N.Y. Insurance Law § 3217-a: Disclosure of information

§ 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;

* NB Effective until January 1, 2027

* (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-related and addictive 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;

* NB Effective January 1, 2027

(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.

(g) (1) As used in this subsection:

(A) "Pharmacy benefit manager" shall have the meanings set forth in

section two hundred eighty-a of the public health law.

(B) "Cost-sharing information" means the amount an insured is required

to pay to receive a drug that is covered under the insured's insurance

policy.

(C) "Covered/coverage" means those health care services to which an

insured is entitled under the terms of the insurance policy.

(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" means an electronic prescription as

defined 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) An insurer subject to this article or pharmacy benefit manager

shall, upon request of the insured, the insured's health care provider,

or an authorized third party on the insured's behalf, made to the

insurer or pharmacy benefit manager, furnish the cost, benefit, and

coverage data required by this subsection to the insured, the insured'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 an RTBT when the request is made by the insured'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 insurer 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; or

(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 insurer or pharmacy benefit manager shall provide the

following data for any drug covered under the insured's insurance

policy:

(A) insured-specific eligibility information;

(B) insured-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) insured-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) Any insurer 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. An insurer or pharmacy benefit manager

shall not deny or unreasonably delay processing a request.

(8) An insurer 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

an insurer or pharmacy benefit manager penalize a health care provider

for disclosing such information to an insured 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 insured-specific eligibility or insured-specific

prescription cost and benefit data by the insurer or pharmacy benefit

manager.

(10) Nothing in this subsection shall interfere with insured choice

and a health care provider's ability to convey the full range of

prescription drug cost options to an insured. Insurers and pharmacy

benefit managers shall not restrict a health care provider from

communicating to the insured prescription cost options.