§ 4409 — Health maintenance organizations; examinations

§ 4409. Health maintenance organizations; examinations. 1. In order to\ncarry out the provisions of this article, the commissioner, pursuant to\nhis authority under section two hundred six of this chapter, shall\nexamine not less than once every three years, each health maintenance\norganization and all participating entities through which such health\nmaintenance organization offers health services as to the quality of\nhealth care services offered, and the adequacy of its provider\narrangements.\n 2. (a) The superintendent shall examine not less than once every three\nyears into the financial affairs of each health maintenance\norganization, and transmit his findings to the commissioner. In\nconnection with any such examination, the superintendent shall have\nconvenient access at all reasonable hours to all books, records, files\nand other documents relating to the affairs of such organization, which\nare relevant to the examination. The superintendent may exercise the\npowers set forth in sections three hundred six and three hundred ten of\nthe insurance law in connection with such examinations, and may also\nrequire special reports from such health maintenance organizations as\nspecified in section three hundred eight of the insurance law. As part\nof an examination, the superintendent shall review determinations of\ncoverage for substance use disorder treatment and shall ensure that such\ndeterminations are issued in compliance with section four thousand three\nhundred three of the insurance law and title one of article forty-nine\nof this chapter.\n (b) The department is authorized to address to any health maintenance\norganization, and managed long term care plan with a certificate of\nauthority pursuant to section forty-four hundred three-f of this\narticle, or officers thereof, any inquiry in relation to its contracts\nwith providers and other entities providing covered services to the\nhealth maintenance organization's or managed long term care plan's\nenrollees, including but not limited to the rates of payment and payment\nterms and conditions therein. Every entity or person so addressed shall\nreply in writing to such inquiry promptly and truthfully, and such reply\nshall be, if required by the department, signed by such individual, or\nby such officer or officers of a corporation, as the department shall\ndesignate, and affirmed by them as true under penalty of perjury.\nFailure to comply with the requirements of this section shall be subject\nto civil penalties under section twelve of this chapter. Each day after\nthe deadline established by the department for reply until such time\nthat the provider submits a good faith response shall be considered a\nseparate and subsequent violation. In accordance with the process\noutlined in this paragraph, employers shall provide any documents or\nmaterials in the employer's possession, custody, or control that are\nrequested by the department as needed to support or verify the\nemployer's reply.\n (c) Any report, information, documents, or other materials furnished\nto the department under this subdivision shall be deemed a confidential\ncommunication and shall not be subject to inspection or disclosure in\nany manner, including article six of the public officers law or\ndepartment regulations in conformance therewith, except as provided in\nthis section, pursuant to a judicial subpoena issued in a pending action\nor proceeding, or upon formal written request by the department of\nlabor, the office of attorney general, or a duly authorized public\nagency.\n (d) The department shall no less than annually provide a report to the\ngovernor, temporary president of the senate, and speaker of the assembly\nsummarizing the information obtained by the department under paragraph\n(b) of this subdivision. Such report shall not contain individually\nidentifiable data.\n 3. The superintendent and the commissioner are authorized to share and\nexchange information obtained by them in the exercise of their\nrespective responsibilities under the insurance law and this chapter.\n 4. Nothing contained in this section shall be deemed to require the\npublic disclosure of privileged patient information.\n