Bill Text: NY S05068 | 2011-2012 | General Assembly | Introduced
Bill Title: Requires health plans providing coverage for out-of-network care to provide certain information to insureds, subscribers and enrollees.
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2012-01-10 - REPORTED AND COMMITTED TO INSURANCE [S05068 Detail]
Download: New_York-2011-S05068-Introduced.html
S T A T E O F N E W Y O R K
________________________________________________________________________
5068
2011-2012 Regular Sessions
I N S E N A T E
May 3, 2011
___________
Introduced by Sen. HANNON -- read twice and ordered printed, and when
printed to be committed to the Committee on Health
AN ACT to amend the public health law and the insurance law, in relation
to prohibiting the approval of a health care plan which does not
provide coverage of out of network care
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Paragraph (a) of subdivision 2 of section 4406 of the
2 public health law, as amended by chapter 504 of the laws of 1995, is
3 amended and two new paragraphs (j) and (k) are added to read as follows:
4 (a) Upon approval of the commissioner, an organization may implement
5 an out-of-plan benefits system that allows enrollees to use providers
6 not participating in the plan pursuant to a contract, employment or
7 other association. The commissioner, in consultation with the super-
8 intendent, shall not approve an organization to implement an out-of-plan
9 benefits system unless the organization demonstrates that:
10 (i) the requirements of this article and any regulations promulgated
11 thereunder have been met and will continue to be met;
12 (ii) it can establish and maintain a contingent reserve fund of not
13 less than two percent of the entire net premium income for the calendar
14 year of the organization in addition to any other contingent reserve
15 fund required by the commissioner in regulations subject to the approval
16 of the superintendent; [and]
17 (iii) it has established mechanisms to ensure and monitor compliance
18 with the provisions of paragraph (b) of this subdivision[.];
19 (IV) THE OUT OF PLAN BENEFITS SYSTEM WILL PROVIDE SIGNIFICANT COVERAGE
20 OF THE USUAL COSTS OF OUT-OF-PLAN HEALTH SERVICES.
21 (J) AN ORGANIZATION OFFERING AN OUT-OF-PLAN BENEFITS SYSTEM PURSUANT
22 TO THIS SUBDIVISION SHALL PROVIDE TO THEIR SUBSCRIBERS AND ENROLLEES A
23 DESCRIPTION OF ITS METHODOLOGY FOR REIMBURSING OUT-OF-PLAN BENEFITS,
24 WHICH SHALL BE EXPRESSED AS A PERCENTAGE OF THE USUAL COST OF
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD10981-01-1
S. 5068 2
1 OUT-OF-PLAN HEALTH CARE SERVICES. SUCH ORGANIZATION SHALL INCLUDE WITHIN
2 THIS DESCRIPTION EXAMPLES OF ANTICIPATED OUT OF POCKET COSTS FOR
3 FREQUENTLY BILLED OUT-OF-PLAN HEALTH CARE SERVICES PROVIDED BY VARIOUS
4 PHYSICIAN SPECIALISTS. UPON REQUEST OF AN ENROLLEE, SUCH ORGANIZATION
5 SHALL PROVIDE INFORMATION TO SUCH ENROLLEE IN WRITING OR THROUGH AN
6 INTERNET WEBSITE THAT REASONABLY PERMITS THE ENROLLEE TO DETERMINE THE
7 ANTICIPATED OUT OF POCKET COSTS FOR A SPECIFIC OUT-OF-PLAN HEALTH CARE
8 SERVICE BASED UPON THE DIFFERENCE BETWEEN THE ORGANIZATION'S METHODOLOGY
9 FOR REIMBURSING OUT-OF-PLAN HEALTH CARE SERVICES AND THE USUAL COST OF
10 OUT-OF-PLAN HEALTH CARE SERVICES.
11 (K) FOR THE PURPOSES OF THIS SUBDIVISION, "USUAL COST OF OUT-OF-PLAN
12 HEALTH CARE SERVICES" SHALL MEAN THE EIGHTIETH PERCENTILE OF THE ACTUAL
13 CHARGES FOR A HEALTH CARE SERVICE PROVIDED IN THE SAME COUNTY AND
14 PERFORMED BY AN OUT-OF-PLAN PHYSICIAN IN THE SAME OR SIMILAR SPECIALTY,
15 AS REPORTED IN A BENCHMARKING DATABASE MAINTAINED BY A NONPROFIT ORGAN-
16 IZATION WITHOUT AFFILIATION WITH AN ORGANIZATION CERTIFIED UNDER THIS
17 ARTICLE OR AN INSURER LICENSED UNDER THE INSURANCE LAW, CREATED AS A
18 RESULT OF SETTLEMENTS ENTERED INTO DURING THE YEAR TWO THOUSAND NINE
19 BETWEEN THE DEPARTMENT OF LAW AND INDIVIDUAL HEALTH INSURANCE ORGANIZA-
20 TIONS.
21 S 2. Section 4322 of the insurance law is amended by adding a new
22 subsection (g-1) to read as follows:
23 (G-1) A HEALTH MAINTENANCE ORGANIZATION ISSUED A CERTIFICATE PURSUANT
24 TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW OR A CORPORATION SUBJECT
25 TO THE PROVISIONS OF THIS ARTICLE OFFERING AN OUT-OF-PLAN BENEFITS
26 SYSTEM PURSUANT TO THIS SECTION SHALL PROVIDE TO AN ENROLLEE OF A
27 CONTRACT A DESCRIPTION OF ITS METHODOLOGY FOR REIMBURSING OUT-OF-PLAN
28 BENEFITS, WHICH SHALL BE EXPRESSED AS A PERCENTAGE OF THE USUAL COST OF
29 OUT-OF-PLAN HEALTH CARE SERVICES. SUCH ORGANIZATION OR CORPORATION SHALL
30 INCLUDE WITHIN THIS DESCRIPTION EXAMPLES OF ANTICIPATED OUT OF POCKET
31 COSTS FOR FREQUENTLY BILLED OUT-OF-PLAN HEALTH CARE SERVICES PROVIDED BY
32 VARIOUS PHYSICIAN SPECIALISTS. UPON REQUEST OF AN ENROLLEE OF SUCH A
33 CONTRACT, SUCH ORGANIZATION OR CORPORATION SHALL PROVIDE INFORMATION TO
34 SUCH PURCHASER IN WRITING OR THROUGH AN INTERNET WEBSITE THAT REASONABLY
35 PERMITS THE ENROLLEE TO DETERMINE THE ANTICIPATED OUT OF POCKET COSTS
36 FOR A SPECIFIC OUT-OF-PLAN HEALTH CARE SERVICE BASED UPON THE DIFFERENCE
37 BETWEEN THE ORGANIZATION'S METHODOLOGY FOR REIMBURSING OUT-OF-PLAN
38 HEALTH CARE SERVICES AND THE USUAL COST OF OUT-OF-PLAN HEALTH CARE
39 SERVICES. FOR THE PURPOSES OF THIS SUBDIVISION, "USUAL COST OF
40 OUT-OF-PLAN HEALTH CARE SERVICES" SHALL MEAN THE EIGHTIETH PERCENTILE OF
41 THE ACTUAL CHARGES FOR A HEALTH CARE SERVICE PROVIDED IN THE SAME COUNTY
42 AND PERFORMED BY AN OUT-OF-PLAN PHYSICIAN IN THE SAME OR SIMILAR
43 SPECIALITY, AS REPORTED IN A BENCHMARKING DATABASE MAINTAINED BY A
44 NONPROFIT ORGANIZATION WITHOUT AFFILIATION WITH AN ORGANIZATION CERTI-
45 FIED UNDER ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW OR CORPORATION
46 LICENSED PURSUANT TO THIS ARTICLE, CREATED AS A RESULT OF SETTLEMENTS
47 ENTERED INTO DURING THE YEAR TWO THOUSAND NINE BETWEEN THE DEPARTMENT OF
48 LAW AND INDIVIDUAL HEALTH INSURANCE ORGANIZATIONS.
49 S 3. This act shall take effect August 1, 2011.
