BILL NUMBER:  S5675

 TITLE OF BILL :  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

 PURPOSE :

Ensures consumer choice by providing for continued access to
out-of-network 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 coverage. 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 coverage. The result has been most insurers chose to
eliminate the out-of-network 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 :

2015-16: S.1846
2014: S.6207

 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.