Legislation

§ 210. Annual consumer guide of health insurers, and entities
certified pursuant to article forty-four of the public health law.

(a) The superintendent shall annually publish on or before September
first, nineteen hundred ninety-nine, and annually thereafter, a consumer
guide to insurers providing managed care products, individual accident
and health insurance or group or blanket accident and health insurance
and entities licensed pursuant to article forty-four of the public
health law providing comprehensive health service plans which includes,
in detail, a ranking from best to worst based upon each company's claim
processing or medical payments record during the preceding calendar year
using criteria available to the department, adjusted for volume of
coverage provided. Such ranking shall also take into consideration the
corresponding total number or percentage of claims denied which were
reversed or compromised after intervention by the department and the
department of health, consumer complaints to the department and the
department of health, violations of section three thousand two hundred
twenty-four-a of this chapter and other pertinent data which would
permit the department to objectively determine a company's performance.
The department in publishing such consumer guide shall publish one
state-wide guide or no more than five regional guides so as to
facilitate comparisons among individual insurers and entities within a
service market area. Such rankings shall be printed in a format which
ranks all health insurers and all entities certified pursuant to article
forty-four of the public health law in one combined list.

(b) The superintendent shall include in such guide annually, and
insurers and entities certified pursuant to article forty-four of the
public health law shall provide to the superintendent the information
required for such guide in a timely fashion, the following information:

(1) The number of grievances filed pursuant to section forty-four
hundred eight-a of the public health law, section three thousand two
hundred seventeen-d of this chapter, section four thousand three hundred
six-c of this chapter, or article forty-eight of this chapter and the
number of such grievances in which an adverse determination of the
insurer or entity was reversed in whole or in part versus the number of
such determinations which were upheld;

(2) Beginning September first, two thousand twenty-seven, the number
of approvals and the number of adverse determinations in whole or part
issued by utilization review agents pursuant to section forty-nine
hundred three of the public health law or section four thousand nine
hundred three of this chapter; and

(3) The number of appeals to utilization review determinations that
were filed pursuant to section forty-nine hundred four of the public
health law and section four thousand nine hundred four of this chapter
and the number of such determinations that were reversed in whole or in
part versus the number of such determinations that were upheld.

(c) Beginning September first, nineteen hundred ninety-nine and
annually thereafter, in addition to the information required in
subsections (a) and (b) of this section, the superintendent, in
conjunction with the commissioner of health, in consultation with the
National Committee on Quality Assurance or a similar national
organization, shall include in such guide the following additional
information, for the most recent year in which such information is
available and where applicable, for health insurers, health insurers
providing managed care products and entities certified under article
forty-four of the public health law providing comprehensive health
service plans pursuant to such article:

(1) the percentage of physicians who are either board certified or
board eligible;

(2) the percentage of primary care physicians who remained
participating providers, provided however, that such percentage shall
exclude voluntary terminations due to physician retirement, relocation
or other similar reasons;

(3) the percentage of enrollees aged twenty-three to thirty-nine and
forty to sixty-four who had one or more visits to a health plan
practitioner during the three years of their continual enrollment.

(4) the methods used to compensate primary care physicians and other
providers, provided however, that nothing in this section shall be
construed to require disclosure of the specific details of any financial
arrangement between the insurer or entity and an individual provider or
practice;

(5) the national accreditation status of insurers and entities, where
applicable;

(6) indices of the quality of care provided, such as the rates of
mammography, prostate, and cervical cancer screening, prenatal care,
well-child care, immunization and such other information collected by
the commissioner of health through the health plan employer data and
information set (HEDIS); or through the quality assurance reporting
requirements for entities not otherwise required to collect and report
health plan employer data and information set (HEDIS) data;

(7) the results of a consumer satisfaction survey among enrollees of
the various health insurers and entities, which shall be conducted by
the superintendent and commissioner of health, in consultation with the
National Committee on Quality Assurance or a similar national
organization;

(8) a toll-free telephone number for each health insurer or plan;

(9) toll-free telephone numbers at the department and the department
of health to which consumers can make complaints about insurers or
entities; and

(10) except as required in paragraph seven of this subsection, health
insurers and entities certified pursuant to article forty-four of the
public health law shall report the information required under this
subdivision to the commissioner of health, and the commissioner shall
provide such information to the superintendent for inclusion in the
annual consumer guide.

(d) Beginning September first, two thousand twenty-seven and annually
thereafter, in addition to the information required in subsections (a),
(b), and (c) of this section, the superintendent shall include in such
guide, and insurers and entities certified pursuant to article
forty-four of the public health law shall provide to the superintendent,
in a form and manner specified by the superintendent, the information
required for such guide in a timely fashion, the following information
regarding pre-authorization requests under article forty-nine of the
public health law or article forty-nine of this chapter:

(1) the number of pre-authorization requests received under section
forty-nine hundred three of the public health law and section four
thousand nine hundred three of this chapter;

(2) the number of pre-authorization requests for which an
authorization was issued under section forty-nine hundred three of the
public health law and section four thousand nine hundred three of this
chapter;

(3) the number of pre-authorization requests for which an adverse
determination was issued in whole or part under section forty-nine
hundred three of the public health law and section four thousand nine
hundred three of this chapter;

(4) the number of pre-authorization requests for which an adverse
determination was appealed under section forty-nine hundred four of the
public health law and section four thousand nine hundred four of this
chapter;

(5) the number of pre-authorization requests for which an adverse
determination was reversed on appeal in whole or part under section
forty-nine hundred four of the public health law and section four
thousand nine hundred four of this chapter;

(6) the number of pre-authorization requests for which an adverse
determination was upheld under section forty-nine hundred four of the
public health law and section four thousand nine hundred four of this
chapter;

(7) the twenty-five current procedural terminology codes with the
highest number of pre-authorization requests and the percentage of
authorizations for each of these current procedural terminology codes
under section forty-nine hundred three of the public health law and
section four thousand nine hundred three of this chapter;

(8) the twenty-five current procedural terminology codes with the
highest number of pre-authorization requests for which an authorization
was issued under section forty-nine hundred three of the public health
law and section four thousand nine hundred three of this chapter;

(9) the twenty-five current procedural terminology codes with the
highest number of pre-authorization requests under section forty-nine
hundred three of the public health law and section four thousand nine
hundred three of this chapter for which an adverse determination was
issued in whole or part but that was reversed by an appeal, in whole or
part, under section forty-nine hundred four of the public health law and
section four thousand nine hundred four of this chapter; and

(10) the twenty-five current procedural terminology codes with the
highest number of pre-authorization requests for which an adverse
determination was issued in whole or part under section forty-nine
hundred three of the public health law and section four thousand nine
hundred three of this chapter.

(e) Health insurers and entities certified pursuant to article
forty-four of the public health law shall provide annually to the
superintendent and the commissioner of health, and the commissioner of
health shall provide to the superintendent by March first of each year,
all of the information necessary for the superintendent to produce the
annual consumer guide. In compiling the guide, the superintendent shall
make every effort to ensure that the information is presented in a
clear, understandable fashion that facilitates comparisons among
individual insurers and entities, and in a format that lends itself to
the widest possible distribution to consumers. The superintendent shall
either include the information from the annual consumer guide in the
consumer shopping guide required by subsection (a) of section four
thousand three hundred twenty-three of this chapter or combine the two
guides as long as consumers in the individual market are provided with
the information required by subsection (a) of section four thousand
three hundred twenty-three of this chapter.

(f) The superintendent shall contract with a national organization for
the purposes of drafting and designing the guide, including the
preparation of relevant explanatory material. Such organization shall
have actual experience in preparing a similar guide for at least one
other state. The superintendent, in consultation with the commissioner
of health, may also contract with one or more national organizations to
assist such commissioner in the collection of data and the analysis and
auditing of the clinical measurers. Such organizations shall consult
periodically with associations representing health insurers and health
maintenance organizations as well as with consumer representatives in
New York in preparing the consumer guide.