N.Y. Comp. Codes R. & Regs. tit. 11 § 52.77

Current through Register Vol. 46, No. 45, November 2, 2024

Section 52.77 - Payment when an issuer provides inaccurate network status information

(a) If an insured who is covered under an accident and health insurance policy that uses a network of health care providers receives a bill for out-of-network services resulting from an issuer providing inaccurate network status information to an insured, the issuer shall not impose on the insured a copayment, coinsurance, or deductible for the service that is greater than the copayment, coinsurance, or deductible that would be owed if the insured had received services from a participating provider. The issuer shall apply the out-of-pocket maximum that would have applied had the services been received from a participating provider.

(b) Pursuant to Insurance Law sections 3217-b(n) and 4325(o) and Public Health Law section 4406-c(12), if an issuer provides inaccurate network status information to an insured, the issuer shall reimburse the provider for the out-of-network services regardless of whether the insured's coverage includes out-of-network services.

(c)

(1) An issuer that issues comprehensive health insurance policies shall provide network status information to an insured in writing through print or electronic means, if the insured consents to electronic communication, within one business day of the insured requesting the information by telephone or through electronic means, if available.

(2) An issuer that issues a policy, other than a comprehensive health insurance policy, that uses a network of providers shall provide network status information to an insured in writing through print or electronic means, if the insured consents to electronic communication, within three business days of the insured requesting the information by telephone or through electronic means, if available.

(3) An issuer shall retain any recordings of telephone requests for network status information and a copy of its written response to the insured in the insured's file in accordance with section 243.2(b)(8) of this Part.

(d) An issuer provides inaccurate network status information when:

(1) the issuer represents in the provider directory posted on its website that a non-participating provider is participating in the issuer's network;

(2) the issuer provides information, upon an insured's request made by telephone or through electronic means, if available, that a nonparticipating provider is participating in the issuer's network;

(3) the issuer fails to provide information in writing through print or electronic means, if the insured consents to electronic communication, regarding a specific provider's participating status within the timeframes established in subdivision (c) of this section; or

(4) the issuer represents in the hard copy provider directory that a provider is participating in the issuer's network and the provider is nonparticipating as of the date of publication of the hard copy provider directory.

(e) An issuer shall include in its hard copy provider directory a notification that the information contained in the directory was accurate as of the date of publication of such directory and that an insured should consult the provider directory posted on the issuer's website to obtain the most current provider directory information.

(f) As used in this section:

(1) Non-participating means not having an agreement with an issuer with respect to the rendering of health care services to an insured.

(2) Participating means having an agreement with an issuer with respect to the rendering of health care services to an insured.

(3) Issuer means an insurer licensed to write accident and health insurance in this State, a corporation organized pursuant to Insurance Law Article 43, a municipal cooperative health benefit plan certified pursuant to Insurance Law Article 47, a health maintenance organization certified pursuant to Public Health Law Article 44, and a student health plan certified pursuant to Insurance Law section 1124.

(g) This section shall apply to all comprehensive health insurance policies issued, renewed, modified, or amended on or after the effective date of this section. This section shall apply to policies other than comprehensive health insurance policies that are issued, renewed, modified, or amended on or after one year after the effective date of this section.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.77

Adopted New York State Register December 7, 2022/Volume XLIV, Issue 49, eff. 12/7/2022