N.Y. Insurance 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) Beginning September first, nineteen hundred ninety-nine and annually thereafter, 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 the information required for such guide in a timely fashion, the following information:
1. (1) The number of grievances filed pursuant to section forty-four hundred eight-a of the public health law 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; and
2. (2) The number of appeals to utilization review determinations which were filed pursuant to article forty-nine of the public health law or article forty-nine of this chapter and the number of such determinations which were reversed versus the number of such determinations which 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. (1) the percentage of physicians who are either board certified or board eligible;
2. (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. (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. (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. (5) the national accreditation status of insurers and entities, where applicable;
6. (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. (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. (8) a toll-free telephone number for each health insurer or plan;
9. (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. (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.
11. (c-1) Beginning September first, two thousand nineteen and annually thereafter, the superintendent shall include in such guide a mental health and substance use disorder parity report detailing each company's compliance with federal and state mental health and substance use disorder parity laws based on each company's record during the preceding calendar year. The superintendent shall include in such report, and each company shall provide to the superintendent the information required for such guide in a timely fashion, the following information:
  1. (1) Rates of utilization review for mental health and substance use disorder claims as compared to medical and surgical claims, including rates of approval and denial, categorized by benefits provided under the following classifications: inpatient in-network, inpatient out-of-network, outpatient in-network, outpatient out-of-network, emergency care, and prescription drugs;
  2. (2) The number of prior or concurrent authorization requests for mental health services and for substance use disorder services and the number of denials for such requests, compared with the number of prior or concurrent authorization requests for medical and surgical services and the number of denials for such requests, categorized by the same classifications identified in paragraph one of this subsection;
  3. (3) The rates of appeals of adverse determinations, including the rates of adverse determinations upheld and overturned, for mental health claims and substance use disorder claims compared with the rates of appeals of adverse determinations, including the rates of adverse determinations upheld and overturned, for medical and surgical claims;
  4. (4) The percentage of claims paid for in-network mental health services and for substance use disorder services compared with the percentage of claims paid for in-network medical and surgical services and the percentage of claims paid for out-of-network mental health services and substance use disorder services compared with the percentage of claims paid for out-of-network medical and surgical services;
  5. (5) The number of behavioral health advocates, pursuant to an agreement with the office of the attorney general if applicable, or staff available to assist policyholders with mental health benefits and substance use disorder benefits;
  6. (6) A comparison of the cost sharing requirements including but not limited to co-pays and coinsurance, and the benefit limitations including limitations on the scope and duration of coverage, for medical and surgical services, and mental health services and substance use disorder services;
  7. (7) The number by type of providers licensed to practice in this state that provide services for the treatment and diagnosis of substance use disorder who are in-network, and the number by type of providers licensed to practice in this state that provide services for the diagnosis and treatment of mental, nervous or emotional disorders and ailments, however defined in a company's policy, who are in-network;
  8. (8) The percentage of providers of services for the treatment and diagnosis of substance use disorder who remained participating providers, and the percentage of providers of services for the diagnosis and treatment of mental, nervous or emotional disorders and ailments, however defined in a company's policy, who remained participating providers; and
  9. (9) Any other data or metric the superintendent deems necessary to measure compliance with mental health and substance use disorder parity including, but not limited to an evaluation and assessment of: (i) the adequacy of the company's in-network mental health services and substance use disorder provider panels pursuant to provisions of the insurance law and public health law; and (ii) the company's reimbursement for in-network and out-of-network mental health services and substance use disorder services as compared to the reimbursement for in-network and out-of-network medical and surgical services.
(d) 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, all of the information necessary for the superintendent to produce the annual consumer guide, including the mental health and substance use disorder parity report. In compiling the guide, the superintendent shall make every effort to ensure that the information is presented in a clear, understandable fashion which facilitates comparisons among individual insurers and entities, and in a format which 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.
(e) 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.