S T A T E O F N E W Y O R K
________________________________________________________________________
7489--B
2011-2012 Regular Sessions
I N A S S E M B L Y
May 6, 2011
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Introduced by M. of A. GOTTFRIED, P. RIVERA, SCHIMEL, WEPRIN -- read
once and referred to the Committee on Health -- passed by Assembly and
delivered to the Senate, recalled from the Senate, vote reconsidered,
bill amended, ordered reprinted, retaining its place on the order of
third reading -- recommitted to the Committee on Health in accordance
with Assembly Rule 3, sec. 2 -- committee discharged, bill amended,
ordered reprinted as amended and recommitted to said committee
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:
Section 1. Subsection (a) of section 3217-a of the insurance law is
amended by adding a new paragraph 18 to read as follows:
(18) WHERE APPLICABLE, IF THE POLICY OFFERS OUT-OF-NETWORK COVERAGE
APPROVED BY THE SUPERINTENDENT PURSUANT TO SECTION THIRTY-TWO HUNDRED
FORTY OF THIS ARTICLE, A DESCRIPTION OF ITS METHODOLOGY FOR REIMBURSING
OUT-OF-NETWORK HEALTH CARE SERVICES WHICH SHALL BE SET FORTH AS THE
PERCENTAGE OF THE USUAL AND CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH
CARE SERVICES THE POLICY WILL COVER. INCLUDED WITHIN THIS DESCRIPTION
SHALL BE EXAMPLES OF ANTICIPATED OUT OF PACKET COSTS FOR FREQUENTLY
BILLED OUT-OF-NETWORK HEALTH CARE SERVICES PROVIDED BY VARIOUS HEALTH
CARE PROVIDER SPECIALISTS. FOR THE PURPOSES OF THIS PARAGRAPH "USUAL AND
CUSTOMARY COSTS OF OUT-OF NETWORK HEALTH CARE SERVICES" SHALL MEAN THE
EIGHTIETH PERCENTILE OF THE ACTUAL CHARGES FOR A HEALTH CARE SERVICE
PERFORMED BY AN OUT-OF-NETWORK HEALTH CARE PROVIDER IN THE SAME OR SIMI-
LAR SPECIALITY, AND PROVIDED IN THE SAME ZIP CODE OR IN THE SAME
GEOGRAPHICAL AREA DEFINED BY LOCALITIES WITH THE SAME FIRST THREE ZIP
CODE DIGITS, AS REPORTED IN A BENCHMARKING DATABASE MAINTAINED BY A
NONPROFIT ORGANIZATION WITHOUT AFFILIATION WITH AN INSURER LICENSED TO
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD10981-04-2
A. 7489--B 2
WRITE ACCIDENT AND HEALTH INSURANCE, A CORPORATION ORGANIZED PURSUANT TO
ARTICLE FORTY-THREE OF THIS CHAPTER, A HEALTH MAINTENANCE ORGANIZATION
CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW,
CREATED AS A RESULT OF SETTLEMENTS ENTERED INTO DURING THE YEAR TWO
THOUSAND NINE BETWEEN THE DEPARTMENT OF LAW AND INDIVIDUAL HEALTH INSUR-
ANCE ORGANIZATIONS.
S 2. The insurance law is amended by adding a new section 3240 to read
as follows:
S 3240. OUT-OF-NETWORK HEALTH CARE SERVICES. (A) A HEALTH PLAN WHICH
PROVIDES COVERAGE FOR OUT-OF-NETWORK HEALTH CARE SERVICES SHALL PROVIDE
TO THEIR INSUREDS, SUBSCRIBERS OR ENROLLEES A DESCRIPTION OF ITS METHOD-
OLOGY FOR REIMBURSING OUT-OF-NETWORK HEALTH CARE SERVICES WHICH SHALL BE
SET FORTH AS A PERCENTAGE OF THE USUAL AND CUSTOMARY COSTS OF
OUT-OF-NETWORK HEALTH CARE SERVICES THE CONTRACT OR POLICY WILL COVER.
THE HEALTH PLAN SHALL INCLUDE WITHIN THIS DESCRIPTION EXAMPLES OF ANTIC-
IPATED OUT OF POCKET COSTS FOR FREQUENTLY BILLED OUT-OF-NETWORK HEALTH
CARE SERVICES PROVIDED BY VARIOUS HEALTH CARE PROVIDER SPECIALISTS. UPON
REQUEST OF AN INSURED, SUBSCRIBER OR ENROLLEE, THE HEALTH PLAN SHALL
PROVIDE INFORMATION TO THE INSURED, SUBSCRIBER OR ENROLLEE IN WRITING OR
THROUGH AN INTERNET WEBSITE THAT REASONABLY PERMITS THE INSURED,
SUBSCRIBER OR ENROLLEE TO DETERMINE THE ANTICIPATED OUT OF PACKET COSTS
FOR A SPECIFIC OUT-OF-NETWORK HEALTH CARE SERVICE BASED UPON THE DIFFER-
ENCE BETWEEN THE ORGANIZATION'S METHODOLOGY FOR REIMBURSING OUT-OF-NET-
WORK HEALTH CARE SERVICES AND THE USUAL AND CUSTOMARY COSTS OF
OUT-OF-NETWORK HEALTH CARE SERVICES. THE SUPERINTENDENT SHALL NOT
APPROVE A POLICY ISSUED BY A HEALTH PLAN THAT PROVIDES COVERAGE FOR
OUT-OF-NETWORK HEALTH CARE SERVICES UNLESS THE HEALTH PLAN DEMONSTRATES
THAT THE POLICY WILL PROVIDE SIGNIFICANT COVERAGE OF THE USUAL AND
CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH CARE SERVICES.
(B) FOR THE PURPOSES OF THIS SECTION, THE TERM:
(1) "HEALTH PLAN" SHALL MEAN AN INSURER LICENSED TO WRITE ACCIDENT AND
HEALTH INSURANCE, A CORPORATION ORGANIZED PURSUANT TO ARTICLE
FORTY-THREE OF THIS CHAPTER, A HEALTH MAINTENANCE ORGANIZATION CERTIFIED
PURSUANT TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW OR A MUNICIPAL
COOPERATIVE HEALTH BENEFIT PLAN PURSUANT TO ARTICLE FORTY-SEVEN OF THIS
CHAPTER; AND
(2) "USUAL AND CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH CARE SERVICES"
SHALL MEAN THE EIGHTIETH PERCENTILE OF THE ACTUAL CHARGES FOR A HEALTH
CARE SERVICE PERFORMED BY AN OUT-OF-NETWORK HEALTH CARE PROVIDER IN THE
SAME OR SIMILAR SPECIALTY, AND PROVIDED IN THE SAME ZIP CODE OR WITHIN
THE SAME GEOGRAPHICAL AREA DEFINED BY LOCALITIES WITH THE SAME FIRST
THREE ZIP CODE DIGITS, AS REPORTED IN A BENCHMARKING DATABASE MAINTAINED
BY A NONPROFIT ORGANIZATION WITHOUT AFFILIATION WITH A HEALTH PLAN,
CREATED AS A RESULT OF SETTLEMENTS ENTERED INTO DURING THE YEAR TWO
THOUSAND NINE BETWEEN THE DEPARTMENT OF LAW AND INDIVIDUAL HEALTH INSUR-
ANCE ORGANIZATIONS.
S 3. Subsection (a) of section 4324 of the insurance law is amended by
adding a new paragraph 19 to read as follows:
(19) WHERE APPLICABLE, IF THE CONTRACT INCLUDES OUT OF NETWORK COVER-
AGE APPROVED BY THE SUPERINTENDENT PURSUANT TO SECTION THIRTY-TWO
HUNDRED FORTY OF THIS CHAPTER, A DESCRIPTION OF THE METHODOLOGY FOR
REIMBURSING OUT-OF-NETWORK HEALTH CARE SERVICES WHICH SHALL BE SET FORTH
AS THE PERCENTAGE OF THE USUAL AND CUSTOMARY COSTS OF OUT-OF-NETWORK
HEALTH CARE SERVICES THE CONTRACT WILL COVER. INCLUDED WITHIN THIS
DESCRIPTION SHALL BE EXAMPLES OF ANTICIPATED OUT OF POCKET COSTS FOR
FREQUENTLY BILLED OUT-OF-NETWORK HEALTH CARE SERVICES PROVIDED BY VARI-
A. 7489--B 3
OUS HEALTH CARE PROVIDER SPECIALISTS. FOR THE PURPOSES OF THIS PARAGRAPH
"USUAL AND CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH CARE SERVICES" SHALL
MEAN THE EIGHTIETH PERCENTILE OF THE ACTUAL CHARGES FOR A HEALTH CARE
SERVICE PERFORMED BY AN OUT-OF-NETWORK HEALTH CARE PROVIDER IN THE SAME
OR SIMILAR SPECIALTY, AND PROVIDED IN THE SAME ZIP CODE OR WITHIN THE
SAME GEOGRAPHICAL AREA DEFINED BY LOCALITIES WITH THE SAME FIRST THREE
ZIP CODE DIGITS, AS REPORTED IN A BENCHMARKING DATABASE MAINTAINED BY A
NONPROFIT ORGANIZATION WITHOUT AFFILIATION WITH AN INSURER LICENSED TO
WRITE ACCIDENT AND HEALTH INSURANCE, A CORPORATION ORGANIZED PURSUANT TO
THIS ARTICLE, OR A HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO
ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW, CREATED AS A RESULT OF
SETTLEMENTS ENTERED INTO DURING THE YEAR TWO THOUSAND NINE BETWEEN THE
DEPARTMENT OF LAW AND INDIVIDUAL HEALTH INSURANCE ORGANIZATIONS.
S 4. Subdivision 1 of section 4408 of the public health law is amended
by adding a new paragraph (s) to read as follows:
(S) WHERE APPLICABLE, IF THE CONTRACT INCLUDES OUT OF NETWORK COVERAGE
APPROVED BY THE SUPERINTENDENT PURSUANT TO SECTION THIRTY-TWO HUNDRED
FORTY OF THE INSURANCE LAW, A DESCRIPTION OF THE METHODOLOGY FOR REIM-
BURSING OUT-OF-PLAN HEALTH CARE SERVICES WHICH SHALL BE SET FORTH AS THE
PERCENTAGE OF THE USUAL AND CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH
CARE SERVICES THE CONTRACT WILL COVER. INCLUDED WITHIN THIS DESCRIPTION
SHALL BE EXAMPLES OF ANTICIPATED OUT OF POCKET COSTS FOR FREQUENTLY
BILLED OUT-OF-PLAN HEALTH CARE SERVICES PROVIDED BY VARIOUS HEALTH CARE
PROVIDER SPECIALISTS. FOR THE PURPOSES OF THIS PARAGRAPH, "USUAL AND
CUSTOMARY COSTS OF OUT-OF-NETWORK HEALTH CARE SERVICES" SHALL MEAN THE
EIGHTIETH PERCENTILE OF THE ACTUAL CHARGES FOR A HEALTH CARE SERVICE
PERFORMED BY AN OUT-OF-PLAN HEALTH CARE PROVIDER IN THE SAME OR SIMILAR
SPECIALTY, AND PROVIDED IN THE SAME ZIP CODE OR WITHIN THE SAME
GEOGRAPHICAL AREA DEFINED BY LOCALITIES WITH THE SAME FIRST THREE ZIP
CODE DIGITS, AS REPORTED IN THE BENCHMARKING DATABASE MAINTAINED BY A
NONPROFIT ORGANIZATION WITHOUT AFFILIATION WITH AN ORGANIZATION CERTI-
FIED UNDER THIS ARTICLE OR AN INSURER OR CORPORATION LICENSED UNDER THE
INSURANCE LAW, CREATED AS A RESULT OF SETTLEMENTS ENTERED INTO DURING
THE YEAR TWO THOUSAND NINE BETWEEN THE DEPARTMENT OF LAW AND INDIVIDUAL
HEALTH INSURANCE ORGANIZATIONS.
S 5. This act shall take effect on the sixtieth day after it shall
have become a law and shall apply to all policies and contracts issued,
renewed, modified, altered or amended on or after such date.