On March 31, 2015, Superintendent of Financial Services Lawsky announced the commencement of a law protecting New Yorkers from out-of-network medical bills. Enacted as part of last year’s budget (specifically S6914), the law requires enhanced consumer disclosures to protect patients from medical bills for visiting out-of-network providers and holds consumers harmless.
The law also creates a fair and independent mediation process which determines appropriate reimbursement between doctors and insurers without involving the consumer.
A consumer will not be charged the out-of-network cost for a surprise bill if they did not have the opportunity to avoid it and stay in network. All health plans must cover at the in-network cost any out-of-network provider bill for emergency services, as well as non-emergency bills for physician services in a hospital or surgical facility when an in-network provider is unavailable, the consumer was not informed in advance, or when a physician refers the consumer to any out-of-network provider.
Also required are enhanced consumer disclosures from insurers, doctors and hospitals resulting in consumers more easily knowing which providers are out-of-network, how much those providers expect to charge, and how much the insurer expects to cover. In addition, all health plans must meet minimum standards for adequate provider networks before offering coverage. Employers need not worry about changing plans as insurers will be responsible for verifying the adequacy of provider networks before the Superintendent approves them.
Finally, all health plans must allow a consumer to go to an out-of-network provider at the in-network cost share if the insurer does not have an appropriate in-network provider. This would come into play when a rating region doesn’t have an in-network option. In those cases, the Superintendent may require an insurer to make available and provide at least one option for coverage of eighty percent of the usual cost of each out-of-network health care service after any permissible deductible or benefit maximum. The law also makes out-of-network claim submissions easier for consumers, among other protections.