§ 3217-a. Disclosure of information. The requirements of this section\nshall apply to all comprehensive, expense-reimbursed health insurance\ncontracts; managed care health insurance contracts; or any other health\ninsurance contract or product for which the superintendent deems such\ndisclosure appropriate.\n (a) Each insurer subject to this article shall supply each insured,\nand upon request each prospective insured prior to enrollment, written\ndisclosure information, which may be incorporated into the insurance\ncontract or certificate, containing at least the information set forth\nbelow. In the event of any inconsistency between any separate written\ndisclosure statement and the insurance contract or certificate, the\nterms of the insurance contract or certificate shall be controlling. The\ninformation to be disclosed shall include at least the following:\n (1) a description of coverage provisions; health care benefits;\nbenefit maximums, including benefit limitations; and exclusions of\ncoverage, including the definition of medical necessity used in\ndetermining whether benefits will be covered;\n (2) a description of all prior authorization or other requirements for\ntreatments and services;\n (3) a description of utilization review policies and procedures, used\nby the insurer, including:\n (A) the circumstances under which utilization review will be\nundertaken;\n (B) the toll-free telephone number of the utilization review agent;\n (C) the time frames under which utilization review decisions must be\nmade for prospective, retrospective and concurrent decisions;\n (D) the right to reconsideration;\n (E) the right to an appeal, including the expedited and standard\nappeals processes and the time frames for such appeals;\n (F) the right to designate a representative;\n (G) a notice that all denials of claims will be made by qualified\nclinical personnel and that all notices of denials will include\ninformation about the basis of the decision;\n (H) a notice of the right to an external appeal together with a\ndescription, jointly promulgated by the superintendent and the\ncommissioner of health as required pursuant to subsection (e) of section\nfour thousand nine hundred fourteen of this chapter, of the external\nappeal process established pursuant to title two of article forty-nine\nof this chapter and the time frames for such appeals; and\n (I) further appeal rights, if any;\n (4) a description prepared annually of the types of methodologies the\ninsurer uses to reimburse providers specifying the type of methodology\nthat is used to reimburse particular types of providers or reimburse for\nthe provision of particular types of services; provided, however, that\nnothing in this paragraph should be construed to require disclosure of\nindividual contracts or the specific details of any financial\narrangement between an insurer and a health care provider;\n (5) an explanation of an insured's financial responsibility for\npayment of premiums, coinsurance, co-payments, deductibles and any other\ncharges, annual limits on an insured's financial responsibility, caps on\npayments for covered services and financial responsibility for\nnon-covered health care procedures, treatments or services;\n (6) an explanation, where applicable, of an insured's financial\nresponsibility for payment when services are provided by a health care\nprovider who is not part of the insurer's network of providers or by any\nprovider without required authorization, or when a procedure, treatment\nor service is not a covered benefit;\n (7) a description of the grievance procedures to be used to resolve\ndisputes between an insurer and an insured, including: the right to file\na grievance regarding any dispute between an insured and an insurer; the\nright to file a grievance orally when the dispute is about referrals or\ncovered benefits; the toll-free telephone number which insureds may use\nto file an oral grievance; the timeframes
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