What's happening
This bill allows New York health insurers to offer out-of-network coverage outside the state health benefit exchange, regardless of exchange offerings.
Why it matters
Expands consumer choice. by allowing health insurers, health maintenance organizations (HMOs), and not-for-profit health corporations to offer out-of-network coverage directly to individuals and groups outside the official state health benefit exchange, even if such plans are not available on the exchange.
Potentially increases access to providers. for people who want or need coverage for health care providers not included in standard, exchange-based insurance networks—such as those with established patient-provider relationships or those needing specialized care.
Could impact insurance market competition and pricing. by enabling insurers to design and price plans outside the standardized framework of the exchange, potentially leading to greater plan variety but also possibly less regulatory oversight and consumer protections.
May affect risk pools and premiums. within the exchange if healthier or higher-income individuals opt for out-of-network coverage outside the exchange, potentially leaving sicker or lower-income individuals in exchange plans and influencing overall plan costs.
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Who cares
Health insurers and HMOs
The bill would allow them to offer out-of-network coverage outside the health benefit exchange without offering that coverage within the exchange, notwithstanding contrary rules or regulations.
Consumers buying coverage outside the exchange
They could have access to out-of-network coverage if insurers choose to offer it, even when that coverage is unavailable through the exchange.
Out-of-network health care providers
Their patients could gain coverage for out-of-network care through plans offered outside the exchange.
Headline styles
Allow Out-of-Network Coverage
Plain English, a few words. Used as the page title.
Sponsors
No co-sponsors yet.
History
- Referred to health
- Referred to health
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
2244
2017-2018 Regular Sessions
IN SENATE
January 12, 2017
Introduced by Sen. HANNON -- read twice and ordered printed, and when printed to be committed to the Committee on Health
AN ACT to amend the public health law and the insurance law, in relation to allowing health care insurers to offer out-of-network coverage
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Section 4403 of the public health law is amended by adding a new subdivision 9 to read as follows:
9. Notwithstanding any rule or regulation to the contrary, every health maintenance organization may offer, pursuant to other provisions of law, out-of-network coverage outside of the health benefit exchange regardless of whether such coverage is made available within the health benefit exchange.
§ 2. Section 3217-e of the insurance law, as added by chapter 219 of the laws of 2011, is amended to read as follows:
§ 3217-e. Choice of health care provider. (a) An insurer that is subject to this article and requires or provides for designation by an insured of a participating primary care provider shall permit the insured to designate any participating primary care provider who is available to accept such individual, and in the case of a child, shall permit the insured to designate a physician (allopathic or osteopathic) who specializes in pediatrics as the child's primary care provider if such provider participates in the network of the insurer.
(b) Notwithstanding any rule or regulation to the contrary, every insurer that offers health insurance and is subject to the provisions of this article, may offer, pursuant to other provisions of law, out-ofnetwork coverage outside of the health benefit exchange regardless of whether such coverage is made available within the health benefit exchange.
§ 3. Section 4306-d of the insurance law, as added by chapter 219 of the laws of 2011, is amended to read as follows:
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD02911-01-7
S. 2244 2
§ 4306-d. Choice of health care provider. (a) A corporation that is subject to the provisions of this article and requires or provides for designation by a subscriber of a participating primary care provider shall permit the subscriber to designate any participating primary care provider who is available to accept such individual, and in the case of a child, shall permit the subscriber to designate a physician (allopathic or osteopathic) who specializes in pediatrics as the child's primary care provider if such provider participates in the network of the corporation.
(b) Notwithstanding any rule or regulation to the contrary, every corporation that is subject to the provisions of this article, may offer, pursuant to other provisions of law, out-of-network coverage outside of the health benefit exchange regardless of whether such coverage is made available within the health benefit exchange.
§ 4. This act shall take effect immediately, and shall apply to contracts and policies issued, renewed, modified or amended on or after such date.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
Title of bill
An act to amend the public health law and the insurance law, in relation to allowing health care insurers to offer out-of-network coverage
Purpose
Ensures consumer choice by providing for continued access to out-of-network insurance coverage.
Summary of provisions
This bill amends Public Health Law § 4403 and Insurance Law §§ 3217-e and 4306-d to require that every insurer offer, both inside and outside of the exchange, out-of-network coverage in at least one policy option and as an optional rider.
Read the full memo (607 words)
It provides an effective date of January 1st next succeeding the date of enactment.
Justification
Across the state, individuals accessing insurance through the statewide health benefit exchange, "the New York State of Health," and outside of the exchange are finding plans no longer include out-of-network coverage. Citing concerns of keeping plan costs affordable and predictable, the New York State of Health did not require plans sold on the exchange offer out-of-network coverage. Rather, in establishing the New York State of Health, the only condition regulators imposed on insurers regarding out-of-network coverage was the requirement that if they offer out-of-network coverage to individuals purchasing insurance directly, they must also offer it through the exchange. While the Department of Health had indicated that the 2015 exchange invitation would include a requirement for out-of-network benefits, the final invitation did not include such requirement. Instead the 2015 invitation continued the requirement that if the applicant offered an out-of-network product outside of the exchange, it must also offer such within the exchange at platinum and silver levels. Further, the invitation encouraged insurers to offer such products within the exchange if they do not offer such outside of the exchange.
As insurance carriers put into effect cost saving measures, coverage the Affordable Care Act does not mandate, such as out-of-network coverage, is being eliminated. Insurers across the state faced concerns that competitors would not offer out-of-network coverage, leaving them to attract the sickest, most costly patients if they did offer this coverage. The result has been most insurers chose to eliminate the out-of-network option in all their plans marketed to individuals. This coverage remains an option in a handful of counties in the state.
This situation is compounded by recent reports that the plans being offered on the exchange have very limited networks. The Wall Street Journal reported results of a McKinsey report which looked at federal and state-run exchanges in 20 cities, finding that 60% of health plans offered coverage at fewer hospitals compared to current individual plans. Narrow networks restrict access and further illustrate the need for an out-of-network coverage option.
While the 2014-15 Budget did include monumental changes protecting consumers from surprise medical bills resulting from out-of-network care, those provisions did not address access to out of network coverage in the individual market. While policies containing out-of-network coverage will likely cost more than those that do not provide this coverage, for individuals facing certain illnesses or having specific health care needs, this is affordable and necessary option that must be made available. Additionally, for individuals who previously sought care by a particular provider no longer included within their network, this added option may be well worth the extra expense. By requiring insurers to provide out-of-network coverage as an option, this legislation will provide and protect consumer choice, and ensure patients can maintain access to the provider of their choice.
Legislative history
2015-2016: S.1847 - Passed Senate, died in Assembly (both years) 2014: S.6207
Fiscal implications
None.
Effective date
Immediately, provided it shall apply to contracts and policies issued, renewed, modified or amended on or after such date.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.