What's happening
The bill requires all health insurers in New York to offer out-of-network coverage options both inside and outside the health benefit exchange.
Why it matters
Expands consumer choice by requiring all insurers, including HMOs and corporations, to offer at least one plan with out-of-network coverage options. This means individuals and families can access providers not in their insurer’s network if they are willing to pay more, which is especially important for people with specific provider needs or in areas where networks are limited.
Mandates that out-of-network coverage options be available both through New York’s health benefit exchange and outside of it. This closes a gap where some plans previously available only outside the exchange may not have offered out-of-network benefits, ensuring consistency and broader access for consumers shopping in different marketplaces.
May impact premium costs and plan design, as insurers must introduce new plan options and riders for out-of-network coverage. While this increases flexibility, it could also result in higher costs for consumers who select these plans, and may influence how insurers structure their networks and price offerings overall.
Could improve access to care and continuity for patients with established relationships with out-of-network providers, or for those seeking specialized care not available in-network. This change supports individuals who might otherwise face significant barriers to seeing their preferred or necessary health care professionals.
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Who cares
Headline styles
Require Out-of-Network Coverage
Plain English, a few words. Used as the page title.
Sponsors
1 Co-sponsor
History
- Referred to health
- Referred to health
Companion bill
The same bill in the other chamber. A bill becomes law when one version passes both houses and the governor signs it, so either number can carry it.
Require Out-of-Network Coverage
In Assembly Committee · Insurance · Sponsor Linda Rosenthal
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
3461
2019-2020 Regular Sessions
IN SENATE
February 7, 2019
Introduced by Sen. RIVERA -- 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 requiring health care insurers to offer coverage for health care provided by out-of-network providers
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. Every health maintenance organization shall offer out-of-network coverage as an optional rider to any contract and shall offer at least one contract option that includes out-of-network coverage. These options shall be made available both within the statewide health benefit exchange and outside of 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) Every insurer that offers health insurance and is subject to the provisions of this article, shall offer out-of-network coverage as an optional rider to any policy and shall offer at least one policy option that includes out-of-network coverage. These options shall be made available both within the statewide health benefit exchange and outside of the health benefit exchange.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD04689-01-9
S. 3461 2
§ 3. Section 4306-d of the insurance law, as added by chapter 219 of the laws of 2011, is amended to read as follows:
§ 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) Every corporation that is subject to the provisions of this article, shall offer out-of-network coverage as an optional rider to any contract and shall offer at least one contract option that includes out-of-network coverage. These options shall be made available both within the statewide health benefit exchange and outside of the health benefit exchange.
§ 4. This act shall take effect on the first of January next succeeding the date on which it shall have become a law, 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 insur- ance law, in relation to requiring health care insurers to offer cover- age for health care provided by out-of-network providers
Purpose
Ensures consumer choice by providing for continued access to out-of-net- work 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. It provides an effective date of January 1st next succeeding the date of enactment.
Read the full memo (631 words)
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 cover- age. 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 cover- age. The result has been most insurers chose to eliminate the out-ofnet- work 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
2014: S.6207 Hannon/ A8494 Rosenthal 2015-16: S.1846 Hannon/ A3734 Rosenthal 2017-2018: S5675 Hannon/ A7671 Rosenthal L 2019: New Bill
Fiscal implications
None.
Effective date
The first of January next succeeding the date on which it shall become law, and 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.