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

§ 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.