N.Y. Insurance Law § 3241: Network coverage

§ 3241. Network coverage. * (a) (1) 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 and mental 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. The

superintendent shall determine standards for network adequacy for mental

health and substance use disorder treatment services, including

sub-acute care in a residential facility, assertive community treatment

services, critical time intervention services and mobile crisis

intervention services, in consultation with the commissioner of the

office of mental health and the commissioner of the office of addiction

services and supports. 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.

(2) The superintendent, in consultation with the commissioner of

health, the commissioner of the office of mental health, and the

commissioner of the office of addiction services and supports, shall

propose regulations setting forth standards for network adequacy for

mental health and substance use disorder treatment services, including

sub-acute care in a residential facility, assertive community treatment

services, critical time intervention services and mobile crisis

intervention services, by December thirty-first, two thousand

twenty-three.

* NB Effective until January 1, 2027

* (a) (1) 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, substance-related and

addictive disorder and mental 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. The

superintendent shall determine standards for network adequacy for mental

health and substance-related and addictive disorder treatment services,

including sub-acute care in a residential facility, assertive community

treatment services, critical time intervention services and mobile

crisis intervention services, in consultation with the commissioner of

the office of mental health and the commissioner of the office of

addiction services and supports. 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.

(2) The superintendent, in consultation with the commissioner of

health, the commissioner of the office of mental health, and the

commissioner of the office of addiction services and supports, shall

propose regulations setting forth standards for network adequacy for

mental health and substance-related and addictive disorder treatment

services, including sub-acute care in a residential facility, assertive

community treatment services, critical time intervention services and

mobile crisis intervention services, by December thirty-first, two

thousand twenty-three.

* NB Effective January 1, 2027

(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.