Cuomo Proposing Out-of-Network Health Coverage

ALBANY (AP) -

The Cuomo administration has proposed extending out-of-network coverage requirements for emergencies and specialists to all health insurers in New York in what it says is an effort to protect consumers from big, surprise medical bills.

The requirements currently only apply to health maintenance organizations and 16 insurance plans in New York’s new health exchange. When a network lacks an available specialist, patients could get treated elsewhere and pay only their usual insurance fees.

Legislation that Gov. Andrew Cuomo recently proposed as part of a budget for the fiscal year starting April 1 would apply those consumer protections to non-HMOs, which provide most health coverage in New York.

If approved by the Legislature, it would also require advance disclosures by hospitals and doctors about who’s actually in their networks. Payment disputes would go to arbitration between the providers and insurance companies, leaving the patients out.

The protections wouldn’t apply to consumers who simply opt for providers outside their networks.

Concert pianist Claudia Knafo, whose four-hour disc surgery two years ago left her with $97,000 in bills and dunning notices, visited the Capitol on Thursday to advocate passage.

“I was concerned that to get through this I would have to declare bankruptcy,” she recalled.

The surgeon said he was in her insurance plan but wasn’t. Her insurance initially paid almost $67,000, then demanded back all but $3,500. She tried for months to resolve it and hired a lawyer. The company finally dropped its claim after she called Department of Financial Services Superintendent Ben Lawsky.

Lawsky’s department issued a report two years ago examining unexpected medical bills, noting that it received 2,105 complaints in 2011 and that insurers reported another 1,310 that year.

Advocates for the legislation said there are certainly many more patients who’ve had similar problems and didn’t know where to complain. “These are just the tip of the iceberg,” said Chuck Bell of Consumers Union.

Blair Horner, of the New York Public Interest Research Group, said a bill has been stalled so far by two big interest groups, the insurers and the medical providers.

“I would argue this is one of the issues you should hold the budget up over,” Horner said. “Real people lose their houses when these things happen.”