Bill Text: NY S05895 | 2013-2014 | General Assembly | Introduced
Bill Title: Requires health plans providing coverage for out-of-network care to provide certain information to insureds, subscribers and enrollees.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2014-01-08 - REFERRED TO INSURANCE [S05895 Detail]
Download: New_York-2013-S05895-Introduced.html
S T A T E O F N E W Y O R K ________________________________________________________________________ 5895 2013-2014 Regular Sessions I N S E N A T E June 19, 2013 ___________ Introduced by Sen. RIVERA -- read twice and ordered printed, and when printed to be committed to the Committee on Rules AN ACT to amend the insurance law and the public health law, in relation to requiring a health care plan which provides coverage of out of network care to provide certain information to insureds, subscribers or enrollees THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: 1 Section 1. Subsection (a) of section 3217-a of the insurance law is 2 amended by adding a new paragraph 18 to read as follows: 3 (18) WHERE APPLICABLE, IF THE POLICY OFFERS OUT-OF-NETWORK COVERAGE 4 APPROVED BY THE SUPERINTENDENT PURSUANT TO SECTION THIRTY-TWO HUNDRED 5 FORTY OF THIS ARTICLE, A DESCRIPTION OF ITS METHODOLOGY FOR REIMBURSING 6 OUT-OF-NETWORK HEALTH CARE SERVICES WHICH SHALL BE SET FORTH AS THE 7 PERCENTAGE OF THE USUAL AND CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH 8 CARE SERVICES THE POLICY WILL COVER. INCLUDED WITHIN THIS DESCRIPTION 9 SHALL BE EXAMPLES OF ANTICIPATED OUT OF PACKET COSTS FOR FREQUENTLY 10 BILLED OUT-OF-NETWORK HEALTH CARE SERVICES PROVIDED BY VARIOUS HEALTH 11 CARE PROVIDER SPECIALISTS. FOR THE PURPOSES OF THIS PARAGRAPH "USUAL AND 12 CUSTOMARY COSTS OF OUT-OF NETWORK HEALTH CARE SERVICES" SHALL MEAN THE 13 EIGHTIETH PERCENTILE OF THE ACTUAL CHARGES FOR A HEALTH CARE SERVICE 14 PERFORMED BY AN OUT-OF-NETWORK HEALTH CARE PROVIDER IN THE SAME OR SIMI- 15 LAR SPECIALITY, AND PROVIDED IN THE SAME ZIP CODE OR IN THE SAME 16 GEOGRAPHICAL AREA DEFINED BY LOCALITIES WITH THE SAME FIRST THREE ZIP 17 CODE DIGITS, AS REPORTED IN A BENCHMARKING DATABASE MAINTAINED BY A 18 NONPROFIT ORGANIZATION WITHOUT AFFILIATION WITH AN INSURER LICENSED TO 19 WRITE ACCIDENT AND HEALTH INSURANCE, A CORPORATION ORGANIZED PURSUANT TO 20 ARTICLE FORTY-THREE OF THIS CHAPTER, A HEALTH MAINTENANCE ORGANIZATION 21 CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW, 22 CREATED AS A RESULT OF SETTLEMENTS ENTERED INTO DURING THE YEAR TWO EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD01205-01-3 S. 5895 2 1 THOUSAND NINE BETWEEN THE DEPARTMENT OF LAW AND INDIVIDUAL HEALTH INSUR- 2 ANCE ORGANIZATIONS. 3 S 2. The insurance law is amended by adding a new section 3240 to read 4 as follows: 5 S 3240. OUT-OF-NETWORK HEALTH CARE SERVICES. (A) A HEALTH PLAN WHICH 6 PROVIDES COVERAGE FOR OUT-OF-NETWORK HEALTH CARE SERVICES SHALL PROVIDE 7 TO THEIR INSUREDS, SUBSCRIBERS OR ENROLLEES A DESCRIPTION OF ITS METHOD- 8 OLOGY FOR REIMBURSING OUT-OF-NETWORK HEALTH CARE SERVICES WHICH SHALL BE 9 SET FORTH AS A PERCENTAGE OF THE USUAL AND CUSTOMARY COSTS OF 10 OUT-OF-NETWORK HEALTH CARE SERVICES THE CONTRACT OR POLICY WILL COVER. 11 THE HEALTH PLAN SHALL INCLUDE WITHIN THIS DESCRIPTION EXAMPLES OF ANTIC- 12 IPATED OUT OF POCKET COSTS FOR FREQUENTLY BILLED OUT-OF-NETWORK HEALTH 13 CARE SERVICES PROVIDED BY VARIOUS HEALTH CARE PROVIDER SPECIALISTS. UPON 14 REQUEST OF AN INSURED, SUBSCRIBER OR ENROLLEE, THE HEALTH PLAN SHALL 15 PROVIDE INFORMATION TO THE INSURED, SUBSCRIBER OR ENROLLEE IN WRITING OR 16 THROUGH AN INTERNET WEBSITE THAT REASONABLY PERMITS THE INSURED, 17 SUBSCRIBER OR ENROLLEE TO DETERMINE THE ANTICIPATED OUT OF PACKET COSTS 18 FOR A SPECIFIC OUT-OF-NETWORK HEALTH CARE SERVICE BASED UPON THE DIFFER- 19 ENCE BETWEEN THE ORGANIZATION'S METHODOLOGY FOR REIMBURSING OUT-OF-NET- 20 WORK HEALTH CARE SERVICES AND THE USUAL AND CUSTOMARY COSTS OF 21 OUT-OF-NETWORK HEALTH CARE SERVICES. THE SUPERINTENDENT SHALL NOT 22 APPROVE A POLICY ISSUED BY A HEALTH PLAN THAT PROVIDES COVERAGE FOR 23 OUT-OF-NETWORK HEALTH CARE SERVICES UNLESS THE HEALTH PLAN DEMONSTRATES 24 THAT THE POLICY WILL PROVIDE SIGNIFICANT COVERAGE OF THE USUAL AND 25 CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH CARE SERVICES. 26 (B) FOR THE PURPOSES OF THIS SECTION, THE TERM: 27 (1) "HEALTH PLAN" SHALL MEAN AN INSURER LICENSED TO WRITE ACCIDENT AND 28 HEALTH INSURANCE, A CORPORATION ORGANIZED PURSUANT TO ARTICLE 29 FORTY-THREE OF THIS CHAPTER, A HEALTH MAINTENANCE ORGANIZATION CERTIFIED 30 PURSUANT TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW OR A MUNICIPAL 31 COOPERATIVE HEALTH BENEFIT PLAN PURSUANT TO ARTICLE FORTY-SEVEN OF THIS 32 CHAPTER; AND 33 (2) "USUAL AND CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH CARE SERVICES" 34 SHALL MEAN THE EIGHTIETH PERCENTILE OF THE ACTUAL CHARGES FOR A HEALTH 35 CARE SERVICE PERFORMED BY AN OUT-OF-NETWORK HEALTH CARE PROVIDER IN THE 36 SAME OR SIMILAR SPECIALTY, AND PROVIDED IN THE SAME ZIP CODE OR WITHIN 37 THE SAME GEOGRAPHICAL AREA DEFINED BY LOCALITIES WITH THE SAME FIRST 38 THREE ZIP CODE DIGITS, AS REPORTED IN A BENCHMARKING DATABASE MAINTAINED 39 BY A NONPROFIT ORGANIZATION WITHOUT AFFILIATION WITH A HEALTH PLAN, 40 CREATED AS A RESULT OF SETTLEMENTS ENTERED INTO DURING THE YEAR TWO 41 THOUSAND NINE BETWEEN THE DEPARTMENT OF LAW AND INDIVIDUAL HEALTH INSUR- 42 ANCE ORGANIZATIONS. 43 S 3. Subsection (a) of section 4324 of the insurance law is amended by 44 adding a new paragraph 19 to read as follows: 45 (19) WHERE APPLICABLE, IF THE CONTRACT INCLUDES OUT OF NETWORK COVER- 46 AGE APPROVED BY THE SUPERINTENDENT PURSUANT TO SECTION THIRTY-TWO 47 HUNDRED FORTY OF THIS CHAPTER, A DESCRIPTION OF THE METHODOLOGY FOR 48 REIMBURSING OUT-OF-NETWORK HEALTH CARE SERVICES WHICH SHALL BE SET FORTH 49 AS THE PERCENTAGE OF THE USUAL AND CUSTOMARY COSTS OF OUT-OF-NETWORK 50 HEALTH CARE SERVICES THE CONTRACT WILL COVER. INCLUDED WITHIN THIS 51 DESCRIPTION SHALL BE EXAMPLES OF ANTICIPATED OUT OF POCKET COSTS FOR 52 FREQUENTLY BILLED OUT-OF-NETWORK HEALTH CARE SERVICES PROVIDED BY VARI- 53 OUS HEALTH CARE PROVIDER SPECIALISTS. FOR THE PURPOSES OF THIS PARAGRAPH 54 "USUAL AND CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH CARE SERVICES" SHALL 55 MEAN THE EIGHTIETH PERCENTILE OF THE ACTUAL CHARGES FOR A HEALTH CARE 56 SERVICE PERFORMED BY AN OUT-OF-NETWORK HEALTH CARE PROVIDER IN THE SAME S. 5895 3 1 OR SIMILAR SPECIALTY, AND PROVIDED IN THE SAME ZIP CODE OR WITHIN THE 2 SAME GEOGRAPHICAL AREA DEFINED BY LOCALITIES WITH THE SAME FIRST THREE 3 ZIP CODE DIGITS, AS REPORTED IN A BENCHMARKING DATABASE MAINTAINED BY A 4 NONPROFIT ORGANIZATION WITHOUT AFFILIATION WITH AN INSURER LICENSED TO 5 WRITE ACCIDENT AND HEALTH INSURANCE, A CORPORATION ORGANIZED PURSUANT TO 6 THIS ARTICLE, OR A HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO 7 ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW, CREATED AS A RESULT OF 8 SETTLEMENTS ENTERED INTO DURING THE YEAR TWO THOUSAND NINE BETWEEN THE 9 DEPARTMENT OF LAW AND INDIVIDUAL HEALTH INSURANCE ORGANIZATIONS. 10 S 4. Subdivision 1 of section 4408 of the public health law is amended 11 by adding a new paragraph (s) to read as follows: 12 (S) WHERE APPLICABLE, IF THE CONTRACT INCLUDES OUT OF NETWORK COVERAGE 13 APPROVED BY THE SUPERINTENDENT PURSUANT TO SECTION THIRTY-TWO HUNDRED 14 FORTY OF THE INSURANCE LAW, A DESCRIPTION OF THE METHODOLOGY FOR REIM- 15 BURSING OUT-OF-PLAN HEALTH CARE SERVICES WHICH SHALL BE SET FORTH AS THE 16 PERCENTAGE OF THE USUAL AND CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH 17 CARE SERVICES THE CONTRACT WILL COVER. INCLUDED WITHIN THIS DESCRIPTION 18 SHALL BE EXAMPLES OF ANTICIPATED OUT OF POCKET COSTS FOR FREQUENTLY 19 BILLED OUT-OF-PLAN HEALTH CARE SERVICES PROVIDED BY VARIOUS HEALTH CARE 20 PROVIDER SPECIALISTS. FOR THE PURPOSES OF THIS PARAGRAPH, "USUAL AND 21 CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH CARE SERVICES" SHALL MEAN THE 22 EIGHTIETH PERCENTILE OF THE ACTUAL CHARGES FOR A HEALTH CARE SERVICE 23 PERFORMED BY AN OUT-OF-PLAN HEALTH CARE PROVIDER IN THE SAME OR SIMILAR 24 SPECIALTY, AND PROVIDED IN THE SAME ZIP CODE OR WITHIN THE SAME 25 GEOGRAPHICAL AREA DEFINED BY LOCALITIES WITH THE SAME FIRST THREE ZIP 26 CODE DIGITS, AS REPORTED IN THE BENCHMARKING DATABASE MAINTAINED BY A 27 NONPROFIT ORGANIZATION WITHOUT AFFILIATION WITH AN ORGANIZATION CERTI- 28 FIED UNDER THIS ARTICLE OR AN INSURER OR CORPORATION LICENSED UNDER THE 29 INSURANCE LAW, CREATED AS A RESULT OF SETTLEMENTS ENTERED INTO DURING 30 THE YEAR TWO THOUSAND NINE BETWEEN THE DEPARTMENT OF LAW AND INDIVIDUAL 31 HEALTH INSURANCE ORGANIZATIONS. 32 S 5. This act shall take effect on the sixtieth day after it shall 33 have become a law and shall apply to all policies and contracts issued, 34 renewed, modified, altered or amended on or after such date.