Prohibits requiring health care providers to provide services under a qualified health plan in the health benefit exchange, unless such provider participates in the in-network portion of such plan

1 Co-sponsor

• William J. Larkin Jr.

BILL NUMBER:S4789

Title of bill

An act to amend the public health law and the insurance law, in relation to prohibiting health care plans and health insurers from requiring any health care provider to provide services through the state health benefit exchange, unless the health care provider has agreed to participate in the in-network portion of such plan or insurance

Purpose

To assure New York health insurance companies directly contract with physicians and other necessary health care providers to deliver care to their enrollees in Exchange products sold through the New York State of Health Marketplace.

Summary of provisions

Section one of the bill would amend Public Health Law § 4406-c to require health insurance companies offering coverage through New York's Health Insurance Exchange to execute separate contracts with health care providers to provide coverage to Exchange product enrollees rather than rely upon previously-executed contracts.

Sections two and three make corresponding changes to Insurance Law 3217-b and 4325, respectively.

Section four provides that this act shall take effect immediately.

Justification

New York's Health Insurance Exchange has been a model for the rest of country, enrolling hundreds of thousands of New Yorkers who previously did not have any health insurance coverage. At the same time, there have been many complaints and multiple news reports by patients and physicians regarding inaccurate listings of participating providers on these new Exchange plans. In some cases, patients believed when they enrolled in an Exchange plan that their treating physician was a participant in the plan, only to find out after enrollment that they were not.

The New York State Senate examined this and other issues related to Exchange implementation at a public hearing it held in January. The concern is that these inaccurate network listings cause great confusion to patients who may select an Exchange plan based upon the perceived participation status of a particular physician in that plan or, once enrolled in a plan, cause confusion when attempting to make an appointment based upon a physician's perceived participation status.

The problem in many cases is caused by health insurers relying upon pre-existing contracts that may or may not contain provisions requiring physicians to participate in "all products" offered by that insurer, which may have been executed many years earlier. In other cases, insurers have sent communications to physician offices that fail to clearly specify that physicians are being directed to participate in Exchange products offered by that insurer unless they affirmatively notify the insurer that they have opted out of participation. In other cases, insurers have simply ignored physician requests to not participate in these products, which some have

indicated provide reimbursement that is far below other commercial products offered by that insurer.

To address this problem and provide greater transparency for Exchange plan enrollees and those shopping for coverage, this legislation would require health insurance companies to execute separate contracts with health care providers to participate in their Exchange products, rather than relying upon these other pre-existing contacts and peripheral communications. Health insurers should assure that there network listings are accurate by assuring that physicians, hospitals and other necessary providers have expressly agreed to participate in their Exchange plans. This measure will provide patients with accurate, transparent information so they can be confident in what they are purchasing.

Legislative history

S.7166 of 2014

Fiscal implications

None.

Effective date

Immediately.