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This entry was published on 2022-04-22
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SECTION 3217-A
Disclosure of information
Insurance (ISC) CHAPTER 28, ARTICLE 32
§ 3217-a. Disclosure of information. The requirements of this section
shall apply to all comprehensive, expense-reimbursed health insurance
contracts; managed care health insurance contracts; or any other health
insurance contract or product for which the superintendent deems such
disclosure appropriate.

(a) Each insurer subject to this article shall supply each insured,
and upon request each prospective insured prior to enrollment, written
disclosure information, which may be incorporated into the insurance
contract or certificate, containing at least the information set forth
below. In the event of any inconsistency between any separate written
disclosure statement and the insurance contract or certificate, the
terms of the insurance contract or certificate shall be controlling. The
information to be disclosed shall include at least the following:

(1) a description of coverage provisions; health care benefits;
benefit maximums, including benefit limitations; and exclusions of
coverage, including the definition of medical necessity used in
determining whether benefits will be covered;

(2) a description of all prior authorization or other requirements for
treatments and services;

(3) a description of utilization review policies and procedures, used
by the insurer, including:

(A) the circumstances under which utilization review will be
undertaken;

(B) the toll-free telephone number of the utilization review agent;

(C) the time frames under which utilization review decisions must be
made for prospective, retrospective and concurrent decisions;

(D) the right to reconsideration;

(E) the right to an appeal, including the expedited and standard
appeals processes and the time frames for such appeals;

(F) the right to designate a representative;

(G) a notice that all denials of claims will be made by qualified
clinical personnel and that all notices of denials will include
information about the basis of the decision;

(H) a notice of the right to an external appeal together with a
description, jointly promulgated by the superintendent and the
commissioner of health as required pursuant to subsection (e) of section
four thousand nine hundred fourteen of this chapter, of the external
appeal process established pursuant to title two of article forty-nine
of this chapter and the time frames for such appeals; and

(I) further appeal rights, if any;

(4) a description prepared annually of the types of methodologies the
insurer uses to reimburse providers specifying the type of methodology
that is used to reimburse particular types of providers or reimburse for
the provision of particular types of services; provided, however, that
nothing in this paragraph should be construed to require disclosure of
individual contracts or the specific details of any financial
arrangement between an insurer and a health care provider;

(5) an explanation of an insured's financial responsibility for
payment of premiums, coinsurance, co-payments, deductibles and any other
charges, annual limits on an insured's financial responsibility, caps on
payments for covered services and financial responsibility for
non-covered health care procedures, treatments or services;

(6) an explanation, where applicable, of an insured's financial
responsibility for payment when services are provided by a health care
provider who is not part of the insurer's network of providers or by any
provider without required authorization, or when a procedure, treatment
or service is not a covered benefit;

(7) a description of the grievance procedures to be used to resolve
disputes between an insurer and an insured, including: the right to file
a grievance regarding any dispute between an insured and an insurer; the
right to file a grievance orally when the dispute is about referrals or
covered benefits; the toll-free telephone number which insureds may use
to file an oral grievance; the timeframes and circumstances for
expedited and standard grievances; the right to appeal a grievance
determination and the procedures for filing such an appeal; the
timeframes and circumstances for expedited and standard appeals; the
right to designate a representative; a notice that all disputes
involving clinical decisions will be made by qualified clinical
personnel and that all notices of determination will include information
about the basis of the decision and further appeal rights, if any;

(8) a description of the procedure for obtaining emergency services.
Such description shall include a definition of emergency services,
notice that emergency services are not subject to prior approval, and
shall describe the insured's financial and other responsibilities
regarding obtaining such services including when such services are
received outside the insurer's service area, if any;

(9) where applicable, a description of procedures for insureds to
select and access the insurer's primary and specialty care providers,
including notice of how to determine whether a participating provider is
accepting new patients;

(10) where applicable, a description of the procedures for changing
primary and specialty care providers within the insurer's network of
providers;

(11) where applicable, notice that an insured enrolled in a managed
care product or in a comprehensive policy that utilizes a network of
providers offered by the insurer may obtain a referral or
preauthorization for a health care provider outside of the insurer's
network or panel when the insurer does not have a health care provider
who is geographically accessible to the insured and who has the
appropriate training and experience in the network or panel to meet the
particular health care needs of the insured and the procedure by which
the insured can obtain such referral or preauthorization;

(12) where applicable, notice that an insured enrolled in a managed
care product or a comprehensive policy that utilizes a network of
providers offered by the insurer with a condition which requires ongoing
care from a specialist may request a standing referral to such a
specialist and the procedure for requesting and obtaining such a
standing referral;

(13) where applicable, notice that an insured enrolled in a managed
care product or a comprehensive policy that utilizes a network of
providers offered by the insurer with (A) a life-threatening condition
or disease, or (B) a degenerative and disabling condition or disease,
either of which requires specialized medical care over a prolonged
period of time may request a specialist responsible for providing or
coordinating the insured's medical care and the procedure for requesting
and obtaining such a specialist;

(14) where applicable, notice that an insured enrolled in a managed
care product or a comprehensive policy that utilizes a network of
providers offered by the insurer with (A) a life-threatening condition
or disease, or (B) a degenerative and disabling condition or disease,
either of which requires specialized medical care over a prolonged
period of time, may request access to a specialty care center and the
procedure by which such access may be obtained;

(15) a description of how the insurer addresses the needs of
non-English speaking insureds;

(16) notice of all appropriate mailing addresses and telephone numbers
to be utilized by insureds seeking information or authorization;

(16-a) where applicable, notice that an insured shall have direct
access to primary and preventive obstetric and gynecologic services,
including annual examinations, care resulting from such annual
examinations, and treatment of acute gynecologic conditions, from a
qualified provider of such services of her choice from within the plan
or for any care related to a pregnancy;

(17) where applicable, a listing by specialty, which may be in a
separate document that is updated annually, of the name, address,
telephone number, and digital contact information of all participating
providers, including facilities, and: (A) whether the provider is
accepting new patients; (B) in the case of mental health or substance
use disorder services providers, any affiliations with participating
facilities certified or authorized by the office of mental health or the
office of addiction services and supports, and any restrictions
regarding the availability of the individual provider's services; and
(C) in the case of physicians, board certification, languages spoken and
any affiliations with participating hospitals. The listing shall also be
posted on the insurer's website and the insurer shall update the website
within fifteen days of the addition or termination of a provider from
the insurer's network or a change in a physician's hospital affiliation;

(18) a description of the method by which an insured may submit a
claim for health care services;

(19) with respect to out-of-network coverage:

(A) a clear description of the methodology used by the insurer to
determine reimbursement for out-of-network health care services;

(B) the amount that the insurer will reimburse under the methodology
for out-of-network health care services set forth as a percentage of the
usual and customary cost for out-of-network health care services; and

(C) examples of anticipated out-of-pocket costs for frequently billed
out-of-network health care services;

(20) information in writing and through an internet website that
reasonably permits an insured or prospective insured to estimate the
anticipated out-of-pocket cost for out-of-network health care services
in a geographical area or zip code based upon the difference between
what the insurer will reimburse for out-of-network health care services
and the usual and customary cost for out-of-network health care
services; and

(21) the most recent comparative analysis performed by the insurer to
assess the provision of its covered services in accordance with the Paul
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008, 42 U.S.C. 18031(j), and any amendments to, and federal
guidance or regulations issued under those acts.

(b) Each insurer subject to this article, upon request of an insured,
or prospective insured, shall:

(1) provide a list of the names, business addresses and official
positions of the membership of the board of directors, officers, and
members of the insurer;

(2) provide a copy of the most recent annual certified financial
statement of the insurer, including a balance sheet and summary of
receipts and disbursements prepared by a certified public accountant;

(3) provide a copy of the most recent individual, direct pay
subscriber contracts;

(4) provide information relating to consumer complaints compiled
pursuant to section two hundred ten of this chapter;

(5) provide the procedures for protecting the confidentiality of
medical records and other insured information;

(6) where applicable, allow insureds and prospective insureds to
inspect drug formularies used by such insurer; and provided further,
that the insurer shall also disclose whether individual drugs are
included or excluded from coverage to an insured or prospective insured
who requests this information;

(7) provide a written description of the organizational arrangements
and ongoing procedures of the insurer's quality assurance program, if
any;

(8) provide a description of the procedures followed by the insurer in
making decisions about the experimental or investigational nature of
individual drugs, medical devices or treatments in clinical trials;

(9) provide individual health practitioner affiliations with
participating hospitals, if any;

(10) upon written request, provide specific written clinical review
criteria relating to a particular condition or disease including
clinical review criteria relating to a step therapy protocol override
determination pursuant to subsection (c-1), subsection (c-2) and
subsection (c-3) of section forty-nine hundred three of this chapter,
and, where appropriate, other clinical information which the insurer
might consider in its utilization review and the insurer may include
with the information a description of how it will be used in the
utilization review process; provided, however, that to the extent such
information is proprietary to the insurer, the insured or prospective
insured shall only use the information for the purposes of assisting the
enrollee or prospective enrollee in evaluating the covered services
provided by the organization. Such clinical review criteria, and other
clinical information shall also be made available to a health care
professional as defined in subsection (f) of section forty-nine hundred
of this chapter, on behalf of an insured and upon written request;

(11) where applicable, provide the written application procedures and
minimum qualification requirements for health care providers to be
considered by the insurer for participation in the insurer's network for
a managed care product;

(12) disclose such other information as required by the
superintendent, provided that such requirements are promulgated pursuant
to the state administrative procedure act;

(13) disclose whether a health care provider scheduled to provide a
health care service is an in-network provider; and

(14) with respect to out-of-network coverage, disclose the approximate
dollar amount that the insurer will pay for a specific out-of-network
health care service. The insurer shall also inform the insured through
such disclosure that such approximation is not binding on the insurer
and that the approximate dollar amount that the insurer will pay for a
specific out-of-network health care service may change.

(c) Nothing in this section shall prevent an insurer from changing or
updating the materials that are made available to insureds.

(d) As to any program where the insured must select a primary care
provider, if a participating primary care provider becomes unavailable
to provide services to an insured, the insurer shall provide written
notice within fifteen days from the time the insurer becomes aware of
such unavailability to each insured who has chosen the provider as their
primary care provider. If an insured enrolled in a managed care product
is in an ongoing course of treatment with any other participating
provider who becomes unavailable to continue to provide services to such
insured, and the insurer is aware of such ongoing course of treatment,
the insurer shall provide written notice within fifteen days from the
time that the insurer becomes aware of such unavailability to such
insured. Each notice shall also describe the procedures for continuing
care pursuant to subsections (e) and (f) of section forty-eight hundred
four of this chapter and for choosing an alternative provider.

(e) For purposes of this section, a "managed care product" shall mean
a contract which requires that all medical or other health care services
covered under the contract, other than emergency care services, be
provided by, or pursuant to a referral from, a designated health care
provider chosen by the insured (i.e. a primary care gatekeeper), and
that services provided pursuant to such a referral be rendered by a
health care provider participating in the insurer's managed care
provider network. In addition, in the case of (i) an individual health
insurance contract, or (ii) a group health insurance contract covering
no more than three hundred lives, imposing a coinsurance obligation of
more than twenty-five percent upon services received outside of the
insurer's managed care provider network, and which has been sold to five
or more groups, a managed care product shall also mean a contract which
requires that all medical or other health care services covered under
the contract, other than emergency care services, be provided by, or
pursuant to a referral from, a designated health care provider chosen by
the insured (i.e. a primary care gatekeeper), and that services provided
pursuant to such a referral be rendered by a health care provider
participating in the insurer's managed care provider network, in order
for the insured to be entitled to the maximum reimbursement under the
contract.

(f) For purposes of this section, "usual and customary cost" shall
mean the eightieth percentile of all charges for the particular health
care service performed by a provider in the same or similar specialty
and provided in the same geographical area as reported in a benchmarking
database maintained by a nonprofit organization specified by the
superintendent. The nonprofit organization shall not be affiliated with
an insurer, a corporation subject to article forty-three of this
chapter, a municipal cooperative health benefit plan certified pursuant
to article forty-seven of this chapter, or a health maintenance
organization certified pursuant to article forty-four of the public
health law.