BILL NUMBER: S3461

SPONSOR: RIVERA
 
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.

 
              

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.