Some New Yorkers can choose from more than a hundred health insurance products offered by more than a dozen insurers participating in the state-run health insurance exchange, depending on where they live, but they’re hard-pressed to find anything other than the HMO-style plans that dominate the landscape.

There are a few exceptions in the far western part of the Empire State and Albany area, Kaiser Health News recently reported, noting that residents who seek out-of-network care “for anything other than emergency care are generally going to be responsible for the entire bill.”

It’s a highly unusual arrangement. The same article noted a McKinsey & Co. study that found just 1% of Americans who were eligible for HIX coverage in 2015 were confined to an HMO option, while 4% could choose between an HMO or exclusive provider organization.

Roughly 75% of New Yorkers who purchase coverage through the individual marketplace have incomes at or below 400% of the federal poverty level, according to a NY State of Health (NYSOH) spokesperson. She says network plans are more affordable and have far more predictable out-of-pocket costs when consumers access services.

Also see: Public exchanges reported to be more satisfying than employer-sponsored coverage

Sabrina Corlette, project director at Georgetown University’s Center on Health Insurance Reforms, believes a state requirement that plans with out-of-network benefits sold outside the HIX marketplace also must be sold inside the NYSOH discouraged PPO offerings.

Consequently, most insurers decided not to sell PPOs than have their hand forced – with their cautious demeanor also a reaction to a history of tight regulation of the state’s health insurance market. “They were worried about adverse selection, so they only offered HMO-style plans,” Corlette told Kaiser Health News.

New York regulators also have taken steps to raise the level of consumer protections amid a dearth of other delivery mechanisms for health insurance. Consumers who want out-of-network benefits run the risk of balance billing by providers who refuse to accept the insurer’s rate. With this in mind, New York passed a law in 2014 to prevent surprise out-of-network bills by improving adequacy standards for plans networks and, thus, reducing a need for out-of-network care.

Also see: As income rises, HIX enrollment more challenging

“If the health plan does not have a network provider that meets the patient’s needs, the plan must approve a referral to an out-of-network provider and the consumer will be responsible for only the amount of in-network cost sharing,” says the NYSOH spokesperson. “With these protections in place, we believe that health plans with robust, high-quality health provider networks are the best option for consumers.” 

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