Provides that a non-network pharmacy that provides causally related medications to a claimant shall be entitled to payment at the network rate negotiated between the carrier and the pharmacy network if the carrier's network provides mail order service or is located within a reasonable distance from the claimant; reduces costs of treatment by requiring out of network providers accept payment at the carrier's negotiated network rate, while at the same time allowing injured workers to obtain treatment in a timely manner by providing for payment to the provider when they do not obtain the treatment within the network; provides that any special diagnostic tests, x-ray examinations, magnetic resonance imaging or other radiological examinations or tests costing more than one thousand dollars performed by a provider who is not a member of the carrier's, self insured's or state insurance fund's diagnostic networks, shall be entitled to payment at the negotiated network rate.
Summary
S00306 would amend New York’s Workers’ Compensation Law to limit what out-of-network providers can be paid for certain workers’ compensation-related services. First, it would require a non-network pharmacy that dispenses causally related medications to a claimant to be paid at the carrier’s negotiated network rate, so long as the carrier’s network offers mail-order service or is located within a reasonable distance of the claimant. Second, it would require payment at the negotiated network rate for certain high-cost diagnostic services—special diagnostic tests, x-rays, MRIs, and other radiological exams or tests costing more than $1,000—when those services are performed by providers outside the carrier’s, self-insured employer’s, or State Insurance Fund’s diagnostic networks.
The bill is aimed at reducing workers’ compensation treatment costs while preserving access to care. Its stated approach is to allow injured workers to obtain needed medications and testing even when they do not use an in-network provider, but to cap reimbursement at the rate already negotiated by the carrier and its network. The bill would take effect immediately if enacted and would directly affect workers’ compensation carriers, self-insured employers, the State Insurance Fund, pharmacies, diagnostic imaging providers, and injured workers receiving causally related treatment.
Impact
If enacted, the bill would amend sections 13 and 13-a of the Workers’ Compensation Law to create new reimbursement rules for out-of-network pharmacies and certain out-of-network diagnostic providers. It would not prohibit claimants from using those providers, but it would require payment to be limited to the negotiated network rate in the circumstances described. This would likely reduce reimbursement exposure for carriers and employers while shifting some pricing leverage away from non-network providers in the workers’ compensation system.
Sentiment
The available bill materials suggest a generally cost-containment and access-balancing rationale, with the bill framed as both reducing treatment costs and ensuring timely care for injured workers. No committee transcript or recorded vote data is available here, so there is no direct evidence of opposition or support from legislators in the provided record. The caption indicates the sponsor’s intent to address out-of-network billing in a way that preserves access while controlling expenses.
Contention
The main point of contention is likely to be whether it is appropriate to force non-network providers to accept the carrier’s negotiated network rate, especially when the claimant chooses or must use an out-of-network pharmacy or diagnostic provider. Providers may view the measure as reducing reimbursement and limiting their ability to charge market rates, while carriers and employers are likely to support it as a cost-saving reform. Another potential issue is the bill’s reliance on concepts such as a carrier network being within a “reasonable distance,” which could raise disputes over access and whether network options are truly available to injured workers.
INSURANCE: Requests the Department of Insurance to study the impact on automobile insurance rates when bodily injury claimants submit medical treatment claims for accident-related injuries to out-of-network providers rather than in-network providers
Requests the Department of Insurance to study the impact on automobile insurance rates when bodily injury claimants submit medical treatment claims for accident-related injuries to out-of-network providers rather than in-network providers
Establishes arbitration and notification process for health insurance carriers and provider networks when dispute arises over maintaining providers as in-network.
Allows for treatment costing less than $1,500 to be done without prior approval, and more clearly defines the list of "pre-authorized procedures" as a floor on treatment as opposed to its current status as a ceiling; allows non-network providers of testing to be compensated at the provider network rate negotiated by the carrier.
Allows for treatment costing less than $1,500 to be done without prior approval, and more clearly defines the list of "pre-authorized procedures" as a floor on treatment as opposed to its current status as a ceiling; allows non-network providers of testing to be compensated at the provider network rate negotiated by the carrier.