1. Each subscriber, and upon request each prospective subscriber prior to enrollment, shall be supplied with written disclosure information which may be incorporated into the member handbook or 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:
(a) 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;
(b) a description of all prior authorization or other requirements for treatments and services;
(c) a description of utilization review policies and procedures used by the health maintenance organization, including:
(i) the circumstances under which utilization review will be undertaken;
(ii) the toll-free telephone number of the utilization review agent;
(iii) the timeframes under which utilization review decisions must be made for prospective, retrospective and concurrent decisions;
(iv) the right to reconsideration;
(v) the right to an appeal, including the expedited and standard appeals processes and the time frames for such appeals;
(vi) the right to designate a representative;
(vii) 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;
(viii) a notice of the right to an external appeal together with a description, jointly promulgated by the commissioner and the superintendent of financial services as required pursuant to subdivision five of section forty-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 timeframes for such appeals; and
(ix) further appeal rights, if any;
(d) a description prepared annually of the types of methodologies the health maintenance organization 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 health maintenance organization and a health care provider;
(e) 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 provided within the health maintenance organization;
(f) an explanation of a subscriber's financial responsibility for payment when services are provided by a health care provider who is not part of the health maintenance organization or by any provider without required authorization or when a procedure, treatment or service is not a covered health care benefit;
(g) a description of the grievance procedures to be used to resolve disputes between a health maintenance organization and an enrollee, including: the right to file a grievance regarding any dispute between an enrollee and a health maintenance organization; the right to file a grievance orally when the dispute is about referrals or covered benefits; the toll-free telephone number which enrollees 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;
(h) a description of the procedure for providing care and coverage twenty-four hours a day for 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 enrollee's financial and other responsibilities regarding obtaining such services including when such services are received outside the health maintenance organization's service area;
(i) a description of procedures for enrollees to select and access the health maintenance organization's primary and specialty care providers, including notice of how to determine whether a participating provider is accepting new patients;
(j) a description of the procedures for changing primary and specialty care providers within the health maintenance organization;
(k) notice that an enrollee may obtain a referral to a health care provider outside of the health maintenance organization's network or panel when the health maintenance organization does not have a health care provider who is geographically accessible to the enrollee and who has appropriate training and experience in the network or panel to meet the particular health care needs of the enrollee and the procedure by which the enrollee can obtain such referral;
(l) notice that an enrollee 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;
(m) notice that an enrollee 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 enrollee's medical care and the procedure for requesting and obtaining such a specialist;
(n) notice that an enrollee with a 1 (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 access to a specialty care center and the procedure by which such access may be obtained;
(o) a description of the mechanisms by which enrollees may participate in the development of the policies of the health maintenance organization;
(p) a description of how the health maintenance organization addresses the needs of non-English speaking enrollees;
(p-1) 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;
(q) notice of all appropriate mailing addresses and telephone numbers to be utilized by enrollees seeking information or authorization;
(r) a listing by specialty, which may be in a separate document that is updated annually, of the name, address and telephone number of all participating providers, including facilities, and, in addition, in the case of physicians, board certification, languages spoken and any affiliations with participating hospitals. The listing shall also be posted on the health maintenance organization's website and the health maintenance organization shall update the website within fifteen days of the addition or termination of a provider from the health maintenance organization's network or a change in a physician's hospital affiliation;
(s) where applicable, a description of the method by which an enrollee may submit a claim for health care services;
(t) with respect to out-of-network coverage:
(i) a clear description of the methodology used by the health maintenance organization to determine reimbursement for out-of-network health care services;
(ii) the amount that the health maintenance organization 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;
(iii) examples of anticipated out-of-pocket costs for frequently billed out-of-network health care services; and
(u) information in writing and through an internet website that reasonably permits an enrollee or prospective enrollee 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 health maintenance organization will reimburse for out-of-network health care services and the usual and customary cost for out-of-network health care services.
2. Each health maintenance organization shall, upon request of an enrollee or prospective enrollee:
(a) provide a list of the names, business addresses and official positions of the membership of the board of directors, officers, controlling persons, owners or partners of the health maintenance organization;
(b) provide a copy of the most recent annual certified financial statement of the health maintenance organization, including a balance sheet and summary of receipts and disbursements prepared by a certified public accountant;
(c) provide a copy of the most recent individual, direct pay subscriber contracts;
(d) provide information relating to consumer complaints compiled pursuant to section two hundred ten of the insurance law ;
(e) provide the procedures for protecting the confidentiality of medical records and other enrollee information;
(f) allow enrollees and prospective enrollees to inspect drug formularies used by such health maintenance organization; and provided further, that the health maintenance organization shall also disclose whether individual drugs are included or excluded from coverage to an enrollee or prospective enrollee who requests this information;
(g) provide a written description of the organizational arrangements and ongoing procedures of the health maintenance organization's quality assurance program;
(h) provide a description of the procedures followed by the health maintenance organization in making decisions about the experimental or investigational nature of individual drugs, medical devices or treatments in clinical trials;
(i) provide individual health practitioner affiliations with participating hospitals, if any;
(j) 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 subdivisions three-a , three-b and three-c of section forty-nine hundred three of this chapter, and, where appropriate, other clinical information which the organization might consider in its utilization review and the organization 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 organization, the enrollee or prospective enrollee 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 subdivision six of section forty-nine hundred of this chapter, on behalf of an enrollee and upon written request;
(k) provide the written application procedures and minimum qualification requirements for health care providers to be considered by the health maintenance organization;
(l) disclose other information as required by the commissioner, provided that such requirements are promulgated pursuant to the state administrative procedure act;
(m) disclose whether a health care provider scheduled to provide a health care service is an in-network provider; and
(n) with respect to out-of-network coverage, disclose the approximate dollar amount that the health maintenance organization will pay for a specific out-of-network health care service. The health maintenance organization shall also inform an enrollee through such disclosure that such approximation is not binding on the health maintenance organization and that the approximate dollar amount that the health maintenance organization will pay for a specific out-of-network health care service may change.
3. Nothing in this section shall prevent a health maintenance organization from changing or updating the materials that are made available to enrollees.
4. If a primary care provider ceases participation in the health maintenance organization, the organization shall provide written notice within fifteen days from the date that the organization becomes aware of such change in status to each enrollee who has chosen the provider as their primary care provider. If an enrollee is in an ongoing course of treatment with any other participating provider who becomes unavailable to continue to provide services to such enrollee and the health maintenance organization is aware of such ongoing course of treatment, the health maintenance organization shall provide written notice within fifteen days from the date that the health maintenance organization becomes aware of such unavailability to such enrollee. Each notice shall also describe the procedures for continuing care pursuant to paragraphs (e) and (f) of subdivision six of section four thousand four hundred three of this article and for choosing an alternative provider.
5. Every health maintenance organization shall annually on or before April first, file a report with the commissioner and superintendent of financial services showing its financial condition as of the last day of the preceding calendar year, in such form and providing such information as the commissioner shall prescribe.
6. Every health maintenance organization offering to indemnify enrollees pursuant to subdivision nine of section forty-four hundred five and subdivision two of section forty-four hundred six of this article shall on a quarterly basis file a report with the commissioner and the superintendent of financial services showing the percentage utilization for the preceding quarter of non-participating provider services in such form and providing such other information as the commissioner shall prescribe.
7. 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 of financial services. The nonprofit organization shall not be affiliated with an insurer, a corporation subject to article forty-three of the insurance law, a municipal cooperative health benefit plan certified pursuant to article forty-seven of the insurance law, or a health maintenance organization certified pursuant to this article.
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