Requirements for Disclosure of Information by a Health Maintenance Organization – N.Y. Pub. Health Law § 4408

Upon request, each prospective subscriber to a health maintenance organization must be supplied with all written information that may be incorporated into the member handbook or the subscriber contract.  The information to be disclosed must include at least the information listed under  § 4408.

Additionally, each health maintenance organization must, upon request of an enrollee or prospective enrollee:

• 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;
• 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;
• Provide a copy of the most recent individual, direct pay subscriber contracts;
• Provide information relating to consumer complaints compiled pursuant to section two hundred ten of the insurance law;
• Provide the procedures for protecting the confidentiality of medical records and other enrollee information;
• 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;
• Provide a written description of the organizational arrangements and ongoing procedures of the health maintenance organization's quality assurance program;
• 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;
• Provide individual health practitioner affiliations with participating hospitals, if any;
• Upon written request, provide specific written clinical review criteria relating to a particular condition or disease 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;
• Provide the written application procedures and minimum qualification requirements for health care providers to be considered by the health maintenance organization; and
• Disclose other information as required by the commissioner