appropriate mailing addresses and telephone numbers\nto be utilized by enrollees seeking information or authorization;\n (r) a listing by specialty, which may be in a separate document that\nis updated annually, of the name, address, telephone number, and digital\ncontact information of all participating providers, including\nfacilities, and: (i) whether the provider is accepting new patients;\n(ii) in the case of mental health or substance use disorder services\nproviders, any affiliations with participating facilities certified or\nauthorized by the office of mental health or the office of addiction\nservices and supports, and any restrictions regarding the availability\nof the individual provider's services; and (iii) in the case of\nphysicians, board certification, languages spoken and any affiliations\nwith participating hospitals. The listing shall also be posted on the\nhealth maintenance organization's website and the health maintenance\norganization shall update the website within fifteen days of the\naddition or termination of a provider from the health maintenance\norganization's network or a change in a physician's hospital\naffiliation;\n (s) where applicable, a description of the method by which an enrollee\nmay submit a claim for health care services;\n (t) with respect to out-of-network coverage:\n (i) a clear description of the methodology used by the health\nmaintenance organization to determine reimbursement for out-of-network\nhealth care services;\n (ii) the amount that the health maintenance organization will\nreimburse under the methodology for out-of-network health care services\nset forth as a percentage of the usual and customary cost for\nout-of-network health care services;\n (iii) examples of anticipated out-of-pocket costs for frequently\nbilled out-of-network health care services;\n (u) information in writing and through an internet website that\nreasonably permits an enrollee or prospective enrollee 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 health maintenance organization will reimburse for\nout-of-network health care services and the usual and customary cost for\nout-of-network health care services; and\n (v) the most recent comparative analysis performed by the health\nmaintenance organization to assess the provision of its covered services\nin accordance with the Paul Wellstone and Pete Dominici Mental Health\nParity and Addiction Equity Act of 2008, 42 U.S.C. 18031(j) and any\namendments to, and federal guidance and regulations issued under, those\nActs.\n 2. Each health maintenance organization shall, upon request of an\nenrollee or prospective enrollee:\n (a) provide a list of the names, business addresses and official\npositions of the membership of the board of directors, officers,\ncontrolling persons, owners or partners of the health maintenance\norganization;\n (b) provide a copy of the most recent annual certified financial\nstatement of the health maintenance organization, including a balance\nsheet and summary of receipts and disbursements prepared by a certified\npublic accountant;\n (c) provide a copy of the most recent individual, direct pay\nsubscriber contracts;\n (d) provide information relating to consumer complaints compiled\npursuant to section two hundred ten of the insurance law;\n (e) provide the procedures for protecting the confidentiality of\nmedical records and other enrollee information;\n (f) allow enrollees and prospective enrollees to inspect drug\nformularies used by such health maintenance organization; and provided\nfurther, that the health maintenance organization shall also disclose\nwhether individual drugs are included or excluded from coverage to an\nenrollee or prospective enrollee who requests this information;\n (g) provide a written description of the organizational arrangements\nand ongoing procedures of the health maintenance organization's quality\nassurance program;\n (h) provide a description of the procedures followed by the health\nmaintenance organization in making decisions about the experimental or\ninvestigational nature of individual drugs, medical devices or\ntreatments in clinical trials;\n (i) provide individual health practitioner affiliations with\nparticipating hospitals, if any;\n (j) 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 subdivisions three-a, three-b and three-c of\nsection forty-nine hundred three of this chapter, and, where\nappropriate, other clinical information which the organization might\nconsider in its utilization review and the organization may include with\nthe information a description of how it will be used in the utilization\nreview process; provided, however, that to the extent such information\nis proprietary to the organization, the enrollee or prospective enrollee\nshall 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 subdivision six of section forty-nine hundred\nof this chapter, on behalf of an enrollee and upon written request;\n (k) provide the written application procedures and minimum\nqualification requirements for health care providers to be considered by\nthe health maintenance organization;\n (l) disclose other information as required by the commissioner,\nprovided that such requirements are promulgated pursuant to the state\nadministrative procedure act;\n (m) disclose whether a health care provider scheduled to provide a\nhealth care service is an in-network provider; and\n (n) with respect to out-of-network coverage, disclose the approximate\ndollar amount that the health maintenance organization will pay for a\nspecific out-of-network health care service. The health maintenance\norganization shall also inform an enrollee through such disclosure that\nsuch approximation is not binding on the health maintenance organization\nand that the approximate dollar amount that the health maintenance\norganization will pay for a specific out-of-network health care service\nmay change.\n 3. Nothing in this section shall prevent a health maintenance\norganization from changing or updating the materials that are made\navailable to enrollees.\n 4. If a primary care provider ceases participation in the health\nmaintenance organization, the organization shall provide written notice\nwithin fifteen days from the date that the organization becomes aware of\nsuch change in status to each enrollee who has chosen the provider as\ntheir primary care provider. If an enrollee is in an ongoing course of\ntreatment with any other participating provider who becomes unavailable\nto continue to provide services to such enrollee and the health\nmaintenance organization is aware of such ongoing course of treatment,\nthe health maintenance organization shall provide written notice within\nfifteen days from the date that the health maintenance organization\nbecomes aware of such unavailability to such enrollee. Each notice shall\nalso describe the procedures for continuing care pursuant to paragraphs\n(e) and (f) of subdivision six of section four thousand four hundred\nthree of this article and for choosing an alternative provider.\n 5. Every health maintenance organization shall annually on or before\nApril first, file a report with the commissioner and superintendent of\nfinancial services showing its financial condition as of the last day of\nthe preceding calendar year, in such form and providing such information\nas the commissioner shall prescribe.\n 6. Every health maintenance organization offering to indemnify\nenrollees pursuant to subdivision nine of section forty-four hundred\nfive and subdivision two of section forty-four hundred six of this\narticle shall on a quarterly basis file a report with the commissioner\nand the superintendent of financial services showing the percentage\nutilization for the preceding quarter of non-participating provider\nservices in such form and providing such other information as the\ncommissioner shall prescribe.\n 7. For purposes of this section, "usual and customary cost" shall mean\nthe eightieth percentile of all charges for the particular health care\nservice performed by a provider in the same or similar specialty and\nprovided in the same geographical area as reported in a benchmarking\ndatabase maintained by a nonprofit organization specified by the\nsuperintendent of financial services. The nonprofit organization shall\nnot be affiliated with an insurer, a corporation subject to article\nforty-three of the insurance law, a municipal cooperative health benefit\nplan certified pursuant to article forty-seven of the insurance law, or\na health maintenance organization certified pursuant to this article.\n * 8. Every contract delivered or issued for delivery in this state\nwhich provides major medical or similar comprehensive-type coverage\nshall provide space on any enrollment, renewal or initial online portal\nprocess setup forms required of a subscriber or applicant for coverage,\nexcepting forms issued by the NY State of Health, the official Health\nPlan Marketplace, other than those specifically referenced in\nsubparagraph (iv) of paragraph (a) of subdivision five of section\nforty-three hundred ten and paragraph (v) of subdivision one of section\ntwo hundred six of this chapter, so that the subscriber or applicant for\ncoverage shall register or decline registration in the donate life\nregistry for organ, eye and tissue donations under this section of the\nenrollment or renewal form and that the following is stated on the form\nin clear and conspicuous type:\n "You must fill out the following section: Would you like to be added\nto the Donate Life Registry? Check box for 'yes' or 'skip this\nquestion'."\n * NB There are 2 sb 8's\n * 8. (a) As used in this subdivision:\n (i) "Pharmacy benefit manager" shall have the meaning set forth in\nsection two hundred eighty-a of this chapter.\n (ii) "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 (iii) "Covered/coverage" means those health care services to which a\nsubscriber is entitled under the terms of the subscriber contract.\n (iv) "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 (v) "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 (vi) "Electronic prescription" shall have the meaning set forth in\nsection thirty-three hundred two of this chapter.\n (vii) "Prescriber" means a health care provider licensed to prescribe\nmedication or medical devices in this state.\n (viii) "Real-time benefit tool" or "RTBT" means an electronic\nprescription decision support tool that: (1) is capable of integrating\nwith prescribers' electronic prescribing system and, if feasible,\nelectronic health record systems; and (2) complies with the technical\nstandards adopted by an American National Standards Institute (ANSI)\naccredited standards development organization.\n (ix) "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 (b) 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 this\nchapter, 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 (c) A health maintenance organization or pharmacy benefit manager\nshall, upon request of the subscriber, the subscriber's health care\nprovider, or an authorized third party on the subscriber's behalf, made\nto the health maintenance organization or pharmacy benefit manager,\nfurnish the cost, benefit, and coverage data required by this\nsubdivision to the subscriber, the subscriber's health care provider, or\nthe authorized third party and shall ensure that such data is: (i)\ncurrent no later than one business day after any change to the cost,\nbenefit, or coverage data is made; (ii) provided through a RTBT when the\nrequest is made by the subscriber's health care provider; and (iii) in a\nformat that is easily accessible to the requestor.\n (d) When providing the data required by paragraph (c) of this\nsubdivision, the health maintenance organization or pharmacy benefit\nmanager shall use established industry content and transport standards\npublished by:\n (i) 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 (ii) 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 (iii) another format deemed acceptable to the department which\nprovides the data prescribed in paragraph (c) of this subdivision and in\nthe same timeliness as required by this section.\n (e) A facsimile shall not be considered an acceptable electronic\nformat pursuant to this subdivision.\n (f) Upon a request made pursuant to paragraph (c) of this subdivision,\nthe health maintenance organization or pharmacy benefit manager shall\nprovide the following data for any drug covered under the subscriber's\nsubscriber contract:\n (i) subscriber-specific eligibility information;\n (ii) 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 (iii) 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 (iv) applicable utilization management requirements.\n (g) A health maintenance organization or pharmacy benefit manager\nshall furnish the data as required whether the request is made using the\ndrug's unique billing code, such as a National Drug Code or Healthcare\nCommon Procedure Coding System code or descriptive term. A health\nmaintenance organization or pharmacy benefit manager shall not deny or\nunreasonably delay processing a request.\n (h) A health maintenance organization and pharmacy benefit manager\nshall not, except as may be required or authorized by law, interfere\nwith, prevent, or materially discourage access, exchange, or use of the\ndata as required; nor shall a health maintenance organization or\npharmacy benefit manager penalize a health care provider for disclosing\nsuch information to a subscriber or legally prescribing, administering,\nor ordering a lower cost, clinically appropriate alternative.\n (i) Nothing in this subdivision 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\nmaintenance organization or pharmacy benefit manager.\n (j) Nothing in this subdivision 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 maintenance\norganizations and pharmacy benefit managers shall not restrict a health\ncare provider from communicating to the subscriber prescription cost\noptions.\n * NB There are 2 sb 8's\n