The New York State Senate

§ 3241. Network coverage. (a) An insurer, a corporation organized
pursuant to article forty-three of this chapter, a municipal cooperative
health benefit plan certified pursuant to article forty-seven of this
chapter, or a student health plan established or maintained pursuant to
section one thousand one hundred twenty-four of this chapter, that
issues a health insurance policy or contract with a network of health
care providers shall ensure that the network is adequate to meet the
health needs of insureds and provide an appropriate choice of providers
sufficient to render the services covered under the policy or contract.
The superintendent shall review the network of health care providers for
adequacy at the time of the superintendent's initial approval of a
health insurance policy or contract; at least every three years
thereafter; and upon application for expansion of any service area
associated with the policy or contract in conformance with the standards
set forth in subdivision five of section four thousand four hundred
three of the public health law. To the extent that the network has been
determined by the commissioner of health to meet the standards set forth
in subdivision five of section four thousand four hundred three of the
public health law, such network shall be deemed adequate by the
superintendent.

(b)(1)(A) An insurer, a corporation organized pursuant to article
forty-three of this chapter, a municipal cooperative health benefit plan
certified pursuant to article forty-seven of this chapter, a health
maintenance organization certified pursuant to article forty-four of the
public health law or a student health plan established or maintained
pursuant to section one thousand one hundred twenty-four of this
chapter, that issues a comprehensive group or group remittance health
insurance policy or contract that covers out-of-network health care
services shall make available and, if requested by the policyholder or
contractholder, provide at least one option for coverage for at least
eighty percent of the usual and customary cost of each out-of-network
health care service after imposition of a deductible or any permissible
benefit maximum.

(B) If there is no coverage available pursuant to subparagraph (A) of
this paragraph in a rating region, then the superintendent may require
an insurer, a corporation organized pursuant to article forty-three of
this chapter, a municipal cooperative health benefit plan certified
pursuant to article forty-seven of this chapter, a health maintenance
organization certified pursuant to article forty-four of the public
health law, or a student health plan established or maintained pursuant
to section one thousand one hundred twenty-four of this chapter issuing
a comprehensive group or group remittance health insurance policy or
contract in the rating region, to make available and, if requested by
the policyholder or contractholder, provide at least one option for
coverage of eighty percent of the usual and customary cost of each
out-of-network health care service after imposition of any permissible
deductible or benefit maximum. The superintendent may, after giving
consideration to the public interest, permit an insurer, a corporation,
or a health maintenance organization to satisfy the requirements of this
paragraph on behalf of another insurer, corporation, or health
maintenance organization within the same holding company system, as
defined in article fifteen of this chapter, including a health
maintenance organization operated as a line of business of a health
service corporation organized pursuant to article forty-three of this
chapter. The superintendent may, upon written request, waive the
requirement for coverage of out-of-network health care services to be
made available pursuant to this subparagraph if the superintendent
determines that it would pose an undue hardship upon an insurer, a
corporation organized pursuant to article forty-three of this chapter, a
municipal cooperative health benefit plan certified pursuant to article
forty-seven of this chapter, a health maintenance organization certified
pursuant to article forty-four of the public health law, or a student
health plan established or maintained pursuant to section one thousand
one hundred twenty-four of this chapter.

(2) For the purposes of this subsection, "usual and customary cost"
shall mean the eightieth percentile of all charges for the particular
health care service performed by a provider in the same or similar
specialty and provided in the same geographical area as reported in a
benchmarking database maintained by a nonprofit organization specified
by the superintendent. The nonprofit organization shall not be
affiliated with an insurer, a corporation subject to article forty-three
of this chapter, a municipal cooperative health benefit plan certified
pursuant to article forty-seven of this chapter, a health maintenance
organization certified pursuant to article forty-four of the public
health law or a student health plan established or maintained pursuant
to section one thousand one hundred twenty-four of this chapter.

(3) This subsection shall not apply to emergency care services in
hospital facilities or prehospital emergency medical services as defined
in clause (i) of subparagraph (E) of paragraph twenty-four of subsection
(i) of section three thousand two hundred sixteen of this article, or
clause (i) of subparagraph (E) of paragraph fifteen of subsection (l) of
section three thousand two hundred twenty-one of this chapter, or
subparagraph (A) of paragraph five of subsection (aa) of section four
thousand three hundred three of this chapter.

(4) Nothing in this subsection shall limit the superintendent's
authority pursuant to section three thousand two hundred seventeen of
this article to establish minimum standards for the form, content and
sale of accident and health insurance policies and subscriber contracts,
to require additional coverage options for out-of-network services, or
to provide for standardization and simplification of coverage.

(c) When an insured or enrollee under a contract or policy that
provides coverage for emergency services receives the services from a
health care provider that does not participate in the provider network
of an insurer, a corporation organized pursuant to article forty-three
of this chapter, a municipal cooperative health benefit plan certified
pursuant to article forty-seven of this chapter, a health maintenance
organization certified pursuant to article forty-four of the public
health law, or a student health plan established or maintained pursuant
to section one thousand one hundred twenty-four of this chapter ("health
care plan"), the health care plan shall ensure that the insured or
enrollee shall incur no greater out-of-pocket costs for the emergency
services than the insured or enrollee would have incurred with a health
care provider that participates in the health care plan's provider
network. For the purpose of this section, "emergency services" shall
have the meaning set forth in subparagraph (D) of paragraph nine of
subsection (i) of section three thousand two hundred sixteen of this
article, subparagraph (D) of paragraph four of subsection (k) of section
three thousand two hundred twenty-one of this article, and subparagraph
(D) of paragraph two of subsection (a) of section four thousand three
hundred three of this chapter.