STATE OF NEW YORK
________________________________________________________________________
264--B
2019-2020 Regular Sessions
IN ASSEMBLY(Prefiled)
January 9, 2019
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Introduced by M. of A. CAHILL, COLTON, ARROYO, JEAN-PIERRE, TAYLOR,
McDONOUGH, JACOBSON -- Multi-Sponsored by -- M. of A. EPSTEIN -- read
once and referred to the Committee on Insurance -- committee
discharged, bill amended, ordered reprinted as amended and recommitted
to said committee -- again reported from said committee with amend-
ments, ordered reprinted as amended and recommitted to said committee
AN ACT to amend the financial services law, in relation to establishing
protections from excess hospital charges
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Section 605 of the financial services law, as added by
2 section 26 of part H of chapter 60 of the laws of 2014, is amended to
3 read as follows:
4 § 605. Dispute resolution for emergency services. (a) Emergency
5 services for an insured. (1) When a health care plan receives a bill for
6 emergency services from a non-participating physician or hospital,
7 including a bill for inpatient services which follow an emergency room
8 visit, the health care plan shall pay an amount that it determines is
9 reasonable for the emergency services rendered by the non-participating
10 physician or hospital, in accordance with section three thousand two
11 hundred twenty-four-a of the insurance law, except for the insured's
12 co-payment, coinsurance or deductible, if any, and shall ensure that the
13 insured shall incur no greater out-of-pocket costs for the emergency
14 services than the insured would have incurred with a participating
15 physician or hospital pursuant to subsection (c) of section three thou-
16 sand two hundred forty-one of the insurance law.
17 (2) A non-participating physician or hospital or a health care plan
18 may submit a dispute regarding a fee or payment for emergency services
19 for review to an independent dispute resolution entity. In cases where
20 a health care plan submits a dispute regarding a fee for payment of a
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD03101-05-9
A. 264--B 2
1 non-participating hospital's emergency services, the health care plan
2 shall, after the initial payment, pay any additional amounts it deter-
3 mines is reasonable directly to the non-participating hospital.
4 (3) The independent dispute resolution entity shall make a determi-
5 nation within thirty days of receipt of the dispute for review.
6 (4) In determining a reasonable fee for the services rendered, an
7 independent dispute resolution entity shall select either the health
8 care plan's payment or the non-participating physician's or hospital's
9 fee. The independent dispute resolution entity shall determine which
10 amount to select based upon the conditions and factors set forth in
11 section six hundred four of this article. If an independent dispute
12 resolution entity determines, based on the health care plan's payment
13 and the non-participating physician's or hospital's fee, that a settle-
14 ment between the health care plan and non-participating physician or
15 hospital is reasonably likely, or that both the health care plan's
16 payment and the non-participating physician's or hospital's fee repre-
17 sent unreasonable extremes, then the independent dispute resolution
18 entity may direct both parties to attempt a good faith negotiation for
19 settlement. The health care plan and non-participating physician or
20 hospital may be granted up to ten business days for this negotiation,
21 which shall run concurrently with the thirty day period for dispute
22 resolution.
23 (b) Emergency services for a patient that is not an insured. (1) A
24 patient that is not an insured or the patient's physician may submit a
25 dispute regarding a fee for emergency services for review to an inde-
26 pendent dispute resolution entity upon approval of the superintendent.
27 (2) An independent dispute resolution entity shall determine a reason-
28 able fee for the services based upon the same conditions and factors set
29 forth in section six hundred four of this article.
30 (3) A patient that is not an insured shall not be required to pay the
31 physician's or hospital's fee in order to be eligible to submit the
32 dispute for review to an independent dispute resolution entity.
33 (c) The determination of an independent dispute resolution entity
34 shall be binding on the health care plan, physician or hospital and
35 patient, and shall be admissible in any court proceeding between the
36 health care plan, physician or hospital or patient, or in any adminis-
37 trative proceeding between this state and the physician or hospital.
38 (d) The provisions of this section shall not apply to hospitals that
39 had at least sixty percent of inpatient discharges annually which
40 consisted of medicaid, uninsured, and dual eligible individuals as
41 determined by the department of health in its determination of safety
42 net hospitals.
43 § 2. Subsection (a) of section 608 of the financial services law, as
44 added by section 26 of part H of chapter 60 of the laws of 2014, is
45 amended to read as follows:
46 (a) For disputes involving an insured, when the independent dispute
47 resolution entity determines the health care plan's payment is reason-
48 able, payment for the dispute resolution process shall be the responsi-
49 bility of the non-participating physician or hospital. When the inde-
50 pendent dispute resolution entity determines the non-participating
51 physician's or hospital's fee is reasonable, payment for the dispute
52 resolution process shall be the responsibility of the health care plan.
53 When a good faith negotiation directed by the independent dispute resol-
54 ution entity pursuant to paragraph four of subsection (a) of section six
55 hundred five of this article, or paragraph six of subsection (a) of
56 section six hundred seven of this article results in a settlement
A. 264--B 3
1 between the health care plan and non-participating physician or
2 hospital, the health care plan and the non-participating physician or
3 hospital shall evenly divide and share the prorated cost for dispute
4 resolution.
5 § 3. Section 604 of the financial services law, as added by section 26
6 of part H of chapter 60 of the laws of 2014, is amended to read as
7 follows:
8 § 604. Criteria for determining a reasonable fee. In determining the
9 appropriate amount to pay for a health care service, an independent
10 dispute resolution entity shall consider all relevant factors, includ-
11 ing:
12 (a) whether there is a gross disparity between the fee charged by the
13 [physician] health care provider for services rendered as compared to:
14 (1) fees paid to the involved [physician] health care provider for the
15 same services rendered by the [physician] health care provider to other
16 patients in health care plans in which the [physician] health care
17 provider is not participating, and
18 (2) in the case of a dispute involving a health care plan, fees paid
19 by the health care plan to reimburse similarly qualified [physicians]
20 health care providers for the same services in the same region who are
21 not participating with the health care plan;
22 (b) the level of training, education and experience of the [physician]
23 health care provider;
24 (c) the [physician's] health care provider's usual charge for compara-
25 ble services with regard to patients in health care plans in which the
26 [physician] health care provider is not participating;
27 (d) the circumstances and complexity of the particular case, including
28 time and place of the service;
29 (e) individual patient characteristics; and, with regard to physician
30 services,
31 (f) the usual and customary cost of the service.
32 § 4. This act shall take effect immediately.