N.Y. Public Health Law § 4409: Health maintenance organizations; examinations

§ 4409. Health maintenance organizations; examinations. 1. In order to

carry out the provisions of this article, the commissioner, pursuant to

his authority under section two hundred six of this chapter, shall

examine not less than once every three years, each health maintenance

organization and all participating entities through which such health

maintenance organization offers health services as to the quality of

health care services offered, and the adequacy of its provider

arrangements.

2. (a) The superintendent shall examine not less than once every three

years into the financial affairs of each health maintenance

organization, and transmit his findings to the commissioner. In

connection with any such examination, the superintendent shall have

convenient access at all reasonable hours to all books, records, files

and other documents relating to the affairs of such organization, which

are relevant to the examination. The superintendent may exercise the

powers set forth in sections three hundred six and three hundred ten of

the insurance law in connection with such examinations, and may also

require special reports from such health maintenance organizations as

specified in section three hundred eight of the insurance law. As part

of an examination, the superintendent shall review determinations of

coverage for substance use disorder treatment and shall ensure that such

determinations are issued in compliance with section four thousand three

hundred three of the insurance law and title one of article forty-nine

of this chapter.

(b) The department is authorized to address to any health maintenance

organization, and managed long term care plan with a certificate of

authority pursuant to section forty-four hundred three-f of this

article, or officers thereof, any inquiry in relation to its contracts

with providers and other entities providing covered services to the

health maintenance organization's or managed long term care plan's

enrollees, including but not limited to the rates of payment and payment

terms and conditions therein. Every entity or person so addressed shall

reply in writing to such inquiry promptly and truthfully, and such reply

shall be, if required by the department, signed by such individual, or

by such officer or officers of a corporation, as the department shall

designate, and affirmed by them as true under penalty of perjury.

Failure to comply with the requirements of this section shall be subject

to civil penalties under section twelve of this chapter. Each day after

the deadline established by the department for reply until such time

that the provider submits a good faith response shall be considered a

separate and subsequent violation. In accordance with the process

outlined in this paragraph, employers shall provide any documents or

materials in the employer's possession, custody, or control that are

requested by the department as needed to support or verify the

employer's reply.

(c) Any report, information, documents, or other materials furnished

to the department under this subdivision shall be deemed a confidential

communication and shall not be subject to inspection or disclosure in

any manner, including article six of the public officers law or

department regulations in conformance therewith, except as provided in

this section, pursuant to a judicial subpoena issued in a pending action

or proceeding, or upon formal written request by the department of

labor, the office of attorney general, or a duly authorized public

agency.

(d) The department shall no less than annually provide a report to the

governor, temporary president of the senate, and speaker of the assembly

summarizing the information obtained by the department under paragraph

(b) of this subdivision. Such report shall not contain individually

identifiable data.

3. The superintendent and the commissioner are authorized to share and

exchange information obtained by them in the exercise of their

respective responsibilities under the insurance law and this chapter.

4. Nothing contained in this section shall be deemed to require the

public disclosure of privileged patient information.