S T A T E   O F   N E W   Y O R K
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                                  5216

                       2013-2014 Regular Sessions

                          I N  A S S E M B L Y

                            February 21, 2013
                               ___________

Introduced  by  M.  of  A.  GOTTFRIED,  SCHIMEL, WEPRIN, TITONE, JACOBS,
  PAULIN, COLTON, CLARK, QUART, ABINANTI, ENGLEBRIGHT, GUNTHER,  JAFFEE,
  STEVENSON,  ZEBROWSKI,  MAISEL,  GALEF, ROBERTS, THIELE -- Multi-Spon-
  sored by -- M. of A. ARROYO, HOOPER, LAVINE, LENTOL, LUPARDO, MONTESA-
  NO, RA, RAIA, SKARTADOS, SWEENEY -- read  once  and  referred  to  the
  Committee on Health

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
WRITE ACCIDENT AND HEALTH INSURANCE, A CORPORATION ORGANIZED PURSUANT TO

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01205-01-3
              

A. 5216                             2

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-
OUS HEALTH CARE PROVIDER SPECIALISTS. FOR THE PURPOSES OF THIS PARAGRAPH

A. 5216                             3

"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.