New York Laws
Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations
4324 - Disclosure of Information.

(a) Each health service, hospital service, or medical expense
indemnity corporation subject to this article shall supply each
subscriber, and upon request each prospective subscriber prior to
enrollment, written disclosure information, which may be incorporated
into 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:
(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 corporation, 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
corporation 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 corporation and a health care provider;
(5) 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;
(6) an explanation, where applicable, of a subscriber's financial
responsibility for payment when services are provided by a health care
provider who is not part of the corporation's network of providers or by
any provider without required authorization;
(7) a description of the grievance procedures to be used to resolve
disputes between the corporation and a subscriber, including: the right
to file a grievance regarding any dispute between the corporation and a
subscriber; the right to file a grievance orally when the dispute is
about referrals or covered benefits; the toll-free telephone number
which subscribers 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 subscriber's financial and other responsibilities
regarding obtaining such services including when such services are
received outside the corporation's service area, if any;
(9) where applicable, a description of procedures for subscribers to
select and access the corporation'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 corporation's network of
providers;
(11) where applicable, notice that a subscriber enrolled in a managed
care product or in a comprehensive contract that utilizes a network of
providers offered by the corporation may obtain a referral or
preauthorization for a health care provider outside of the corporation's
network or panel when the corporation 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 subscriber and the procedure by
which the subscriber can obtain such referral or preauthorization;
(12) where applicable, notice that a subscriber enrolled in a managed
care product or a comprehensive contract that utilizes a network of
providers offered by the corporation 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 a subscriber enrolled in a managed
care product or a comprehensive contract that utilizes a network of
providers offered by the corporation 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 subscriber's medical care and the
procedure for requesting and obtaining such a specialist;
(14) where applicable, notice that a subscriber enrolled in a managed
care product or a comprehensive contract that utilizes a network of
providers offered by the corporation 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 corporation addresses the needs of
non-English speaking subscribers;
(16) notice of all appropriate mailing addresses and telephone numbers
to be utilized by subscribers seeking information or authorization;
(16-a) where applicable, 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;
(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; (C) in
the case of physicians, board certification, languages spoken and any
affiliations with participating hospitals. The listing shall also be
posted on the corporation's website and the corporation shall update the
website within fifteen days of the addition or termination of a provider
from the corporation's network or a change in a physician's hospital
affiliation;
(18) a description of the mechanisms by which subscribers may
participate in the development of the policies of the corporation;
(19) the method by which a subscriber may submit a claim for health
care services;
(20) with respect to out-of-network coverage:
(A) a clear description of the methodology used by the corporation to
determine reimbursement for out-of-network health care services;
(B) a description of the amount that the corporation 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;
(21) information in writing and through an internet website that
reasonably permits a subscriber or prospective subscriber 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 corporation will reimburse for out-of-network health
care services and the usual and customary cost for out-of-network health
care services; and
(22) the most recent comparative analysis performed by the corporation
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 health service, hospital service, or medical expense
indemnity corporation subject to this article, upon request of a
subscriber or prospective subscriber 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 corporation;
(2) provide a copy of the most recent annual certified financial
statement of the corporation, 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 subscriber information;
(6) where applicable, to allow subscribers and prospective subscribers
to inspect drug formularies used by such corporation; and provided
further, that the corporation shall also disclose whether individual
drugs are included or excluded from coverage to a subscriber or
prospective subscriber who requests this information;
(7) provide a written description of the organizational arrangements
and ongoing procedures of the corporation's quality assurance program,
if any;
(8) provide a description of the procedures followed by the
corporation 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 corporation
might consider in its utilization review and the corporation 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 corporation, the subscriber or
prospective subscriber shall only use the information for the purposes
of assisting the subscriber or prospective subscriber 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 corporation for participation in the corporation'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 corporation will pay for a specific
out-of-network health care service. The corporation shall also inform
the insured through such disclosure that such approximation is not
binding on the corporation and that the approximate dollar amount that
the corporation will pay for a specific out-of-network health care
service may change.
(c) Nothing in this section shall prevent a corporation from changing
or updating the materials that are made available to subscribers.
(d) As to any program where the subscriber must select a primary care
provider, if a participating primary care provider becomes unavailable
to provide services to a subscriber, the corporation shall provide

written notice within fifteen days from the time the corporation becomes
aware of such unavailability to each subscriber who has chosen the
provider as their primary care provider. If a subscriber is enrolled in
a managed care product and is in an ongoing course of treatment with any
other participating provider who becomes unavailable to continue to
provide services to such subscriber, and the corporation is aware of
such ongoing course of treatment, the corporation shall provide written
notice within fifteen days from the time the corporation becomes aware
of such unavailability to such subscriber. 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 subscriber (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 corporation'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
corporation'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 subscriber (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 corporation's managed care provider
network, in order for the subscriber 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 this article, 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.
(g) (1) As used in this subsection:
(A) "Pharmacy benefit manager" shall have the meaning set forth in
section two hundred eighty-a of the public health law.
(B) "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.
(C) "Covered/coverage" means those health care services to which a
subscriber is entitled under the terms of the insurance contract.
(D) "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.
(E) "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.
(F) "Electronic prescription" shall have the meaning set forth in
section thirty-three hundred two of the public health law.
(G) "Prescriber" means a health care provider licensed to prescribe
medication or medical devices in this state.
(H) "Real-time benefit tool" or "RTBT" means an electronic
prescription decision support tool that: (i) is capable of integrating
with prescribers' electronic prescribing system and, if feasible,
electronic health record systems; and (ii) complies with the technical
standards adopted by an American National Standards Institute (ANSI)
accredited standards development organization.
(I) "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.
(2) 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 the public
health law, 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.
(3) A health service, hospital service, or medical expense indemnity
corporation subject to this article 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 service, hospital service, or medical expense indemnity
corporation or pharmacy benefit manager, furnish the cost, benefit, and
coverage data required by this subsection to the subscriber, the
subscriber's health care provider, or the authorized third party and
shall ensure that such data is: (A) current no later than one business
day after any change to the cost, benefit, or coverage data is made; (B)
provided through a RTBT when the request is made by the subscriber's
health care provider; and (C) in a format that is easily accessible to
the requestor.
(4) When providing the data required by paragraph three of this
subsection, the health service, hospital service, or medical expense
indemnity corporation or pharmacy benefit manager shall use established
industry content and transport standards published by:
(A) 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
(B) 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.
(C) another format deemed acceptable to the department which provides
the data prescribed in paragraph three of this subsection and in the
same timeliness as required by this section.
(5) A facsimile shall not be considered an acceptable electronic
format pursuant to this subsection.
(6) Upon a request made pursuant to paragraph three of this
subsection, the health service, hospital service, or medical expense
indemnity corporation or pharmacy benefit manager shall provide the
following data for any drug covered under the subscriber's insurance
contract:
(A) subscriber-specific eligibility information;
(B) 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;
(C) 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
(D) applicable utilization management requirements.
(7) A health service, hospital service, or medical expense indemnity
corporation 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 service, hospital service, or
medical expense indemnity corporation or pharmacy benefit manager shall
not deny or unreasonably delay processing a request.
(8) A health service, hospital service, or medical expense indemnity
corporation 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 service, hospital service, or medical expense indemnity
corporation 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.
(9) Nothing in this subsection 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
service, hospital service, or medical expense indemnity corporation or
pharmacy benefit manager.
(10) Nothing in this subsection 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 service, hospital
service, or medical expense indemnity corporations and pharmacy benefit
managers shall not restrict a health care provider from communicating to
the subscriber prescription cost options.