Assembly Speaker Sheldon Silver and Insurance Committee Chair Joseph Morelle announced today that the Assembly has passed a program bill, introduced by Governor Paterson, to provide further protections for consumers and health care providers. The legislation also establishes regulations to ensure the prompt processing and payment of health care claims.

The lawmakers stressed the Assembly Majority's continued commitment to eliminating consumer frustrations and limitations to health insurance claims in New York through the bill (A.8402A), which is sponsored by Morelle. The measure eliminates coverage confusion at in-network health care sources and also grants health care providers the right to dispute the recovery of alleged overpayment by health insurance plans for services rendered.

"This legislation builds upon previous managed care reforms and goes further to address the difficulties encountered by patients seeking to obtain the care they need and by the physicians and hospitals that provide this care," said Silver (D-Manhattan). "Our goal is to provide New Yorkers with the level of care they deserve through sufficient access, ensuring equal treatment and guaranteeing timely payment to providers."

"New York's Managed Care Consumer Bill of Rights contains strong consumer protections, but has left many with frustration and significant financial harm when their health plans refuse to pay for services that have already been approved," said Morelle (D-Rochester). "This legislation will improve the processes for payment and make essential steps toward improving delivery of quality healthcare services for all New Yorkers."

• Encourage electronic filing of claims by authorizing the Superintendent of Insurance to create regulations for electronic filing and by requiring insurers to pay electronic claims within 30 days;

• Protect the integrity of health care contracts between insurers and health care professionals by allowing health care professionals an opportunity to opt out of such contracts upon notice of an adverse reimbursement changes;

• Ensure more comprehensive care by requiring non-managed care policies to provide grievance procedures, access to specialty care through referrals from a primary care providers and transitional care consistent with that offered though managed care contracts;

• Bring due process to the system of overpayment recovery by requiring insurers to provide notice to a health care professional who will be the subject of an audit and establishing written policies and procedures for a health care professional to object if the audit is believed to be inappropriate;

• Ensure that policyholders are reimbursed, by dividend or credit, when Medical Loss Ratios have not been met;

• Improve the external appeal process individuals believed to suffer from rare diseases by clarifying the definition of what constitutes a rare disease;

• Ensure that patients have timely access to home care services upon discharge from the hospital by requiring insurers to approve services within one business day of receipt of the necessary information, and within 72 hours on weekends and holidays;

• Cure discrepancies in the payment for medical services by prohibiting payment for all medical services provided at an in network facility as out of network services solely because one of the services was provided by an out of network health care provider;

• Cure discrepancies in the payment for medical services by prohibiting payment for services provided by an in network health care provider as out of network services solely because the treatment was provided in an out of network facility;

• Improve the appeal process for necessary medical treatment by allowing health care providers to appeal concurrent adverse determinations on behalf of a patient;

• Clarify the concept of timely bill filing by requiring providers to submit claims within 120 days of the date services were provided -- with the option for the parties to agree to a longer timeframe -- and by requiring, in certain instances, at least a portion of payment be made in the instance of late bill filing so long as the bill has been filed within one year from the date of service ; and

• Extend the timeframe in which claims submitted by the policyholder must be submitted from 90 to 120 days to make it consistent with the provider submission timeframes.