2023 New York Laws › ISC - Insurance › Article 32 - Insurance Contracts - Life, Accident and Health, Annuities › 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.
(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.