Extends period during which health maintenance organization enrollees may continue to receive services from a health care provider who disaffiliates from 60 or 90 days to 1 year, or in case of terminal illness, until the time of such insured's death; bars incentives which induce a provider to provide health care to an enrollee in a manner inconsistent with law.
Summary
This bill expands New York’s “continuity of care” protections for people enrolled in managed care products and health maintenance organizations (HMOs) when a provider leaves a network or when a patient joins a plan while already under a provider’s care. It increases the transitional period during which an enrollee may keep seeing the same out-of-network provider from 60 or 90 days to one year, and it extends that period for pregnancy-related care through postpartum care. For patients with a terminal illness or condition, the bill allows continued care with the current provider until the patient’s death.
The bill also broadens the circumstances under which a provider may not be penalized for advocacy or patient complaints, adding protection for providers who render an opinion that a patient’s illness is terminal. It defines “terminal illness or condition” as one likely, in the physician’s opinion, to cause or significantly contribute to death within three years. In addition, it prohibits provider incentives—monetary or otherwise—that are intended to induce care inconsistent with the bill’s continuity-of-care rules. The bill applies these changes to both insurance law and public health law, covering insurers and HMOs.
Impact
S04431 would amend sections of the Insurance Law and Public Health Law governing managed care and HMO networks. It would require insurers and HMOs to give written notice when a provider disaffiliates and to allow continued treatment with that provider for a much longer period than current law, while keeping the provider subject to network-style reimbursement, quality assurance, referral, and preauthorization rules. It also adds a new statutory definition of terminal illness and creates a new prohibition on incentives that could pressure providers to act contrary to the continuity-of-care provisions. The bill would apply to contracts issued, renewed, modified, or amended on or after its effective date.
Sentiment
The bill’s stated purpose and structure suggest a generally consumer-protection-oriented approach, with the goal of reducing disruption in ongoing treatment and preserving patient-provider relationships during network changes. The available context does not show recorded committee debate or votes, so there is no documented opposition or support in the provided materials. Based on the text alone, the measure appears designed to be favorable to patients, especially those with serious illness, pregnancy-related care needs, or long-term treatment relationships.
Contention
The main policy tension in the bill is between patient continuity of care and insurer/HMO network management. Extending transitional coverage from 60 or 90 days to one year could increase costs and limit plans’ ability to steer patients to in-network providers, while the bill still requires providers to accept plan reimbursement and follow plan procedures. Another possible point of contention is the new terminal-illness standard, which relies on a physician’s opinion and uses a three-year mortality horizon, potentially raising questions about scope and administration. The prohibition on provider incentives may also be debated by insurers and plans if they view it as limiting care-management tools.
Same As
Extends period during which health maintenance organization enrollees may continue to receive services from a health care provider who disaffiliates from 60 or 90 days to 1 year, or in case of terminal illness, until the time of such insured's death; bars incentives which induce a provider to provide health care to an enrollee in a manner inconsistent with law.
Extends period during which health maintenance organization enrollees may continue to receive services from a health care provider who disaffiliates from 60 or 90 days to 1 year, or in case of terminal illness, until the time of such insured's death; bars incentives which induce a provider to provide health care to an enrollee in a manner inconsistent with law.
Prohibits approved organizations providing coverage under the child health insurance plan from discriminating against health care providers which do not participate in the organization's health care network.
Relating to the form of a claim payment to a health care provider by a health maintenance organization, preferred provider benefit plan, or managed care organization.
Health care providers certain health care provider reimbursement arrangements disclosure to enrollees and health care providers requirement provision, Ombudsperson for public managed health care programs duties modifications, and health carrier liability when a health care provider is limited in providing services by the health carrier
Requires an insurance company which owns a health care provider to pay any health care provider which it does not own an amount that is no less than the amount that it pays a health care provider which it does own for a comparable service; prohibits an insurance company which is owned by a health care provider from paying any health care provider which does not own such insurance company an amount that is less than the amount that it pays a health care provider which does own such company for a comparable service.
Requires an insurance company which owns a health care provider to pay any health care provider which it does not own an amount that is no less than the amount that it pays a health care provider which it does own for a comparable service; prohibits an insurance company which is owned by a health care provider from paying any health care provider which does not own such insurance company an amount that is less than the amount that it pays a health care provider which does own such company for a comparable service.
Allows for a new special open enrollment period to choose a new health insurance plan for consumers in certain instances to allow for continuity of care with an existing health care provider.
Allows for a new special open enrollment period to choose a new health insurance plan for consumers in certain instances to allow for continuity of care with an existing health care provider.