New York State Seal
STATE OF NEW YORK
INSURANCE DEPARTMENT
25 BEAVER STREET
NEW YORK, NEW YORK 10004

David A. Paterson
Governor

Eric R. Dinallo
Superintendent

OGC Op. No. 08-09-08

The Office of General Counsel issued the following opinion on September 23, 2008 representing the position of the New York State Insurance Department.

Re: Refusal of Insurance Company to Accept a Physician as an In-Network Provider

Question Presented:

Does the New York Insurance Law or any federal law require an insurer to accept a physician as an in-network provider?

Conclusion:

No. There is no provision in the New York Insurance Law, nor any federal law of which the New York State Insurance Department (“Department”) is aware, that requires an insurer to accept a physician as an in-network provider.

Facts:

The inquirer reports that physicians are trying to join a health care plan as in-network providers and that the insurer, which offers the plan, will not allow them to do so. In some cases, the providers were told by the insurer that it had a sufficient number of providers “with their specialty,” and that the insurer did not want to allow additional providers into the plan.

Analysis:

The New York Insurance Law does not require insurers, including health maintenance organizations (HMOs), to accept all qualified providers into their networks. Unlike some states, New York has not enacted an “any willing provider” law, which requires insurers to sign on any provider who agrees to abide by the terms of the insurer’s contract and to accept the insurer’s payment levels. Moreover, the Department is unaware of any federal law that requires an insurer to accept any provider who wishes to join its network.

However, an HMO must maintain a network that is sufficient to deliver comprehensive services to its enrolled population. N.Y. Pub. Health Law § 4403(5)(a) (McKinney 2002) reads in relevant part as follows:

The commissioner [of health], at the time of initial licensure, at least every three years thereafter, and upon application for expansion of service area, shall ensure that the health maintenance organization maintains a network of health care providers adequate to meet the comprehensive health needs of its enrollees and to provide an appropriate choice of providers sufficient to provide the services covered under its enrollee's contracts …

The New York State Department of Health handles complaints about whether an HMO is maintaining an adequate network.

For further information, you may contact Associate Attorney Elizabeth Barrett at the New York City office.