Section 4801. Application. 4802. Grievance procedure. 4803. Health care professional applications and terminations. 4804. Access to specialty care. 4805. Access to end of life care. S 4801. Application. The provisions of this article shall apply to all managed care products, as defined in subsection (c) of this section, which are delivered or issued for delivery in this state by insurers licensed under this chapter; provided, however, that none of the provisions of this article shall apply to any health maintenance organization lines of business of such insurers or to health maintenance organizations certified under article forty-four of the public health law or licensed under article forty-three of this chapter, which are subject to the provisions of article forty-four of the public health law. For purposes of this article: (a) an "insured" shall mean a person covered under a managed care health insurance contract. (b) an "insurer" shall mean an insurance company subject to article thirty-two of this chapter, or a corporation subject to article forty-three of this chapter. (c) a "managed care health insurance contract" or "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 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. (d) "in-network benefits" shall mean benefits covered and received under a managed care product from a health care provider participating in the insurer`s managed care provider network pursuant to a referral from the insured`s participating primary care gatekeeper. S 4802. Grievance procedure. (a) An insurer which offers a managed care product shall establish and maintain a grievance procedure with regard to such managed care product. Pursuant to such procedure, insureds shall be entitled to seek a review of determinations by the insurer with regard to such managed care product, other than determinations subject to the provisions of article forty-nine of this chapter. (b) (1) An insurer shall provide to all insureds written notice of the grievance procedure in the contract and at any time that the insurer denies access to a referral or determines that a requested benefit is not covered pursuant to the terms of the contract; provided, however, that nothing herein shall be deemed to require a health care provider to provide such notice. In the event that an insurer denies a service as an adverse determination as defined in article forty-nine of this chapter, the insurer shall inform the insured or the insured`s designee of the appeal rights provided for in article forty-nine of this chapter. (2) The notice to an insured describing the grievance process shall explain: (i) the process for filing a grievance with the insurer; (ii) the timeframes within which a grievance determination must be made; and (iii) the right of an insured to designate a representative to file a grievance on behalf of the insured. (3) The insurer shall assure that the grievance procedure is reasonably accessible to those who do not speak English. (c) (1) The insurer may require an insured to file a grievance in writing, by letter or by a grievance form which shall be made available by the insurer, and which shall conform to applicable standards for readability. (2) Notwithstanding the provisions of paragraph (1) of this subsection, an insured may submit an oral grievance in connection with (i) a denial of, or failure to pay for, a referral; or (ii) a determination as to whether a benefit is covered pursuant to the terms of the insured`s contract. In connection with the submission of an oral grievance, an insurer may require that the insured sign a written acknowledgment of the grievance, prepared by the insurer summarizing the nature of the grievance. Such acknowledgment shall be mailed promptly to the insured, who shall sign and return the acknowledgment, with any amendments, in order to initiate the grievance. The grievance acknowledgment shall prominently state that the insured must sign and return the acknowledgment to initiate the grievance. If an insurer does not require such a signed acknowledgment, an oral grievance shall be initiated at the time of the telephone call. (3) Upon receipt of a grievance, the insurer shall provide notice specifying what information must be provided to the insurer in order to render a decision on the grievance. (4) (i) An insurer shall designate personnel to accept the filing of an insured`s grievance by toll-free telephone no less than forty hours per week during normal business hours and, shall have a telephone system available to take calls during other than normal business hours and shall respond to all such calls no less than one business day after the call was recorded. (ii) Notwithstanding the provisions of subparagraph (i) of this paragraph, an insurer may, in the alternative, designate personnel to accept the filing of an insured`s grievance by toll-free telephone no less than forty hours per week during normal business hours and, in the case of grievances subject to subparagraph (1) of subsection (d) of this section, on a twenty-four hour a day, seven day a week basis. (d) Within fifteen business days of receipt of the grievance, the insurer shall provide written acknowledgment of the grievance, including the name, address and telephone number of the individual or department designated by the insurer to respond to the grievance. All grievances shall be resolved in an expeditious manner, and in any event, no more than: (1) forty-eight hours after the receipt of all necessary information when a delay would significantly increase the risk to an insured`s health; (2) thirty days after the receipt of all necessary information in the case of requests for referrals or determinations concerning whether a requested benefit is covered pursuant to the contract; and (3) forty-five days after the receipt of all necessary information in all other instances. (e) The insurer shall designate one or more qualified personnel to review the grievance; provided further, that when the grievance pertains to clinical matters, the personnel shall include, but not be limited to, one or more licensed, certified or registered health care professionals. (f) The notice of a determination of the grievance shall be made in writing to the insured or to the insured`s designee. In the case of a determination made in conformance with subparagraph (1) of subsection (d) of this section, notice shall be made by telephone directly to the insured with written notice to follow within three business days. (g) The notice of a determination shall include: (1) the detailed reasons for the determination; (2) in cases where the determination has a clinical basis, the clinical rationale for the determination; and (3) the procedures for the filing of an appeal of the determination, including a form for the filing of such an appeal. (h) An insured or an insured`s designee shall have not less than sixty business days after receipt of notice of the grievance determination to file a written appeal, which may be submitted by letter or by a form supplied by the insurer. (i) Within fifteen business days of receipt of the appeal, the insurer shall provide written acknowledgment of the appeal, including the name, address and telephone number of the individual designated by the insurer to respond to the appeal and what additional information, if any, must be provided in order for the insurer to render a decision. (j) The determination of an appeal on a clinical matter must be made by personnel qualified to review the appeal, including licensed, certified or registered health care professionals who did not make the initial determination, at least one of whom must be a clinical peer reviewer as defined in article forty-nine of this chapter. The determination of an appeal on a matter which is not clinical shall be made by qualified personnel at a higher level than the personnel who made the grievance determination. (k) The insurer shall seek to resolve all appeals in the most expeditious manner and shall make a determination and provide notice no more than: (1) two business days after the receipt of all necessary information when a delay would significantly increase the risk to an insured`s health; and (2) thirty business days after the receipt of all necessary information in all other instances. (l) The notice of a determination on an appeal shall include: (1) the detailed reasons for the determination; and (2) in cases where the determination has a clinical basis, the clinical rationale for the determination. (m) An insurer shall not retaliate or take any discriminatory action against an insured because an insured has filed a grievance or appeal. (n) An insurer shall maintain a file on each grievance and associated appeal, if any, that shall include the date the grievance was filed; a copy of the grievance, if any; the date of receipt of and a copy of the insured`s acknowledgment of the grievance, if any; the determination made by the insurer including the date of the determination, and the titles and, in the case of a clinical determination, the credentials of the insurer`s personnel who reviewed the grievance. If an insured files an appeal of the grievance, the file shall include the date and a copy of the insured`s appeal, the determination made by the insurer including the date of the determination and the titles and, in the case of clinical determinations, the credentials of the insurer`s personnel who reviewed the appeal. (o) The rights and remedies conferred in this article upon insureds shall be cumulative and in addition to and not in lieu of any other rights or remedies available under law. S 4803. Health care professional applications and terminations. (a) An insurer which offers a managed care product shall, upon request, make available and disclose to health care professionals written application procedures and minimum qualification requirements which a health care professional must meet in order to be considered by the insurer for participation in the in-network benefits portion of the insurer`s network for the managed care product. The insurer shall consult with appropriately qualified health care professionals in developing its qualification requirements for participation in the in-network benefits portion of the insurer`s network for the managed care product. (b) (1) An insurer shall not terminate a contract with a health care professional for participation in the in-network benefits portion of the insurer`s network for a managed care product unless the insurer provides to the health care professional a written explanation of the reasons for the proposed contract termination and an opportunity for a review or hearing as hereinafter provided. This section shall not apply in cases involving imminent harm to patient care, a determination of fraud, or a final disciplinary action by a state licensing board or other governmental agency that impairs the health care professional`s ability to practice. (2) The notice of the proposed contract termination provided by the insurer to the health care professional shall include: (i) the reasons for the proposed action; (ii) notice that the health care professional has the right to request a hearing or review, at the professional`s discretion, before a panel appointed by the insurer; (iii) a time limit of not less than thirty days within which a health care professional may request a hearing or review; and (iv) a time limit for a hearing date which must be held within not less than thirty days after the date of receipt of a request for a hearing. (3) The hearing panel shall be comprised of three persons appointed by the insurer. At least one person on such panel shall be a clinical peer in the same discipline and the same or similar specialty as the health care professional under review. The hearing panel may consist of more than three persons, provided however that the number of clinical peers on such panel shall constitute one-third or more of the total membership of the panel. (4) The hearing panel shall render a decision on the proposed action in a timely manner. Such decision shall include reinstatement of the health care professional by the insurer, provisional reinstatement subject to conditions set forth by the insurer or termination of the health care professional. Such decision shall be provided in writing to the health care professional. (5) A decision by the hearing panel to terminate a health care professional shall be effective not less than thirty days after the receipt by the health care professional of the hearing panel`s decision; provided, however, that the provisions of subsection (e) of section four thousand eight hundred four shall apply to such termination.
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(6) In no event shall termination be effective earlier than sixty days from the receipt of the notice of termination. (c) Either party to a contract for participation in the in-network benefits portion of an insurer`s network for a managed care product may exercise a right of non-renewal at the expiration of the contract period set forth therein or, for a contract without a specific expiration date, on each January first occurring after the contract has been in effect for at least one year, upon sixty days notice to the other party; provided, however, that any non-renewal shall not constitute a termination for purposes of this section. (d) An insurer shall develop and implement policies and procedures to ensure that health care providers participating in the the in-network benefits portion of an insurer`s network for a managed care product are regularly informed of information maintained by the insurer to evaluate the performance or practice of the health care professional. The insurer shall consult with health care professionals in developing methodologies to collect and analyze provider profiling data. Insurers shall provide any such information and profiling data and analysis to these health care professionals. Such information, data or analysis shall be provided on a periodic basis appropriate to the nature and amount of data and the volume and scope of services provided. Any profiling data used to evaluate the performance or practice of such a health care professional shall be measured against stated criteria and an appropriate group of health care professionals using similar treatment modalities serving a comparable patient population. Upon presentation of such information or data, each such health care professional shall be given the opportunity to discuss the unique nature of the health care professional`s patient population which may have a bearing on the professional`s profile and to work cooperatively with the insurer to improve performance. (e) No insurer shall terminate or refuse to renew a contract for participation in the in-network benefits portion of an insurer`s network for a managed care product solely because the health care professional has (1) advocated on behalf of an insured; (2) has filed a complaint against the insurer; (3) has appealed a decision of the insurer; (4) provided information or filed a report pursuant to section forty-four hundred six-c of the public health law; or (5) requested a hearing or review pursuant to this section. (f) Except as provided herein, no contract or agreement between an insurer and a health care professional for participation in the in-network benefits portion of an insurer`s network for a managed care product shall contain any provision which shall supersede or impair a health care professional`s right to notice of reasons for termination and the opportunity for a hearing concerning such termination. (g) Any contract provision in violation of this section shall be deemed to be void and unenforceable. (h) For purposes of this section, "health care professional" shall mean a health care professional licensed, registered or certified pursuant to title eight of the education law. S 4804. Access to specialty care. (a) If an insurer offering a managed care product determines that it does not have a health care provider in the in-network benefits portion of its network with appropriate training and experience to meet the particular health care needs of an insured, the insurer shall make a referral to an appropriate provider, pursuant to a treatment plan approved by the insurer in consultation with the primary care provider, the non-participating provider and the insured or the insured`s designee, at no additional cost to the insured beyond what the insured would otherwise pay for services received within the network. (b) An insurer offering a managed care product shall have a procedure by which an insured enrolled in such managed care product who needs ongoing care from a specialist may receive a standing referral to such specialist. If the insurer, or the primary care provider in consultation with the insurer and the specialist, determines that such a standing referral is appropriate, the insurer shall make such a referral to a specialist. In no event shall an insurer be required to permit an insured to elect to have a non-participating specialist, except pursuant to the provisions of subsection (a) of this section. Such referral shall be pursuant to a treatment plan approved by the insurer in consultation with the primary care provider, the specialist, and the insured or the insured`s designee. Such treatment plan may limit the number of visits or the period during which such visits are authorized and may require the specialist to provide the primary care provider with regular updates on the specialty care provided, as well as all necessary medical information. (c) An insurer shall have a procedure by which a new insured upon enrollment in a managed care product, or an insured in a managed care product upon diagnosis, with (1) a life-threatening condition or disease or (2) a degenerative and disabling condition or disease, either of which requires specialized medical care over a prolonged period of time, may receive a referral to a specialist with expertise in treating the life-threatening or degenerative and disabling disease or condition who shall be responsible for and capable of providing and coordinating the insured`s primary and specialty care. If the insurer, or primary care provider in consultation with the insurer and the specialist, if any, determines that the insured`s care would most appropriately be coordinated by such a specialist, the insurer shall refer the insured to such specialist. In no event shall an insurer be required to permit an insured to elect to have a non-participating specialist, except pursuant to the provisions of subsection (a) of this section. Such referral shall be pursuant to a treatment plan approved by the insurer, in consultation with the primary care provider if appropriate, the specialist, and the insured or the insured`s designee. Such specialist shall be permitted to treat the insured without a referral from the insured`s primary care provider and may authorize such referrals, procedures, tests and other medical services as the insured`s primary care provider would otherwise be permitted to provide or authorize, subject to the terms of the treatment plan. If an insurer refers an insured to a non-participating provider, services provided pursuant to the approved treatment plan shall be provided at no additional cost to the insured beyond what the insured would otherwise pay for services received within the network. (d) An insurer offering a managed care product shall have a procedure by which an insured enrolled in such managed care product with (1) a life-threatening condition or disease or (2) a degenerative and disabling condition or disease, either of which requires specialized medical care over a prolonged period of time, may receive a referral to a specialty care center with expertise in treating the life-threatening or degenerative and disabling disease or condition. If the insurer, or the primary care provider or the specialist designated pursuant to subsection (c) of this section, in consultation with the insurer, determines that the insured`s care would most appropriately be provided by such a specialty care center, the insurer shall refer the insured to such center. In no event shall an insurer be required to permit an insured to elect to have a non-participating speciality care center, unless the insurer does not have an appropriate specialty care center to treat the insured`s disease or condition within its network. Such referral shall be pursuant to a treatment plan developed by the specialty care center and approved by the insurer, in consultation with the primary care provider, if any, or a specialist designated pursuant to subsection (c) of this section, and the insured or the insured`s designee. If an insurer refers an insured to a specialty care center that does not participate in the insurer`s managed care provider network, services provided pursuant to the approved treatment plan shall be provided at no additional cost to the insured beyond what the insured would otherwise pay for services received within the network. For purposes of this subsection, a specialty care center shall mean only such centers as are accredited or designated by an agency of the state or federal government or by a voluntary national health organization as having special expertise in treating the life-threatening disease or condition or degenerative and disabling disease or condition for which it is accredited or designated. (e) (1) If an insured`s health care provider leaves the insurer`s in-network benefits portion of its network of providers for a managed care product for reasons other than those for which the provider would not be eligible to receive a hearing pursuant to paragraph one of subsection (b) of section forty-eight hundred three of this chapter, the insurer shall permit the insured to continue an ongoing course of treatment with the insured`s current health care provider during a transitional period of (i) up to ninety days from the date of notice to the insured of the provider`s disaffiliation from the insurer`s network; or (ii) if the insured has entered the second trimester of pregnancy at the time of the provider`s disaffiliation, for a transitional period that includes the provision of post-partum care directly related to the delivery. (2) Notwithstanding the provisions of paragraph one of this subsection, such care shall be authorized by the insurer during the transitional period only if the health care provider agrees (i) to continue to accept reimbursement from the insurer at the rates applicable prior to the start of the transitional period as payment in full; (ii) to adhere to the insurer`s quality assurance requirements and to provide to the insurer necessary medical information related to such care; and (iii) to otherwise adhere to the insurer`s policies and procedures including, but not limited to procedures regarding referrals and obtaining pre-authorization and a treatment plan approved by the insurer. (f) If a new insured whose health care provider is not a member of the insurer`s in-network benefits portion of the provider network enrolls in the managed care product, the insurer shall permit the insured to continue an ongoing course of treatment with the insured`s current health care provider during a transitional period of up to sixty days from the effective date of enrollment, if (1) the insured has a life-threatening disease or condition or a degenerative and disabling disease or condition or (2) the insured has entered the second trimester of pregnancy at the time of enrollment, in which case the transitional period shall include the provision of post-partum care directly related to the delivery. If an insured elects to continue to receive care from such health care provider pursuant to this paragraph, such care shall be authorized by the insurer for the transitional period only if the health care provider agrees (A) to accept reimbursement from the insurer at rates established by the insurer as payment in full, which rates shall be no more than the level of reimbursement applicable to similar providers within the in-network benefits portion of the insurer`s network for such services; (B) to adhere to the insurer`s quality assurance requirements and agrees to provide to the insurer necessary medical information related to such care; and (C) to otherwise adhere to the insurer`s policies and procedures including, but not limited to procedures regarding referrals and obtaining pre-authorization and a treatment plan approved by the insurer. In no event shall this subsection be construed to require an insurer to provide coverage for benefits not otherwise covered or to diminish or impair pre-existing condition limitations contained within the insured`s contract. S 4805. Access to end of life care. (a) Every contract issued by an insurer that provides coverage for hospital, surgical or medical care that includes coverage for acute care services shall provide coverage for an insured diagnosed with advanced cancer (with no hope of reversal of primary disease and fewer than sixty days to live, as certified by the patient`s attending health care practitioner) for acute care services at an acute care facility licensed pursuant to article twenty-eight of the public health law specializing in the treatment of terminally ill patients if the patient`s attending health care practitioner, in consultation with the medical director of the facility determines that the insured`s care would appropriately be provided by such a facility. (b) Notwithstanding the provisions of article forty-nine of this chapter, if the insurer disagrees with the admission of or provision or continuation of care for the insured by the facility, the insurer shall initiate an expedited external appeal in accordance with the provisions of paragraph three of subsection (b) of section four thousand nine hundred fourteen of this chapter, provided further, that until such decision is rendered, the admission of or provision or continuation of the care by the facility shall not be denied by the insurer and the insurer shall provide coverage and reimburse the facility for services provided subject to the provisions of this section and other limitations otherwise applicable under the insured`s contract. The decision of the external appeal agent shall be binding on all parties. If the insurer does not initiate an expedited external appeal the insurer shall reimburse the facility for services provided subject to the provisions of this section and other limitations otherwise applicable under the insured`s contract. (c) An insurer shall provide reimbursement for those services prescribed by this section at rates negotiated between the insurer and the facility. In the absence of agreed upon rates, an insurer shall pay for acute care at the facility`s acute care rate under the Medicare program (Title XVIII of the federal Social Security Act), including the Part A rate for Part A services and the Part B rate for Part B services, and shall pay for alternate level care days at seventy-five percent of the acute care rate, including the Part A rate for Part A services and the Part B rate for Part B services. (d) Payment by an insurer pursuant to this section shall be payment in full for the services provided to the insured. An acute care facility reimbursed pursuant to this section shall not charge or seek any reimbursement from, or have any recourse against an insured for the services provided by the acute care facility pursuant to this section, except for the collection of copayments, coinsurance or visit fees, or deductibles for which the insured is responsible under the terms of the applicable contract. (e) No provision of this section shall be construed to require an insurer to provide coverage for benefits not otherwise covered under the insured`s contract.
