N.Y. Ins. Law § 210

§ 210. Annual consumer guide of health insurers, and entities\ncertified pursuant to article forty-four of the public health law.\n (a) The superintendent shall annually publish on or before September\nfirst, nineteen hundred ninety-nine, and annually thereafter, a consumer\nguide to insurers providing managed care products, individual accident\nand health insurance or group or blanket accident and health insurance\nand entities licensed pursuant to article forty-four of the public\nhealth law providing comprehensive health service plans which includes,\nin detail, a ranking from best to worst based upon each company's claim\nprocessing or medical payments record during the preceding calendar year\nusing criteria available to the department, adjusted for volume of\ncoverage provided. Such ranking shall also take into consideration the\ncorresponding total number or percentage of claims denied which were\nreversed or compromised after intervention by the department and the\ndepartment of health, consumer complaints to the department and the\ndepartment of health, violations of section three thousand two hundred\ntwenty-four-a of this chapter and other pertinent data which would\npermit the department to objectively determine a company's performance.\nThe department in publishing such consumer guide shall publish one\nstate-wide guide or no more than five regional guides so as to\nfacilitate comparisons among individual insurers and entities within a\nservice market area. Such rankings shall be printed in a format which\nranks all health insurers and all entities certified pursuant to article\nforty-four of the public health law in one combined list.\n (b) The superintendent shall include in such guide annually, and\ninsurers and entities certified pursuant to article forty-four of the\npublic health law shall provide to the superintendent the information\nrequired for such guide in a timely fashion, the following information:\n (1) The number of grievances filed pursuant to section forty-four\nhundred eight-a of the public health law, section three thousand two\nhundred seventeen-d of this chapter, section four thousand three hundred\nsix-c of this chapter, or article forty-eight of this chapter and the\nnumber of such grievances in which an adverse determination of the\ninsurer or entity was reversed in whole or in part versus the number of\nsuch determinations which were upheld;\n (2) Beginning September first, two thousand twenty-seven, the number\nof approvals and the number of adverse determinations in whole or part\nissued by utilization review agents pursuant to section forty-nine\nhundred three of the public health law or section four thousand nine\nhundred three of this chapter; and\n (3) The number of appeals to utilization review determinations that\nwere filed pursuant to section forty-nine hundred four of the public\nhealth law and section four thousand nine hundred four of this chapter\nand the number of such determinations that were reversed in whole or in\npart versus the number of such determinations that were upheld.\n (c) Beginning September first, nineteen hundred ninety-nine and\nannually thereafter, in addition to the information required in\nsubsections (a) and (b) of this section, the superintendent, in\nconjunction with the commissioner of health, in consultation with the\nNational Committee on Quality Assurance or a similar national\norganization, shall include in such guide the following additional\ninformation, for the most recent year in which such information is\navailable and where applicable, for health insurers, health insurers\nproviding managed care products and entities certified under article\nforty-four of the public health law providing comprehensive health\nservice plans pursuant to such article:\n (1) the percentage of physicians who are either board certified or\nboard eligible;\n (2) the percentage of primary care physicians who remained\nparticipating providers, provided however, that such percentage shall\nexclude voluntary terminations due to physician retirement, relocation\nor other similar reasons;\n (3) the percentage of enrollees aged twenty-three to thirty-nine and\nforty to sixty-four who had one or more visits to a health plan\npractitioner during the three years of their continual enrollment.\n (4) the methods used to compensate primary care physicians and other\nproviders, provided however, that nothing in this section shall be\nconstrued to require disclosure of the specific details of any financial\narrangement between the insurer or entity and an individual provider or\npractice;\n (5) the national accreditation status of insurers and entities, where\napplicable;\n (6) indices of the quality of care provided, such as the rates of\nmammography, prostate, and cervical cancer screening, prenatal care,\nwell-child care, immunization and such other information collected by\nthe commissioner of health through the health plan employer data and\ninformation set (HEDIS); or through the quality assurance reporting\nrequirements for entities not otherwise required to collect and report\nhealth plan employer data and information set (HEDIS) data;\n (7) the results of a consumer satisfaction survey among enrollees of\nthe various health insurers and entities, which shall be conducted by\nthe superintendent and commissioner of health, in consultation with the\nNational Committee on Quality Assurance or a similar national\norganization;\n (8) a toll-free telephone number for each health insurer or plan;\n (9) toll-free telephone numbers at the department and the department\nof health to which consumers can make complaints about insurers or\nentities; and\n (10) except as required in paragraph seven of this subsection, health\ninsurers and entities certified pursuant to article forty-four of the\npublic health law shall report the information required under this\nsubdivision to the commissioner of health, and the commissioner shall\nprovide such information to the superintendent for inclusion in the\nannual consumer guide.\n (d) Beginning September first, two thousand twenty-seven and annually\nthereafter, in addition to the information required in subsections (a),\n(b), and (c) of this section, the superintendent shall include in such\nguide, and insurers and entities certified pursuant to article\nforty-four of the public health law shall provide to the superintendent,\nin a form and manner specified by the superintendent, the information\nrequired for such guide in a timely fashion, the following information\nregarding pre-authorization requests under article forty-nine of the\npublic health law or article forty-nine of this chapter:\n (1) the number of pre-authorization requests received under section\nforty-nine hundred three of the public health law and section four\nthousand nine hundred three of this chapter;\n (2) the number of pre-authorization requests for which an\nauthorization was issued under section forty-nine hundred three of the\npublic health law and section four thousand nine hundred three of this\nchapter;\n (3) the number of pre-authorization requests for which an adverse\ndetermination was issued in whole or part under section forty-nine\nhundred three of the public health law and section four thousand nine\nhundred three of this chapter;\n (4) the number of pre-authorization requests for which an adverse\ndetermination was appealed under section forty-nine hundred four of the\npublic health law and section four thousand nine hundred four of this\nchapter;\n (5) the number of pre-authorization requests for which an adverse\ndetermination was reversed on appeal in whole or part under section\nforty-nine hundred four of the public health law and section four\nthousand nine hundred four of this chapter;\n (6) the number of pre-authorization requests for which an adverse\ndetermination was upheld under section forty-nine hundred four of the\npublic health law and section four thousand nine hundred four of this\nchapter;\n (7) the twenty-five current procedural terminology codes with the\nhighest number of pre-authorization requests and the percentage of\nauthorizations for each of these current procedural terminology codes\nunder section forty-nine hundred three of the public health law and\nsection four thousand nine hundred three of this chapter;\n (8) the twenty-five current procedural terminology codes with the\nhighest number of pre-authorization requests for which an authorization\nwas issued under section forty-nine hundred three of the public health\nlaw and section four thousand nine hundred three of this chapter;\n (9) the twenty-five current procedural terminology codes with the\nhighest number of pre-authorization requests under section forty-nine\nhundred three of the public health law and section four thousand nine\nhundred three of this chapter for which an adverse determination was\nissued in whole or part but that was reversed by an appeal, in whole or\npart, under section forty-nine hundred four of the public health law and\nsection four thousand nine hundred four of this chapter; and\n (10) the twenty-five current procedural terminology codes with the\nhighest number of pre-authorization requests for which an adverse\ndetermination was issued in whole or part under section forty-nine\nhundred three of the public health law and section four thousand nine\nhundred three of this chapter.\n (e) Health insurers and entities certified pursuant to article\nforty-four of the public health law shall provide annually to the\nsuperintendent and the commissioner of health, and the commissioner of\nhealth shall provide to the superintendent by March first of each year,\nall of the information necessary for the superintendent to produce the\nannual consumer guide. In compiling the guide, the superintendent shall\nmake every effort to ensure that the information is presented in a\nclear, understandable fashion that facilitates comparisons among\nindividual insurers and entities, and in a format that lends itself to\nthe widest possible distribution to consumers. The superintendent shall\neither include the information from the annual consumer guide in the\nconsumer shopping guide required by subsection (a) of section four\nthousand three hundred twenty-three of this chapter or combine the two\nguides as long as consumers in the individual market are provided with\nthe information required by subsection (a) of section four thousand\nthree hundred twenty-three of this chapter.\n (f) The superintendent shall contract with a national organization for\nthe purposes of drafting and designing the guide, including the\npreparation of relevant explanatory material. Such organization shall\nhave actual experience in preparing a similar guide for at least one\nother state. The superintendent, in consultation with the commissioner\nof health, may also contract with one or more national organizations to\nassist such commissioner in the collection of data and the analysis and\nauditing of the clinical measurers. Such organizations shall consult\nperiodically with associations representing health insurers and health\nmaintenance organizations as well as with consumer representatives in\nNew York in preparing the consumer guide.\n