§ 3241 — Network coverage

§ 3241. Network coverage. (a) (1) An insurer, a corporation organized\npursuant to article forty-three of this chapter, a municipal cooperative\nhealth benefit plan certified pursuant to article forty-seven of this\nchapter, or a student health plan established or maintained pursuant to\nsection one thousand one hundred twenty-four of this chapter, that\nissues a health insurance policy or contract with a network of health\ncare providers shall ensure that the network is adequate to meet the\nhealth and mental health needs of insureds and provide an appropriate\nchoice of providers sufficient to render the services covered under the\npolicy or contract. The superintendent shall review the network of\nhealth care providers for adequacy at the time of the superintendent's\ninitial approval of a health insurance policy or contract; at least\nevery three years thereafter; and upon application for expansion of any\nservice area associated with the policy or contract in conformance with\nthe standards set forth in subdivision five of section four thousand\nfour hundred three of the public health law. The superintendent shall\ndetermine standards for network adequacy for mental health and substance\nuse disorder treatment services, including sub-acute care in a\nresidential facility, assertive community treatment services, critical\ntime intervention services and mobile crisis intervention services, in\nconsultation with the commissioner of the office of mental health and\nthe commissioner of the office of addiction services and supports. To\nthe extent that the network has been determined by the commissioner of\nhealth to meet the standards set forth in subdivision five of section\nfour thousand four hundred three of the public health law, such network\nshall be deemed adequate by the superintendent.\n (2) The superintendent, in consultation with the commissioner of\nhealth, the commissioner of the office of mental health, and the\ncommissioner of the office of addiction services and supports, shall\npropose regulations setting forth standards for network adequacy for\nmental health and substance use disorder treatment services, including\nsub-acute care in a residential facility, assertive community treatment\nservices, critical time intervention services and mobile crisis\nintervention services, by December thirty-first, two thousand\ntwenty-three.\n (b)(1)(A) An insurer, a corporation organized pursuant to article\nforty-three of this chapter, a municipal cooperative health benefit plan\ncertified pursuant to article forty-seven of this chapter, a health\nmaintenance organization certified pursuant to article forty-four of the\npublic health law or a student health plan established or maintained\npursuant to section one thousand one hundred twenty-four of this\nchapter, that issues a comprehensive group or group remittance health\ninsurance policy or contract that covers out-of-network health care\nservices shall make available and, if requested by the policyholder or\ncontractholder, provide at least one option for coverage for at least\neighty percent of the usual and customary cost of each out-of-network\nhealth care service after imposition of a deductible or any permissible\nbenefit maximum.\n (B) If there is no coverage available pursuant to subparagraph (A) of\nthis paragraph in a rating region, then the superintendent may require\nan insurer, a corporation organized pursuant to article forty-three of\nthis chapter, a municipal cooperative health benefit plan certified\npursuant to article forty-seven of this chapter, a health maintenance\norganization certified pursuant to article forty-four of the public\nhealth law, or a student health plan established or maintained pursuant\nto section one thousand one hundred twenty-four of this chapter issuing\na comprehensive group or group remittance health insurance policy or\ncontract in the rating region, to make available and, if requested by\nthe policyholder or contractholder, provide at least one option for\ncoverage of eighty percent of the usual and customary cost of each\nout-of-network health care service after imposition of any permissible\ndeductible or benefit maximum. The superintendent may, after giving\nconsideration to the public interest, permit an insurer, a corporation,\nor a health maintenance organization to satisfy the requirements of this\nparagraph on behalf of another insurer, corporation, or health\nmaintenance organization within the same holding company system, as\ndefined in article fifteen of this chapter, including a health\nmaintenance organization operated as a line of business of a health\nservice corporation organized pursuant to article forty-three of this\nchapter. The superintendent may, upon written request, waive the\nrequirement for coverage of out-of-network health care services to be\nmade available pursuant to this subparagraph if the superintendent\ndetermines that it would pose an undue hardship upon an insurer, a\ncorporation organized pursuant to article forty-three of this chapter, a\nmunicipal cooperative health benefit plan certified pursuant to article\nforty-seven of this chapter, a health maintenance organization certified\npursuant to article forty-four of the public health law, or a student\nhealth plan established or maintained pursuant to section one thousand\none hundred twenty-four of this chapter.\n (2) For the purposes of this subsection, "usual and customary cost"\nshall mean the eightieth percentile of all charges for the particular\nhealth care service performed by a provider in the same or similar\nspecialty and provided in the same geographical area as reported in a\nbenchmarking database maintained by a nonprofit organization specified\nby the superintendent. The nonprofit organization shall not be\naffiliated with an insurer, a corporation subject to article forty-three\nof this chapter, a municipal cooperative health benefit plan certified\npursuant to article forty-seven of this chapter, a health maintenance\norganization certified pursuant to article forty-four of the public\nhealth law or a student health plan established or maintained pursuant\nto section one thousand one hundred twenty-four of this chapter.\n (3) This subsection shall not apply to emergency care services in\nhospital facilities or prehospital emergency medical services as defined\nin clause (i) of subparagraph (E) of paragraph twenty-four of subsection\n(i) of section three thousand two hundred sixteen of this article, or\nclause (i) of subparagraph (E) of paragraph fifteen of subsection (l) of\nsection three thousand two hundred twenty-one of this chapter, or\nsubparagraph (A) of paragraph five of subsection (aa) of section four\nthousand three hundred three of this chapter.\n (4) Nothing in this subsection shall limit the superintendent's\nauthority pursuant to section three thousand two hundred seventeen of\nthis article to establish minimum standards for the form, content and\nsale of accident and health insurance policies and subscriber contracts,\nto require additional coverage options for out-of-network services, or\nto provide for standardization and simplification of coverage.\n (c) When an insured or enrollee under a contract or policy that\nprovides coverage for emergency services receives the services from a\nhealth care provider that does not participate in the provider network\nof an insurer, a corporation organized pursuant to article forty-three\nof this chapter, a municipal cooperative health benefit plan certified\npursuant to article forty-seven of this chapter, a health maintenance\norganization certified pursuant to article forty-four of the public\nhealth law, or a student health plan established or maintained pursuant\nto section one thousand one hundred twenty-four of this chapter ("health\ncare plan"), the health care plan shall ensure that the insured or\nenrollee shall incur no greater out-of-pocket costs for the emergency\nservices than the insured or enrollee would have incurred with a health\ncare provider that participates in the health care plan's provider\nnetwork. For the purpose of this section, "emergency services" shall\nhave the meaning set forth in subparagraph (D) of paragraph nine of\nsubsection (i) of section three thousand two hundred sixteen of this\narticle, subparagraph (D) of paragraph four of subsection (k) of section\nthree thousand two hundred twenty-one of this article, and subparagraph\n(D) of paragraph two of subsection (a) of section four thousand three\nhundred three of this chapter.\n