N.Y. Civil Service Law § 162: Contract for health benefits

§ 162. Contract for health benefits. 1. The president is hereby

authorized and directed to purchase a contract or contracts to provide

the benefits under the plan of health benefits determined upon in

accordance with the provisions of this article. Such contract or

contracts shall be purchased from one or more corporations licensed to

transact accident and health insurance business in this state or subject

to article forty-three of the insurance law.

(a) Alternatively, the president may provide health benefits directly

to plan participants, in which case the president is hereby authorized

to purchase a contract or contracts with one or more firms qualified to

administer, on New York state health benefit plan's behalf, the plan of

benefits required under this article.

(b) In the event the president elects to provide health benefits

directly to plan participants in accordance with paragraph (a) of this

subdivision:

(i) Any and all health insurance coverage mandated by any law, rule or

regulation, including but not limited to coverage mandated pursuant to

article forty-three of the insurance law, applicable to contracts for

health insurance entered into under this section shall be provided in a

manner assuring uninterrupted continuance of coverage for all covered

persons. For the purposes of this paragraph "coverage" shall include but

shall not be limited to all benefits, services, rights, privileges and

guarantees allowed by law;

(ii) Plan participants shall be afforded all internal and external

review and appeal rights as described in article forty-nine of the

insurance law;

(iii) A plan participant receiving covered services rendered by a

health care provider prior to the date upon which the president elects

to provide health benefits directly to plan participants in accordance

with paragraph (a) of this subdivision shall be permitted to continue

receiving services from such health care provider after the effective

date of the election at the discretion of such plan participant.

Services provided by such health care provider after the effective date

of the election as described in this paragraph shall be covered in a

manner consistent with covered services provided directly to plan

participants in accordance with paragraph (a) of this subdivision; and

(iv) Notwithstanding the provisions of this subdivision, the

president's election to provide health benefits directly to plan

participants shall not constitute the doing of insurance business within

the meaning of article eleven of the insurance law; provided however,

the provision of direct benefits as per this subdivision shall be

subject to review by the superintendent of financial services for the

purposes of ensuring compliance with applicable insurance law and any

and all associated insurance rules and regulations as noted in this

subdivision.

(c) All of the benefits to be provided under this article may be

included in one or more similar contracts, or the benefits may be

classified into different types with each type included under one or

more similar contracts issued by the same or different companies.

2. A reasonable time before entering into any insurance contract or

contract with an administrator or administrators hereunder, the

president shall invite proposals from such qualified insurers or

administrators as in his or her opinion would desire to accept any part

of the insurance coverage or administrative services authorized by this

article.

3. The president may arrange with any corporation licensed to transact

accident and health insurance business in this state or subject to

article forty-three of the insurance law issuing any such contract to

reinsure portions of such contract with any other such corporation which

elects to be a reinsurer and is legally competent to enter into a

reinsurance agreement.

4. The president may designate one or more of such corporations as the

administering corporation or corporations.

5. Each employee who is covered under any such contract or contracts

shall receive a certificate setting forth the benefits to which the

employee and his dependents are entitled thereunder, to whom such

benefits shall be payable, to whom claims should be submitted, and

summarizing the provisions of the contract principally affecting the

employee and his dependents. Such certificate shall be in lieu of the

certificate which the corporation or corporations issuing such contract

or contracts would otherwise issue.

6. The corporations eligible to participate as reinsurers, and the

amount of coverage under the contract or contracts to be allocated to

each issuing corporation or reinsurer, may be redetermined by the

president for and in advance of any contract year after the first year

on a basis consistent with subdivision three of this section, and with

any modifications thereof he deems appropriate to carry out the intent

of such subdivision.

7. The president shall not purchase any contract or contracts for any

period except upon the prior approval of the director of the budget.

8. The president may, on March thirty-first, nineteen hundred

fifty-seven or at the end of any fiscal year thereafter, discontinue any

contract or contracts he has purchased from any corporation or

corporations and replace it or them with a contract or contracts in any

other corporation or corporations meeting the requirements of this

section.

9. (a) (i) As soon as is practicable, but no later than the first of

September, two thousand fourteen, the department shall, upon request,

but no more frequently than semi-annually, provide to any participating

employer a standard report which contains data relating to the use of

benefits by persons covered under the plan by such employer. Such report

shall include: premiums paid by month for each month covered in the

report and paid claims by month for the following categories of

services: inpatient hospital, outpatient hospital, in network medical,

out of network medical, prescription drugs, and treatment of behavioral

conditions, each reported separately. To the extent allowed by state and

federal privacy laws, such report shall also contain claims information

for individual claimants for claims in excess of fifty thousand dollars

that were paid in any of the months covered by the report.

(ii) The department shall provide such reports to any participating

employer, upon request submitted on or after the first of April for data

from the first of January through the thirty-first of December of the

prior year, and on or after the first of September for data from the

first of June of the prior year through the thirty-first of May of the

current year, within thirty days of receipt of said request. However,

requests submitted in the two thousand fourteen calendar year shall be

provided as soon as practicable, but no later than the first of

September, two thousand fourteen, or within thirty days after said

request if request is submitted on or after the first of August, two

thousand fourteen.

(b) (i) As soon as practicable, but not later than December first of

each year, the department shall collect and analyze health care claims

data from the Empire Plan, or its successor, to develop, and make

publicly available, a New York state health benefit plan hospital

pricing report. Such report shall exclude optional benefit plan health

care claims data and claims for Medicare primary individuals. The report

shall include, but not be limited to, a comparative analysis of actual

hospital in-network allowed amounts and out-of-network allowed amounts

for each hospital facility located in the state of New York identified

by name and CMS certification number (CCN) or successor identifier,

based on the following service categories: (A) inpatient hospital, (B)

outpatient hospital, (C) emergency room services, and (D) physician

services provided (1) during an inpatient hospital admission and (2) as

part of an outpatient visit or in connection with the provision of

emergency room services, except to the extent that the department

determines that the analysis of physician services is not technically

feasible and explains the basis for such determination.

(ii) The report shall also include the in-network allowed amount and

out-of-network allowed amount per service per hospital facility on the

top twenty services by volume within each of the following service

categories: (A) inpatient, (B) outpatient, (C) emergency room services,

and (D) physician services provided (1) during an inpatient hospital

admission and (2) as part of an outpatient visit or in connection with

the provision of emergency room services, except to the extent that the

department determines that the analysis of physician services is not

technically feasible and explains the basis for such determination at

each hospital located in the state of New York. The report shall

compare, to the best of the department's ability, the in-network allowed

amounts and out-of-network allowed amounts for similar services

reimbursed under title eighteen of the social security act. Such report

shall also include a comprehensive analysis of the prior two years of

hospital in-network allowed amounts and out-of-network allowed amounts

for such services to illustrate trends in hospital prices. The report

shall also include an all-plan aggregated total yearly spend by hospital

facility identified by name and CMS certification number (CCN) or

successor identifier. In preparing the report, the president shall take

appropriate steps to ensure that individual insurer's or health plan's

confidential proprietary pricing information is maintained as

confidential to the extent permissible by law. Such report shall be

delivered to the legislative fiscal committees, the chairs of the

legislative health care committees, the chair of the senate civil

service and pensions committee, and the chair of the assembly committee

on governmental employees, on or before December thirty-first of each

year, and such report shall be posted on the department's website no

later than January first of the following calendar year. For purposes of

this subdivision, "health care claims data" means any hospital claims

paid by the health benefit plan, or its designee, for the service

categories listed in this subdivision on form UB-04 or successor forms,

with UB-04 being the billing form identified by the Centers for Medicare

and Medicaid Services.