NY Ins L § 3241 (2021)
2021 New York Laws ISC - Insurance Article 32 - Insurance Contracts - Life, Accident and Health, Annuities 3241 - Network Coverage.

§  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.