New York’s Managed Care Reform Act

Managed care is fast becoming the health care delivery system of choice for tens of millions of Americans. Greater oversight and regulation has become necessary to ensure that consumers and providers alike are protected. In the 1990s, New York established new guidelines and requirements; however, as the system has since evolved, so must the regulatory process. For these reasons, the Assembly passed a law that I supported, effective Jan. 1, that will further bolster protections, expand consumer access and guarantee timely payment to providers (Ch. 237 of 2009).

New York’s Managed Care Reform Act, enacted in 1996, instituted standards for all managed-care plans, standardized grievance and appeals procedures, and established requirements for providing all enrollees and potential enrollees with detailed descriptions of a managed-care plan’s benefits and coverage.

Then, in 2007, further protections were put in place, including the right to appeal out-of-network denials, limitations on when claims for preauthorized services may be denied, and a required cooling-off period for terminations of contracts between hospitals and insurers or HMOs. While these reforms went a long way toward strengthening a rapidly expanding system, the Assembly recognized more improvements were needed.

The new law supplements the previous efforts to protect consumers by:

• requiring non-managed care policies to offer grievance procedures, access to specialty care through referrals, and transitional care consistent with that offered though managed-care contracts;

• simplifying the appeals process in instances of coverage for rare diseases;

• ensuring that patients have timely access to home care services upon discharge from the hospital by requiring insurers to approve services more quickly; and

• modifying how insurers issue dividends and/or credits to policyholders when appropriate.

With an eye toward protecting health care providers, the legislation requires that insurers inform them about any adverse reimbursement changes and allow them an opportunity to opt out of the contract. The measure also prohibits services provided in a participating medical facility from being deemed out-of-network because a provider was not a participating physician and authorizes health plans and hospitals to agree to alternative dispute resolutions when possible.

The law also ensures prompt processing and payment of health care claims. It authorizes the superintendent of insurance to issue regulations regarding electronic claims filing, requiring insurers to pay within 30 days for claims transmitted via the Internet or e-mail and requiring providers to submit claims within 120 days of date of service.

This new measure builds upon the Assembly’s longstanding commitment to delivering quality health care, allowing patients and providers to concentrate on personal health needs rather than bureaucracy and red tape.

Alan Maisel is an assemblyman in the 59th Assembly District.