Insurance Circular Letter No. 1 (2024)
January 2, 2024
TO: All Insurers Authorized to Write Accident and Health Insurance in New York State, Article 43 Corporations, Health Maintenance Organizations, Student Health Plans Certified Pursuant to Insurance Law § 1124, Municipal Cooperative Health Benefit Plans, and Prepaid Health Services Plans
RE: NYS Standard Form to Designate a Representative to Assist with Health Insurance Authorizations, Complaints, Grievances, and Appeals
STATUTORY REFERENCES: N.Y. Insurance Law § 4802 and Title I of Article 49; N.Y. Pub. Health Law § 4408-a and Title I of Article 49
The purpose of this circular letter is to advise insurers authorized to write accident and health insurance in New York State, Article 43 corporations, health maintenance organizations, student health plans certified pursuant to Insurance Law § 1124, municipal cooperative health benefit plans, and prepaid health services plans (collectively, “issuers”) that they should accept the standard form for an insured to designate a representative to assist with authorizations, complaints, grievances, and appeals as developed by the Department of Financial Services (“Department”). This form should be accepted when used with comprehensive health insurance, vision insurance, and dental insurance. This includes for Child Health Plus, Essential Plan, and Medicaid managed care coverage.
The Health Care Administrative Simplification Workgroup1 (the “Workgroup”), consisting of a diverse group of health care industry leaders representing consumer groups, health care providers, and issuers, discussed and evaluated mechanisms to reduce health care administrative costs and complexities and protect consumers through standardization, simplification, or technology. One of the topics examined by the Workgroup was the development of a standard form for an insured to designate an authorized representative. The Workgroup issued a written report on October 3, 2021 detailing its recommendations, including the recommendation that a standard form to designate an authorized representative be developed and accepted by all issuers.
During Workgroup discussions, Workgroup members representing consumers stated that patient authorization forms vary considerably among issuers, and that the forms are often difficult to obtain unless the insured logs into a member portal. Workgroup members representing consumers recommended that a standard form be developed for an insured to designate an authorized representative. It was also recommended by Workgroup members representing consumers that issuers be required to accept the standard form. Workgroup members representing issuers expressed support for a standard form. The final Workgroup report recommended that a standard form be developed for an insured to designate an authorized representative and that such form be accepted by all issuers.
After the issuance of the Workgroup report, the Department worked with Workgroup members to develop a standard Designation form that is available on the Department’s website. It is the expectation of the Department that issuers accept the standard form for an insured to designate an authorized representative and issuers are strongly encouraged to make the standard form available on their websites. Insurance Law § 4905(l) and Public Health Law § 4905(12) provide that neither an issuer nor its utilization review agent shall take any action that is intended to discourage an insured from undertaking an appeal or dispute resolution of an adverse determination. The Department considers a refusal to accept the standard form, when fully completed, as an action that would discourage an insured from undertaking an appeal or dispute resolution of an adverse determination. Issuers are not precluded from having their own unique form to designate a representative; however, issuers should not require insureds to complete their unique form to designate a representative when the insured has completed the standard form. Issuers are also not precluded from requiring an additional authorization to be completed when required by state or federal law to release sensitive information, such as information pertaining to mental health, substance use disorder, or HIV/AIDS. In such cases, issuers should make their form for release of sensitive information readily accessible to the insured and the insured’s designee.
The Department of Health indicated that there are no restrictions on the use and acceptance of the standard form with its government programs. Therefore, issuers should accept the standard form when submitted by enrollees in Medicaid managed care, Essential Plan, and Child Health Plus.
It is the expectation of the Department that issuers accept New York State’s standard form for an insured to designate a representative to assist with comprehensive health insurance, dental insurance, and vision insurance authorizations, complaints, grievances, and appeals. The standard form can be found on the Department’s website, and issuers are strongly encouraged to make the standard form available on their websites.
Please direct any questions regarding this circular letter by email to [email protected].
Very truly yours,
Chief, Health Bureau
1 The Administrative Simplification Workgroup was established in Part YY of Chapter 56 of the Laws of 2020, which added Insurance Law § 3224-a(k).