§ 4408. Disclosure of information. 1. Each subscriber, and upon
request each prospective subscriber prior to enrollment, shall be
supplied with written disclosure information which may be incorporated
into the member handbook or the subscriber 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
subscriber contract or certificate, the terms of the subscriber contract
or certificate shall be controlling. The information to be disclosed
shall include at least the following:

(a) 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;

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

(c) a description of utilization review policies and procedures used
by the health maintenance organization, including:

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

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

(iii) the timeframes under which utilization review decisions must be
made for prospective, retrospective and concurrent decisions;

(iv) the right to reconsideration;

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

(vi) the right to designate a representative;

(vii) 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;

(viii) a notice of the right to an external appeal together with a
description, jointly promulgated by the commissioner and the
superintendent of financial services as required pursuant to subdivision
five of section forty-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 timeframes for such appeals; and

(ix) further appeal rights, if any;

(d) a description prepared annually of the types of methodologies the
health maintenance organization 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 a health maintenance
organization and a health care provider;

(e) an explanation of a subscriber's financial responsibility for
payment of premiums, coinsurance, co-payments, deductibles and any other
charges, annual limits on a subscriber's financial responsibility, caps
on payments for covered services and financial responsibility for
non-covered health care procedures, treatments or services provided
within the health maintenance organization;

(f) an explanation of a subscriber's financial responsibility for
payment when services are provided by a health care provider who is not
part of the health maintenance organization or by any provider without
required authorization or when a procedure, treatment or service is not
a covered health care benefit;

(g) a description of the grievance procedures to be used to resolve
disputes between a health maintenance organization and an enrollee,
including: the right to file a grievance regarding any dispute between
an enrollee and a health maintenance organization; the right to file a
grievance orally when the dispute is about referrals or covered
benefits; the toll-free telephone number which enrollees 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;

(h) a description of the procedure for providing care and coverage
twenty-four hours a day for 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
enrollee's financial and other responsibilities regarding obtaining such
services including when such services are received outside the health
maintenance organization's service area;

(i) a description of procedures for enrollees to select and access the
health maintenance organization's primary and specialty care providers,
including notice of how to determine whether a participating provider is
accepting new patients;

(j) a description of the procedures for changing primary and specialty
care providers within the health maintenance organization;

(k) notice that an enrollee may obtain a referral to a health care
provider outside of the health maintenance organization's network or
panel when the health maintenance organization does not have a health
care provider who is geographically accessible to the enrollee and who
has appropriate training and experience in the network or panel to meet
the particular health care needs of the enrollee and the procedure by
which the enrollee can obtain such referral;

(l) notice that an enrollee 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;

(m) notice that an enrollee with (i) a life-threatening condition or
disease or (ii) 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 enrollee's medical care and the procedure for requesting and
obtaining such a specialist;

(n) notice that an enrollee with a (i) a life-threatening condition or
disease or (ii) 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;

(o) a description of the mechanisms by which enrollees may participate
in the development of the policies of the health maintenance
organization;

(p) a description of how the health maintenance organization addresses
the needs of non-English speaking enrollees;

(p-1) notice that an enrollee 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;

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

(r) 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: (i) whether the provider is accepting new patients;
(ii) 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 (iii) in the case of
physicians, board certification, languages spoken and any affiliations
with participating hospitals. The listing shall also be posted on the
health maintenance organization's website and the health maintenance
organization shall update the website within fifteen days of the
addition or termination of a provider from the health maintenance
organization's network or a change in a physician's hospital
affiliation;

(s) where applicable, a description of the method by which an enrollee
may submit a claim for health care services;

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

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

(ii) the amount that the health maintenance organization 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;

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

(u) information in writing and through an internet website that
reasonably permits an enrollee or prospective enrollee 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 health maintenance organization will reimburse for
out-of-network health care services and the usual and customary cost for
out-of-network health care services; and

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

2. Each health maintenance organization shall, upon request of an
enrollee or prospective enrollee:

(a) provide a list of the names, business addresses and official
positions of the membership of the board of directors, officers,
controlling persons, owners or partners of the health maintenance
organization;

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

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

(d) provide information relating to consumer complaints compiled
pursuant to section two hundred ten of the insurance law;

(e) provide the procedures for protecting the confidentiality of
medical records and other enrollee information;

(f) allow enrollees and prospective enrollees to inspect drug
formularies used by such health maintenance organization; and provided
further, that the health maintenance organization shall also disclose
whether individual drugs are included or excluded from coverage to an
enrollee or prospective enrollee who requests this information;

(g) provide a written description of the organizational arrangements
and ongoing procedures of the health maintenance organization's quality
assurance program;

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

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

(j) 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 subdivisions three-a, three-b and three-c of
section forty-nine hundred three of this chapter, and, where
appropriate, other clinical information which the organization might
consider in its utilization review and the organization 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 organization, the enrollee or prospective enrollee
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 subdivision six of section forty-nine hundred
of this chapter, on behalf of an enrollee and upon written request;

(k) provide the written application procedures and minimum
qualification requirements for health care providers to be considered by
the health maintenance organization;

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

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

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

3. Nothing in this section shall prevent a health maintenance
organization from changing or updating the materials that are made
available to enrollees.

4. If a primary care provider ceases participation in the health
maintenance organization, the organization shall provide written notice
within fifteen days from the date that the organization becomes aware of
such change in status to each enrollee who has chosen the provider as
their primary care provider. If an enrollee is in an ongoing course of
treatment with any other participating provider who becomes unavailable
to continue to provide services to such enrollee and the health
maintenance organization is aware of such ongoing course of treatment,
the health maintenance organization shall provide written notice within
fifteen days from the date that the health maintenance organization
becomes aware of such unavailability to such enrollee. Each notice shall
also describe the procedures for continuing care pursuant to paragraphs
(e) and (f) of subdivision six of section four thousand four hundred
three of this article and for choosing an alternative provider.

5. Every health maintenance organization shall annually on or before
April first, file a report with the commissioner and superintendent of
financial services showing its financial condition as of the last day of
the preceding calendar year, in such form and providing such information
as the commissioner shall prescribe.

6. Every health maintenance organization offering to indemnify
enrollees pursuant to subdivision nine of section forty-four hundred
five and subdivision two of section forty-four hundred six of this
article shall on a quarterly basis file a report with the commissioner
and the superintendent of financial services showing the percentage
utilization for the preceding quarter of non-participating provider
services in such form and providing such other information as the
commissioner shall prescribe.

7. 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 of financial services. The nonprofit organization shall
not be affiliated with an insurer, a corporation subject to article
forty-three of the insurance law, a municipal cooperative health benefit
plan certified pursuant to article forty-seven of the insurance law, or
a health maintenance organization certified pursuant to this article.

* 8. Space shall be provided on any enrollment, renewal or initial
online portal process setup forms required of a subscriber or applicant
for coverage, excepting forms issued by the NY State of Health, the
official Health Plan Marketplace, other than those specifically
referenced in subparagraph (iv) of paragraph (a) of subdivision five of
section forty-three hundred ten and paragraph (v) of subdivision one of
section two hundred six of this chapter, so that the subscriber or
applicant for coverage shall register or decline registration in the
donate life registry for organ, eye and tissue donations under this
section of the enrollment or renewal form and that the following is
stated on the form in clear and conspicuous type:

"You must fill out the following section: Would you like to be added
to the Donate Life Registry? Check box for 'yes' or 'skip this
question'."

* NB There are 2 sb 8's

* NB Effective June 23, 2024

* 8. (a) As used in this subdivision:

(i) "Pharmacy benefit manager" shall have the meaning set forth in
section two hundred eighty-a of this chapter.

(ii) "Cost-sharing information" means the amount a subscriber is
required to pay to receive a drug that is covered under the subscriber's
insurance contract.

(iii) "Covered/coverage" means those health care services to which a
subscriber is entitled under the terms of the subscriber contract.

(iv) "Electronic health record" means a digital version of a patient's
paper chart and medical history that makes information available
instantly and securely to authorized users.

(v) "Electronic prescribing system" means a system that enables
prescribers to enter prescription information into a computer
prescription device and securely transmit the prescription to pharmacies
using a special software program and connectivity to a transmission
network.

(vi) "Electronic prescription" shall have the meaning set forth in
section thirty-three hundred two of this chapter.

(vii) "Prescriber" means a health care provider licensed to prescribe
medication or medical devices in this state.

(viii) "Real-time benefit tool" or "RTBT" means an electronic
prescription decision support tool that: (1) is capable of integrating
with prescribers' electronic prescribing system and, if feasible,
electronic health record systems; and (2) complies with the technical
standards adopted by an American National Standards Institute (ANSI)
accredited standards development organization.

(ix) "Authorized third party" shall include a third party legally
authorized under state or federal law subject to a Health Insurance
Portability and Accountability Act (HIPAA) business associate agreement.

(b) The provisions of this section shall not apply to any health plan
that exclusively serves individuals enrolled pursuant to a federal or
state insurance affordability program, including the medical assistance
program under title eleven of article five of the social services law,
child health plus under section twenty-five hundred eleven of this
chapter, the basic health program under section three hundred
sixty-nine-gg of the social services law, or a plan providing services
under title XVIII of the federal social security act.

(c) A health maintenance organization or pharmacy benefit manager
shall, upon request of the subscriber, the subscriber's health care
provider, or an authorized third party on the subscriber's behalf, made
to the health maintenance organization or pharmacy benefit manager,
furnish the cost, benefit, and coverage data required by this
subdivision to the subscriber, the subscriber's health care provider, or
the authorized third party and shall ensure that such data is: (i)
current no later than one business day after any change to the cost,
benefit, or coverage data is made; (ii) provided through a RTBT when the
request is made by the subscriber's health care provider; and (iii) in a
format that is easily accessible to the requestor.

(d) When providing the data required by paragraph (c) of this
subdivision, the health maintenance organization or pharmacy benefit
manager shall use established industry content and transport standards
published by:

(i) a standards developing organization accredited by the American
National Standards Institute (ANSI), including, the National Council for
Prescription Drug Programs (NCPDP), ASC X12, Health Level 7; or

(ii) a relevant federal or state governing body, including the Center
for Medicare & Medicaid Services or the Office of the National
Coordinator for Health Information Technology.

(iii) another format deemed acceptable to the department which
provides the data prescribed in paragraph (c) of this subdivision and in
the same timeliness as required by this section.

(e) A facsimile shall not be considered an acceptable electronic
format pursuant to this subdivision.

(f) Upon a request made pursuant to paragraph (c) of this subdivision,
the health maintenance organization or pharmacy benefit manager shall
provide the following data for any drug covered under the subscriber's
subscriber contract:

(i) subscriber-specific eligibility information;

(ii) subscriber-specific prescription cost and benefit data, such as
applicable formulary, benefit, coverage, and cost-sharing data for the
prescribed drug and clinically-appropriate alternatives, when
appropriate;

(iii) subscriber-specific cost-sharing information that describes
variance in cost-sharing based on the pharmacy dispensing the prescribed
drug or its alternatives, and in relation to the insured's benefit; and

(iv) applicable utilization management requirements.

(g) A health maintenance organization or pharmacy benefit manager
shall furnish the data as required whether the request is made using the
drug's unique billing code, such as a National Drug Code or Healthcare
Common Procedure Coding System code or descriptive term. A health
maintenance organization or pharmacy benefit manager shall not deny or
unreasonably delay processing a request.

(h) A health maintenance organization and pharmacy benefit manager
shall not, except as may be required or authorized by law, interfere
with, prevent, or materially discourage access, exchange, or use of the
data as required; nor shall a health maintenance organization or
pharmacy benefit manager penalize a health care provider for disclosing
such information to a subscriber or legally prescribing, administering,
or ordering a lower cost, clinically appropriate alternative.

(i) Nothing in this subdivision shall be construed to limit access to
the most up-to-date subscriber-specific eligibility or
subscriber-specific prescription cost and benefit data by the health
maintenance organization or pharmacy benefit manager.

(j) Nothing in this subdivision shall interfere with subscriber choice
and a health care provider's ability to convey the full range of
prescription drug cost options to a subscriber. Health maintenance
organizations and pharmacy benefit managers shall not restrict a health
care provider from communicating to the subscriber prescription cost
options.

* NB There are 2 sb 8's