BILL NUMBER:S4789

TITLE OF BILL:  An act to amend the public health law and the
insurance law, in relation to prohibiting health care plans and health
insurers from requiring any health care provider to provide services
through the state health benefit exchange, unless the health care
provider has agreed to participate in the in-network portion of such
plan or insurance

PURPOSE:  To assure New York health insurance companies directly
contract with physicians and other necessary health care providers to
deliver care to their enrollees in Exchange products sold through the
New York State of Health Marketplace.

SUMMARY OF PROVISIONS:

Section one of the bill would amend Public Health Law § 4406-c to
require health insurance companies offering coverage through New
York's Health Insurance Exchange to execute separate contracts with
health care providers to provide coverage to Exchange product
enrollees rather than rely upon previously-executed contracts.

Sections two and three make corresponding changes to Insurance Law
3217-b and 4325, respectively.

Section four provides that this act shall take effect immediately.
              

JUSTIFICATION:  New York's Health Insurance Exchange has been a model
for the rest of country, enrolling hundreds of thousands of New
Yorkers who previously did not have any health insurance coverage. At
the same time, there have been many complaints and multiple news
reports by patients and physicians regarding inaccurate listings of
participating providers on these new Exchange plans. In some cases,
patients believed when they enrolled in an Exchange plan that their
treating physician was a participant in the plan, only to find out
after enrollment that they were not.

The New York State Senate examined this and other issues related to
Exchange implementation at a public hearing it held in January. The
concern is that these inaccurate network listings cause great
confusion to patients who may select an Exchange plan based upon the
perceived participation status of a particular physician in that plan
or, once enrolled in a plan, cause confusion when attempting to make
an appointment based upon a physician's perceived participation
status.

The problem in many cases is caused by health insurers relying upon
pre-existing contracts that may or may not contain provisions
requiring physicians to participate in "all products" offered by that
insurer, which may have been executed many years earlier. In other
cases, insurers have sent communications to physician offices that
fail to clearly specify that physicians are being directed to
participate in Exchange products offered by that insurer unless they
affirmatively notify the insurer that they have opted out of
participation. In other cases, insurers have simply ignored physician
requests to not participate in these products, which some have


indicated provide reimbursement that is far below other commercial
products offered by that insurer.

To address this problem and provide greater transparency for Exchange
plan enrollees and those shopping for coverage, this legislation would
require health insurance companies to execute separate contracts with
health care providers to participate in their Exchange products,
rather than relying upon these other pre-existing contacts and
peripheral communications. Health insurers should assure that there
network listings are accurate by assuring that physicians, hospitals
and other necessary providers have expressly agreed to participate in
their Exchange plans. This measure will provide patients with
accurate, transparent information so they can be confident in what
they are purchasing.

LEGISLATIVE HISTORY: S.7166 of 2014

FISCAL IMPLICATIONS: None.

EFFECTIVE DATE: Immediately.