S02551 Summary:

BILL NOS02551
 
SAME ASSAME AS A07253
 
SPONSORHANNON
 
COSPNSRAVELLA, BALL, CARLUCCI, GOLDEN, HOYLMAN, KRUEGER, LARKIN, LATIMER, LAVALLE, MARTINS, RANZENHOFER, YOUNG
 
MLTSPNSR
 
Amd Ins L, generally; add SS23 & 24, amd SS4408, 4900, 4903, 4904, 4910 & 4914, Pub Health L; add Art 7 SS701 - 704, Fin Serv L
 
Establishes protections to prevent surprise medical bills including network adequacy requirements, claim submission requirements, adequacy of and access to out-of-network care and prohibition of excessive emergency charges.
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S02551 Actions:

BILL NOS02551
 
01/18/2013REFERRED TO INSURANCE
06/20/2013COMMITTEE DISCHARGED AND COMMITTED TO RULES
06/20/2013ORDERED TO THIRD READING CAL.1478
06/20/2013PASSED SENATE
06/20/2013DELIVERED TO ASSEMBLY
06/20/2013referred to insurance
01/08/2014died in assembly
01/08/2014returned to senate
01/08/2014REFERRED TO INSURANCE
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S02551 Floor Votes:

There are no votes for this bill in this legislative session.
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S02551 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          2551
 
                               2013-2014 Regular Sessions
 
                    IN SENATE
 
                                    January 18, 2013
                                       ___________
 
        Introduced  by  Sens. HANNON, LAVALLE -- read twice and ordered printed,
          and when printed to be committed to the Committee on Insurance
 
        AN ACT to amend the insurance law, the public health law and the  finan-
          cial  services law, in relation to establishing protections to prevent
          surprise medical bills including network adequacy requirements,  claim

          submission requirements, adequacy of and access to out-of-network care
          and  prohibition of excessive emergency charges; and providing for the
          repeal of certain provisions upon expiration thereof
 
          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:
 
     1    Section  1.  Paragraphs 11, 12, 13, 14, 16 and 17 of subsection (a) of
     2  section 3217-a of the insurance law, as added by chapter 705 of the laws
     3  of 1996, are amended and three new paragraphs 16-a, 18 and 19 are  added
     4  to read as follows:
     5    (11)  where  applicable,  notice that an insured enrolled in a managed
     6  care product or a  comprehensive  policy  that  utilizes  a  network  of
     7  providers  offered by the insurer may obtain a referral to a health care
     8  provider outside of the insurer's network or panel when the insurer does

     9  not have a health care provider with appropriate training and experience
    10  in the network or panel to meet the particular health care needs of  the
    11  insured and the procedure by which the insured can obtain such referral;
    12    (12)  where  applicable,  notice that an insured enrolled in a managed
    13  care product or a  comprehensive  policy  that  utilizes  a  network  of
    14  providers offered by the insurer with a condition which requires ongoing
    15  care  from  a  specialist  may  request  a  standing  referral to such a
    16  specialist and the procedure for requesting and obtaining such a  stand-
    17  ing referral;
    18    (13)    where applicable, notice that an insured enrolled in a managed
    19  care product or a  comprehensive  policy  that  utilizes  a  network  of
    20  providers  offered  by the insurer with (i) a life-threatening condition

    21  or disease, or (ii) a degenerative and disabling condition  or  disease,
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD02652-01-3

        S. 2551                             2
 
     1  either of which requires specialized medical care over a prolonged peri-
     2  od of time may request a specialist responsible for providing or coordi-
     3  nating  the  insured's medical care and the procedure for requesting and
     4  obtaining such a specialist;
     5    (14)  where  applicable,  notice that an insured enrolled in a managed
     6  care product or a  comprehensive  policy  that  utilizes  a  network  of
     7  providers  offered  by the insurer with (i) a life-threatening condition

     8  or disease, or (ii) a degenerative and disabling condition  or  disease,
     9  either of which requires specialized medical care over a prolonged peri-
    10  od of time, may request access to a specialty care center and the proce-
    11  dure by which such access may be obtained;
    12    (16) notice of all appropriate mailing addresses and telephone numbers
    13  to be utilized by insureds seeking information or authorization; [and]
    14    (16-a)  where  applicable,  notice  that  an insured shall have direct
    15  access to primary and  preventive  obstetric  and  gynecologic  services
    16  including  annual examinations, care resulting from such annual examina-
    17  tions, and treatment of acute gynecologic conditions, from  a  qualified
    18  provider  of such services of her choice from within the plan or for any
    19  care related to a pregnancy;

    20    (17) where applicable, a listing by specialty, which may be in a sepa-
    21  rate document that is updated annually, of the name, address, and  tele-
    22  phone  number  of all participating providers, including facilities, and
    23  in  addition,  in  the  case  of  physicians,  board   certification[.],
    24  languages spoken and affiliation with participating hospitals. The list-
    25  ing  shall also be posted on the insurer's website and the insurer shall
    26  update the website within fifteen days of the addition or termination of
    27  a provider from the insurer's network  or  a  change  in  a  physician's
    28  hospital affiliation;
    29    (18)  a  description  of  the  method by which an insured may submit a
    30  claim for health care services, including through  the  internet,  elec-

    31  tronic mail or by facsimile; and
    32    (19)  where  applicable,  when a policy offers out-of-network coverage
    33  pursuant to subsections (b)  and  (c)  of  section  three  thousand  two
    34  hundred forty of this article:
    35    (A)  a  clear  description  of  the methodology used by the insurer to
    36  determine reimbursement for out-of-network health care services;
    37    (B) a description of the amount that the insurer will reimburse  under
    38  the  methodology  for out-of-network health care services set forth as a
    39  percentage of the usual and customary  cost  for  out-of-network  health
    40  care services; and
    41    (C)  examples of anticipated out-of-pocket costs for frequently billed
    42  out-of-network health care services.

    43    § 2. Paragraphs 11 and 12 of subsection (b) of section 3217-a  of  the
    44  insurance  law, as added by chapter 705 of the laws of 1996, are amended
    45  and three new paragraphs 13, 14 and 15 are added to read as follows:
    46    (11) where applicable, provide the written application procedures  and
    47  minimum  qualification  requirements  for  health  care  providers to be
    48  considered by the insurer for participation in the insurer's network for
    49  a managed care product; [and]
    50    (12) disclose such other information as required  by  the  superinten-
    51  dent,  provided  that  such requirements are promulgated pursuant to the
    52  state administrative procedure act[.];
    53    (13) disclose whether a health care provider scheduled  to  provide  a
    54  health care service is an in-network provider;


        S. 2551                             3
 
     1    (14)  where  applicable,  with  respect  to  out-of-network  coverage,
     2  disclose the dollar amount that the insurer  will  pay  for  a  specific
     3  out-of-network health care service; and
     4    (15)  provide  information  in writing and through an internet website
     5  that reasonably permits an insured or prospective insured  to  determine
     6  the  anticipated  out-of-pocket  cost  for  out-of-network  health  care
     7  services in a geographical area or zip code based  upon  the  difference
     8  between  what  the insurer will reimburse for out-of-network health care
     9  services and the usual and customary cost for out-of-network health care
    10  services.
    11    § 3. Section 3217-a of the insurance law is amended by  adding  a  new

    12  subsection (f) to read as follows:
    13    (f)  For  purposes  of  this section, "usual and customary cost" shall
    14  mean the eightieth percentile of all charges for the  particular  health
    15  care  service  performed  by a provider in the same or similar specialty
    16  and provided in the same geographical area as reported in a benchmarking
    17  database maintained by a nonprofit organization specified by the  super-
    18  intendent.  The  nonprofit  organization shall not be affiliated with an
    19  insurer, a corporation subject to article forty-three of this chapter, a
    20  municipal cooperative health benefit plan certified pursuant to  article
    21  forty-seven of this chapter, or a health maintenance organization certi-
    22  fied pursuant to article forty-four of the public health law.

    23    §  4.  Section  3217-d of the insurance law is amended by adding a new
    24  subsection (d) to read as follows:
    25    (d) An insurer that issues a  comprehensive  policy  that  utilizes  a
    26  network of providers and is not a managed care health insurance contract
    27  as  defined in subsection (c) of section four thousand eight hundred one
    28  of  this  chapter,  shall  provide  access  to  out-of-network  services
    29  consistent with the requirements of subsection (a) of section four thou-
    30  sand  eight hundred four of this chapter, subsections (g-6) and (g-7) of
    31  section four thousand nine hundred of this  chapter,  subsections  (a-1)
    32  and  (a-2)  of  section four thousand nine hundred four of this chapter,
    33  paragraphs three and four of subsection (b)  of  section  four  thousand

    34  nine hundred ten of this chapter, and subparagraphs (C) and (D) of para-
    35  graph four of subsection (b) of section four thousand nine hundred four-
    36  teen of this chapter.
    37    §  5.  Section  3224-a of the insurance law is amended by adding a new
    38  subsection (j) to read as follows:
    39    (j) An insurer or an organization or corporation licensed or certified
    40  pursuant to article forty-three or forty-seven of this chapter or  arti-
    41  cle forty-four of the public health law shall accept claims submitted by
    42  a  policyholder  or covered person through the internet, electronic mail
    43  or by facsimile.
    44    § 6. The insurance law is amended by adding a new section 3240 to read
    45  as follows:
    46    § 3240. Network coverage.   (a) An insurer,  a  corporation  organized

    47  pursuant  to article forty-three of this chapter, or a municipal cooper-
    48  ative health benefit plan certified pursuant to article  forty-seven  of
    49  this  chapter  that  issues a health insurance policy or contract with a
    50  network of health care  providers  shall  ensure  that  the  network  is
    51  adequate to meet the health needs of insureds and provide an appropriate
    52  choice  of providers sufficient to render the services covered under the
    53  policy or contract. The  superintendent  shall  review  the  network  of
    54  health  care  providers for adequacy at the time of the superintendent's
    55  initial approval of a health insurance  policy  or  contract;  at  least
    56  every  three years thereafter; and upon application for expansion of any


        S. 2551                             4
 
     1  service area associated with the policy or contract. To the extent  that
     2  the  network  has  been determined by the commissioner of health to meet
     3  the standards set forth in subdivision five  of  section  four  thousand
     4  four  hundred  three  of  the  public  health law, such network shall be
     5  deemed adequate by the superintendent.
     6    (b) An insurer, a corporation organized  pursuant  to  article  forty-
     7  three  of  this  chapter,  a  municipal  cooperative health benefit plan
     8  certified pursuant to article forty-seven of this chapter, or  a  health
     9  maintenance organization certified pursuant to article forty-four of the
    10  public  health  law,  that provides coverage for out-of-network services

    11  shall provide significant coverage of the usual and customary  costs  of
    12  out-of-network health care services.
    13    (c)  An  insurer,  a  corporation organized pursuant to article forty-
    14  three of this chapter,  a  municipal  cooperative  health  benefit  plan
    15  certified  pursuant  to article forty-seven of this chapter, or a health
    16  maintenance organization certified pursuant to article forty-four of the
    17  public health law, that provides coverage  for  out-of-network  services
    18  shall  offer at least one policy or contract option in each geographical
    19  region covered that provides coverage for at least eighty percent of the
    20  usual and customary cost of out-of-network health  care  services  after
    21  imposition of a deductible.

    22    (d)  For the purposes of this section "usual and customary cost" shall
    23  mean the eightieth percentile of all charges for the  particular  health
    24  care  service  performed  by a provider in the same or similar specialty
    25  and provided in the same geographical area as reported in a benchmarking
    26  database maintained by a nonprofit organization specified by the  super-
    27  intendent.  The  nonprofit  organization shall not be affiliated with an
    28  insurer, a corporation subject to article forty-three of this article, a
    29  municipal cooperative health benefit plan certified pursuant to  article
    30  forty-seven of this chapter, or a health maintenance organization certi-
    31  fied pursuant to article forty-four of the public health law.

    32    §  7.  Section  4306-c of the insurance law is amended by adding a new
    33  subsection (d) to read as follows:
    34    (d) A corporation, including a municipal  cooperative  health  benefit
    35  plan  certified  pursuant  to  article forty-seven of this chapter, that
    36  issues a comprehensive policy that utilizes a network of  providers  and
    37  is not a managed care health insurance contract as defined in subsection
    38  (c)  of  section  four thousand eight hundred one of this chapter, shall
    39  provide access to out-of-network services consistent with  the  require-
    40  ments  of  subsection (a) of section four thousand eight hundred four of
    41  this chapter, subsections (g-6) and (g-7) of section four thousand  nine
    42  hundred  of  this  chapter,  subsections (a-1) and (a-2) of section four

    43  thousand nine hundred four of this chapter, paragraphs three and four of
    44  subsection (b) of section four thousand nine hundred ten of  this  chap-
    45  ter,  and  subparagraphs (C) and (D) of paragraph four of subsection (b)
    46  of section four thousand nine hundred fourteen of this chapter.
    47    § 8. Paragraphs 11, 12, 13, 14, 16-a, 17, and 18 of subsection (a)  of
    48  section  4324  of the insurance law, as added by chapter 705 of the laws
    49  of 1996, paragraph 16-a as added by chapter 554 of the laws of 2002, are
    50  amended and two new paragraphs 19 and 20 are added to read as follows:
    51    (11)  where applicable, notice that a subscriber enrolled in a managed
    52  care product or a comprehensive contract  that  utilizes  a  network  of
    53  providers  offered  by the corporation may obtain a referral to a health

    54  care provider outside of the corporation's network  or  panel  when  the
    55  corporation does not have a health care provider with appropriate train-
    56  ing and experience in the network or panel to meet the particular health

        S. 2551                             5
 
     1  care  needs  of the subscriber and the procedure by which the subscriber
     2  can obtain such referral;
     3    (12)  where applicable, notice that a subscriber enrolled in a managed
     4  care product or a comprehensive contract  that  utilizes  a  network  of
     5  providers  offered  by  the  corporation with a condition which requires
     6  ongoing care from a specialist may request a standing referral to such a
     7  specialist and the procedure for requesting and obtaining such a  stand-
     8  ing referral;
     9    (13)  where applicable, notice that a subscriber enrolled in a managed

    10  care product or a comprehensive contract  that  utilizes  a  network  of
    11  providers  offered by the corporation with (i) a life-threatening condi-
    12  tion or disease, or (ii)  a  degenerative  and  disabling  condition  or
    13  disease,  either  of  which  requires  specialized  medical  care over a
    14  prolonged period of  time  may  request  a  specialist  responsible  for
    15  providing  or  coordinating the subscriber's medical care and the proce-
    16  dure for requesting and obtaining such a specialist;
    17    (14) where applicable, notice that a subscriber enrolled in a  managed
    18  care  product  or  a  comprehensive  contract that utilizes a network of
    19  providers offered by the corporation with (i) a life-threatening  condi-
    20  tion  or  disease,  or  (ii)  a  degenerative and disabling condition or

    21  disease, either of  which  requires  specialized  medical  care  over  a
    22  prolonged  period  of time may request access to a specialty care center
    23  and the procedure by which such access may be obtained;
    24    (16-a) where applicable, notice that an  enrollee  shall  have  direct
    25  access  to  primary  and  preventive  obstetric and gynecologic services
    26  including annual examinations, care resulting from such annual  examina-
    27  tions,  and  treatment of acute gynecologic conditions, from a qualified
    28  provider of such services of her choice from within  the  plan  [for  no
    29  fewer  than two examinations annually for such services] or [to] for any
    30  care related to a pregnancy [and that additionally, the  enrollee  shall
    31  have  direct  access to primary and preventive obstetric and gynecologic

    32  services required as a result of such annual examinations or as a result
    33  of an acute gynecologic condition];
    34    (17) where applicable, a listing by specialty, which may be in a sepa-
    35  rate document that is updated annually, of the name, address, and  tele-
    36  phone  number  of all participating providers, including facilities, and
    37  in addition, in the case  of  physicians,  board  certification[;  and],
    38  languages  spoken  and  affiliation  with participating hospitals.   The
    39  listing shall also be posted on the corporation's website and the corpo-
    40  ration shall update the website within fifteen days of the  addition  or
    41  termination  of a provider from the corporation's network or a change in
    42  a physician's hospital affiliation;

    43    (18) a description of the mechanisms by which subscribers may  partic-
    44  ipate in the development of the policies of the corporation[.];
    45    (19)  a  description  of the method by which a subscriber may submit a
    46  claim for health care services, including through  the  internet,  elec-
    47  tronic mail or by facsimile; and
    48    (20)  where applicable, when a contract offers out-of-network coverage
    49  pursuant to subsections (b)  and  (c)  of  section  three  thousand  two
    50  hundred forty of this chapter:
    51    (A)  a clear description of the methodology used by the corporation to
    52  determine reimbursement for out-of-network health care services;
    53    (B) a description of the amount that the  corporation  will  reimburse

    54  under  the methodology for out-of-network health care services set forth
    55  as a percentage of the  usual  and  customary  cost  for  out-of-network
    56  health care services; and

        S. 2551                             6
 
     1    (C)  examples of anticipated out-of-pocket costs for frequently billed
     2  out-of-network health care services.
     3    §  9.  Paragraphs  11  and 12 of subsection (b) of section 4324 of the
     4  insurance law, as added by chapter 705 of the laws of 1996, are  amended
     5  and three new paragraphs 13, 14 and 15 are added to read as follows:
     6    (11)  where applicable, provide the written application procedures and
     7  minimum qualification requirements  for  health  care  providers  to  be
     8  considered  by  the  corporation  for participation in the corporation's

     9  network for a managed care product; [and]
    10    (12) disclose such other information as required  by  the  superinten-
    11  dent,  provided  that  such requirements are promulgated pursuant to the
    12  state administrative procedure act[.];
    13    (13) disclose whether a health care provider scheduled  to  provide  a
    14  health care service is an in-network provider;
    15    (14)  where  applicable,  with  respect  to  out-of-network  coverage,
    16  disclose the dollar amount that the corporation will pay for a  specific
    17  out-of-network health care service; and
    18    (15)  provide  information  in writing and through an internet website
    19  that reasonably permits a subscriber or prospective subscriber to deter-

    20  mine the anticipated out-of-pocket cost for out-of-network  health  care
    21  services  in  a  geographical area or zip code based upon the difference
    22  between what the corporation will reimburse  for  out-of-network  health
    23  care services and the usual and customary cost for out-of-network health
    24  care services.
    25    §  10.  Section  4324  of the insurance law is amended by adding a new
    26  subsection (f) to read as follows:
    27    (f) For purposes of this section, "usual  and  customary  cost"  shall
    28  mean  the  eightieth percentile of all charges for the particular health
    29  care service performed by a provider in the same  or  similar  specialty
    30  and provided in the same geographical area as reported in a benchmarking

    31  database  maintained by a nonprofit organization specified by the super-
    32  intendent. The nonprofit organization shall not be  affiliated  with  an
    33  insurer,  a corporation subject to this article, a municipal cooperative
    34  health benefit plan certified pursuant to article  forty-seven  of  this
    35  chapter,  or  a  health  maintenance  organization certified pursuant to
    36  article forty-four of the public health law.
    37    § 11. Subsection (g-7) of section 4900 of the insurance law is  redes-
    38  ignated  subsection (g-8) and a new subsection (g-7) is added to read as
    39  follows:
    40    (g-7) "Out-of-network referral denial" means a denial under a  managed
    41  care product as defined in subsection (c) of section four thousand eight

    42  hundred  one of this chapter of a request for an authorization or refer-
    43  ral to an out-of-network provider on the basis that the health care plan
    44  has a health care provider in the in-network  benefits  portion  of  its
    45  network  with appropriate training and experience to meet the particular
    46  health care needs of  an  insured,  and  who  is  able  to  provide  the
    47  requested  health  service.  The notice of a denial of an out-of-network
    48  referral provided to an insured  shall  include  information  explaining
    49  what  information  the insured must submit in order to appeal the denial
    50  of an out-of-network referral pursuant to subsection  (a-2)  of  section
    51  four  thousand nine hundred four of this article. A denial of an out-of-

    52  network referral under this subsection does not  constitute  an  adverse
    53  determination  as defined in this article. A denial of an out-of-network
    54  referral shall not be construed to include an out-of-network  denial  as
    55  defined in subsection (g-6) of this section.

        S. 2551                             7
 
     1    § 12. Subsection (b) of section 4903 of the insurance law, as added by
     2  chapter 705 of the laws of 1996, is amended to read as follows:
     3    (b)  A utilization review agent shall make a utilization review deter-
     4  mination involving health care services which require  pre-authorization
     5  and provide notice of a determination to the insured or insured's desig-
     6  nee  and  the insured's health care provider by telephone and in writing

     7  within three business days of receipt of the necessary information.  The
     8  notification  shall identify whether the services are considered in-net-
     9  work or out-of-network.
    10    § 13. Section 4904 of the insurance law is amended  by  adding  a  new
    11  subsection (a-2) to read as follows:
    12    (a-2)  An  insured or the insured's designee may appeal a denial of an
    13  out-of-network referral by a health care plan by  submitting  a  written
    14  statement  from  the  insured's  attending  physician,  who  must  be  a
    15  licensed, board certified or board eligible physician qualified to prac-
    16  tice in the specialty area of practice appropriate to treat the  insured
    17  for  the  health  service  sought  that:  (1) the in-network health care

    18  provider or providers recommended by the health care plan  do  not  have
    19  the  appropriate  training  and experience to meet the particular health
    20  care needs of the insured for the health service; and (2) recommends  an
    21  out-of-network  provider with the appropriate training and experience to
    22  meet the particular health care needs of the insured, and who is able to
    23  provide the requested health service.
    24    § 14. Subsection (b) of section 4910 of the insurance law  is  amended
    25  by adding a new paragraph 4 to read as follows:
    26    (4)  (A)  The insured has had an out-of-network referral denied on the
    27  grounds that the health care plan has a  health  care  provider  in  the
    28  in-network benefits portion of its network with appropriate training and

    29  experience  to  meet the particular health care needs of an insured, and
    30  who is able to provide the requested health service.
    31    (B) The insured's attending physician, who shall be a licensed,  board
    32  certified  or  board  eligible  physician  qualified  to practice in the
    33  specialty area of practice appropriate to  treat  the  insured  for  the
    34  health service sought, certifies that the in-network health care provid-
    35  er  or  providers  recommended  by  the health care plan do not have the
    36  appropriate training and experience to meet the particular  health  care
    37  needs  of an insured, and recommends an out-of-network provider with the
    38  appropriate training and experience to meet the particular  health  care

    39  needs  of  an  insured,  and who is able to provide the requested health
    40  service.
    41    § 15. Paragraph 4 of subsection (b) of section 4914 of  the  insurance
    42  law is amended by adding a new subparagraph (D) to read as follows:
    43    (D)  For  external  appeals  requested  pursuant  to paragraph four of
    44  subsection (b) of section four thousand nine hundred ten of  this  title
    45  relating  to an out-of-network referral, the external appeal agent shall
    46  review the utilization review agent's final adverse  determination  and,
    47  in  accordance  with the provisions of this title, shall make a determi-
    48  nation as to whether the out-of-network referral shall be covered by the
    49  health plan; provided that such determination shall:

    50    (i) be conducted only by one or a greater odd number of clinical  peer
    51  reviewers;
    52    (ii) be accompanied by a written statement:
    53    (I)  that  the  out-of-network referral shall be covered by the health
    54  care plan either when the reviewer or a majority of the panel of review-
    55  ers determines, upon review  of  the  training  and  experience  of  the
    56  in-network  health  care provider or providers proposed by the plan, the

        S. 2551                             8
 
     1  training and experience of the requested  out-of-network  provider,  the
     2  clinical  standards of the plan, the information provided concerning the
     3  insured, the attending physician's recommendation, the insured's medical

     4  record,  and  any other pertinent information, that the health plan does
     5  not have a provider with the appropriate training and experience to meet
     6  the particular health care needs of an insured who is  able  to  provide
     7  the  requested  health service, and that the out-of-network provider has
     8  the appropriate training and experience to meet  the  particular  health
     9  care  needs  of  an  insured,  is  able  to provide the requested health
    10  service, and is likely to produce a more clinically beneficial  outcome;
    11  or
    12    (II) upholding the health plan's denial of coverage;
    13    (iii)  be  subject to the terms and conditions generally applicable to
    14  benefits under the evidence of coverage under the health care plan;

    15    (iv) be binding on the plan and the insured; and
    16    (v) be admissible in any court proceeding.
    17    § 16. The public health law is amended by adding two new  sections  23
    18  and 24 to read as follows:
    19    §  23.  Claim  forms.    A  physician shall include a claim form for a
    20  third-party payor with a patient bill for health  care  services,  other
    21  than a bill for the patient's co-payment, coinsurance or deductible.
    22    §  24.  Disclosure.    1. A health care professional shall disclose to
    23  patients or prospective patients  in  writing  or  through  an  internet
    24  website the health care plans in which the health care professional is a
    25  participating  provider  and  the  hospitals  with which the health care
    26  professional is affiliated.

    27    2. If a health care professional does not participate in  the  network
    28  of  a  patient's  or  prospective patient's health care plan, the health
    29  care professional shall, upon receipt of a request  from  a  patient  or
    30  prospective  patient,  disclose to the patient or prospective patient in
    31  writing the amount or estimated amount the health care professional will
    32  bill the  patient  or  prospective  patient  for  health  care  services
    33  provided  or  anticipated  to  be provided to the patient or prospective
    34  patient.
    35    3. A health care professional who  is  a  physician  shall  provide  a
    36  patient  or  prospective  patient  with the name, practice name, mailing
    37  address, and telephone number of any health care  provider  of  anesthe-

    38  siology,  laboratory, pathology, radiology or assistant surgeon services
    39  performed in the physician's office or coordinated or  referred  by  the
    40  physician.
    41    4.    A  health  care  professional  who  is  a physician shall, for a
    42  patient's scheduled hospital admission or scheduled outpatient  hospital
    43  services,  provide  a  patient  and the hospital with the name, practice
    44  name, mailing address and telephone number of any other physician  whose
    45  services will be arranged by the physician and are scheduled at the time
    46  of the pre-admission testing, registration  or admission.
    47    5.  A  hospital  shall  establish, update, make public and post on the
    48  hospital's website, a list of the hospital's standard charges for  items

    49  and  services  provided by the hospital, including for diagnosis-related
    50  groups established under section 1886(d)(4) of the federal social  secu-
    51  rity act.
    52    6.  A  hospital  shall post on the hospital's website:  (a) the health
    53  care plans in which the hospital is a participating  provider;  and  (b)
    54  the  name,  practice  name, mailing address, and telephone number of any
    55  health care professional who is a physician and whose services  will  be

        S. 2551                             9
 
     1  provided at the hospital, but will not be billed as part of the hospital
     2  charges.
     3    7.  A  hospital shall, at the earlier of either pre-admission testing,

     4  outpatient registration, or  a  non-emergency  hospital  admission:  (a)
     5  provide  a  patient or prospective patient with the name, practice name,
     6  mailing address and telephone number of any health care professional who
     7  is a physician and whose services are reasonably anticipated at the time
     8  of the pre-admission testing, registration  or  admission  and  will  be
     9  provided at the hospital, but will not be billed as part of the hospital
    10  charges, as reported by the patient's physician; and (b) disclose wheth-
    11  er  the  services  of  health  care professionals who are physicians and
    12  typically provide hospital services such as, but not limited to, anesth-
    13  esiology, pathology or radiology are billed  as  part  of  the  hospital
    14  charges.

    15    8. For purposes of this section:
    16    (a)  "Health  care  plan"  means a health insurer including an insurer
    17  licensed to write accident and health insurance subject to article thir-
    18  ty-two of the insurance law; a corporation organized pursuant to article
    19  forty-three of the insurance law; a municipal cooperative health benefit
    20  plan certified pursuant to article forty-seven of the insurance  law;  a
    21  health maintenance organization certified pursuant to article forty-four
    22  of this chapter; or a self-funded employee welfare benefit plan.
    23    (b) "Health care professional" means an appropriately licensed, regis-
    24  tered  or  certified health care professional pursuant to title eight of
    25  the education law.

    26    § 17. Paragraphs (p-1), (q) and (r) of subdivision 1 of  section  4408
    27  of the public health law, paragraph (p-1) as added by chapter 554 of the
    28  laws  of 2002, and paragraphs (q) and (r) as added by chapter 705 of the
    29  laws of 1996, are amended and two new paragraphs (s) and (t)  are  added
    30  to read as follows:
    31    (p-1)  notice that an enrollee shall have direct access to primary and
    32  preventive obstetric and gynecologic services including annual  examina-
    33  tions,  care  resulting  from such annual examinations, and treatment of
    34  acute gynecologic conditions, from a qualified provider of such services
    35  of her choice from within the plan [for no fewer than  two  examinations
    36  annually  for such services] or [to] for any care related to a pregnancy

    37  [and that additionally, the enrollee shall have direct access to primary
    38  and preventive obstetric and gynecologic services required as  a  result
    39  of  such  annual  examinations  or  as  a result of an acute gynecologic
    40  condition];
    41    (q) notice of all appropriate mailing addresses and telephone  numbers
    42  to be utilized by enrollees seeking information or authorization; [and]
    43    (r)  a  listing by specialty, which may be in a separate document that
    44  is updated annually, of the name, address and telephone  number  of  all
    45  participating  providers, including facilities, and, in addition, in the
    46  case of physicians, board certification[.], languages spoken and  affil-
    47  iation with participating hospitals. The listing shall also be posted on

    48  the health maintenance organization's website and the health maintenance
    49  organization  shall  update the website within fifteen days of the addi-
    50  tion or termination of a provider from the health maintenance  organiza-
    51  tion's network or a change in a physician's hospital affiliation;
    52    (s) where applicable, a description of the method by which an enrollee
    53  may  submit  a  claim  for  health  care services, including through the
    54  internet, electronic mail or by facsimile; and

        S. 2551                            10
 
     1    (t) where applicable, when a contract offers  out-of-network  coverage
     2  pursuant  to  subsections  (b)  and  (c)  of  section three thousand two
     3  hundred forty of the insurance law:

     4    (i)  a clear description of the methodology used by the health mainte-
     5  nance organization to determine reimbursement for out-of-network  health
     6  care services;
     7    (ii) a description of the amount that the health maintenance organiza-
     8  tion will reimburse under the methodology for out-of-network health care
     9  services  set  forth as a percentage of the usual and customary cost for
    10  out-of-network health care services; and
    11    (iii) examples  of  anticipated  out-of-pocket  costs  for  frequently
    12  billed out-of-network health care services.
    13    §  18.  Paragraphs (k) and (l) of subdivision 2 of section 4408 of the
    14  public health law, as added by chapter 705 of  the  laws  of  1996,  are
    15  amended  and  three new paragraphs (m), (n) and (o) are added to read as

    16  follows:
    17    (k) provide the written application procedures and minimum  qualifica-
    18  tion  requirements  for  health  care  providers to be considered by the
    19  health maintenance organization; [and]
    20    (1) disclose  other  information  as  required  by  the  commissioner,
    21  provided  that  such  requirements are promulgated pursuant to the state
    22  administrative procedure act[.];
    23    (m) disclose whether a health care provider  scheduled  to  provide  a
    24  health care service is an in-network provider;
    25    (n)   where  applicable,  with  respect  to  out-of-network  coverage,
    26  disclose the dollar amount that the health maintenance organization will
    27  pay for a specific out-of-network health care service; and

    28    (o) provide information in writing and  through  an  internet  website
    29  that reasonably permits an enrollee or prospective enrollee to determine
    30  the  anticipated  out-of-pocket  cost  for  out-of-network  health  care
    31  services in a geographical area or zip code based  upon  the  difference
    32  between  what  the  health  maintenance  organization will reimburse for
    33  out-of-network health care services and the usual and customary cost for
    34  out-of-network health care services.
    35    § 19. Section 4408 of the public health law is amended by adding a new
    36  subdivision 7 to read as follows:
    37    7.  For purposes of this section, "usual  and  customary  cost"  shall
    38  mean  the  eightieth percentile of all charges for the particular health

    39  care service performed by a provider in the same  or  similar  specialty
    40  and provided in the same geographical area as reported in a benchmarking
    41  database  maintained by a nonprofit organization specified by the super-
    42  intendent of financial services. The nonprofit organization shall not be
    43  affiliated with an insurer, a corporation subject to article forty-three
    44  of the insurance law, a municipal cooperative health benefit plan certi-
    45  fied pursuant to article forty-seven of the insurance law, or  a  health
    46  maintenance organization certified pursuant to this article.
    47    §  20.  Subdivision  7-g  of  section 4900 of the public health law is
    48  renumbered subdivision 7-h and a new subdivision 7-g is added to read as
    49  follows:

    50    7-g. "Out-of-network referral denial" means a denial of a request  for
    51  an  authorization or referral to an out-of-network provider on the basis
    52  that the health care plan has a health care provider in  the  in-network
    53  benefits portion of its network with appropriate training and experience
    54  to meet the particular health care needs of an enrollee, and who is able
    55  to  provide  the  requested health service. The notice of a denial of an
    56  out-of-network referral provided to an enrollee shall  include  informa-

        S. 2551                            11
 
     1  tion  explaining  what  information the enrollee must submit in order to
     2  appeal the denial of an out-of-network referral pursuant to  subdivision

     3  one-b  of  section  four  thousand  nine hundred four of this article. A
     4  denial  of  an  out-of-network  referral under this subdivision does not
     5  constitute an adverse determination as defined in this article. A denial
     6  of an out-of-network referral shall not be construed to include an  out-
     7  of-network denial as defined in subdivision seven-f of this section.
     8    § 21. Subdivision 2 of section 4903 of the public health law, as added
     9  by chapter 705 of the laws of 1996, is amended to read as follows:
    10    2. A utilization review agent shall make a utilization review determi-
    11  nation  involving  health  care services which require pre-authorization
    12  and provide notice of a determination  to  the  enrollee  or  enrollee's
    13  designee  and  the  enrollee's  health care provider by telephone and in

    14  writing within three business days of receipt of the necessary  informa-
    15  tion.  The  notification shall identify whether the services are consid-
    16  ered in-network or out-of-network.
    17    § 22. Section 4904 of the public health law is amended by adding a new
    18  subdivision 1-b to read as follows:
    19    1-b. An enrollee or the enrollee's designee may appeal a denial of  an
    20  out-of-network  referral  by  a health care plan by submitting a written
    21  statement from  the  enrollee's  attending  physician,  who  must  be  a
    22  licensed, board certified or board eligible physician qualified to prac-
    23  tice in the specialty area of practice appropriate to treat the enrollee
    24  for  the  health  service  sought  that:  (a) the in-network health care

    25  provider or providers recommended by the health care plan  do  not  have
    26  the  appropriate  training  and experience to meet the particular health
    27  care needs of the enrollee for the health service; and (b) recommends an
    28  out-of-network provider with the appropriate training and experience  to
    29  meet  the  particular health care needs of the enrollee, and who is able
    30  to provide the requested health service.
    31    § 23. Subdivision 2 of section  4910  of  the  public  health  law  is
    32  amended by adding a new paragraph (d) to read as follows:
    33    (d)  (i) The enrollee has had an out-of-network referral denied on the
    34  grounds that the health care plan has a  health  care  provider  in  the
    35  in-network benefits portion of its network with appropriate training and

    36  experience  to meet the particular health care needs of an enrollee, and
    37  who is able to provide the requested health service.
    38    (ii) The enrollee's attending physician,  who  shall  be  a  licensed,
    39  board certified or board eligible physician qualified to practice in the
    40  specialty  area  of  practice  appropriate to treat the enrollee for the
    41  health service sought, certifies that the in-network health care provid-
    42  er or providers recommended by the health care  plan  do  not  have  the
    43  appropriate  training  and experience to meet the particular health care
    44  needs of an enrollee, and recommends an out-of-network provider with the
    45  appropriate training and experience to meet the particular  health  care

    46  needs  of  an  enrollee, and who is able to provide the requested health
    47  service.
    48    § 24. Paragraph (d) of subdivision 2 of section  4914  of  the  public
    49  health  law  is  amended  by  adding  a  new subparagraph (D) to read as
    50  follows:
    51    (D) For external appeals requested pursuant to paragraph (d) of subdi-
    52  vision two of section four thousand  nine  hundred  ten  of  this  title
    53  relating  to an out-of-network referral, the external appeal agent shall
    54  review the utilization review agent's final adverse  determination  and,
    55  in  accordance  with the provisions of this title, shall make a determi-

        S. 2551                            12
 
     1  nation as to whether the out-of-network referral shall be covered by the

     2  health plan; provided that such determination shall:
     3    (i)  be conducted only by one or a greater odd number of clinical peer
     4  reviewers;
     5    (ii) be accompanied by a written statement:
     6    (1) that the out-of-network referral shall be covered  by  the  health
     7  care plan either when the reviewer or a majority of the panel of review-
     8  ers  determines,  upon  review  of  the  training  and experience of the
     9  in-network health care provider or providers proposed by the  plan,  the
    10  training  and  experience  of the requested out-of-network provider, the
    11  clinical standards of the plan, the information provided concerning  the
    12  enrollee,  the  attending  physician's  recommendation,  the  enrollee's

    13  medical record, and any other pertinent  information,  that  the  health
    14  plan  does not have a provider with the appropriate training and experi-
    15  ence to meet the particular health care needs of an enrollee who is able
    16  to provide the requested health service,  and  that  the  out-of-network
    17  provider has the appropriate training and experience to meet the partic-
    18  ular  health care needs of an enrollee, is able to provide the requested
    19  health service, and is likely to produce a  more  clinically  beneficial
    20  outcome; or
    21    (2) upholding the health plan's denial of coverage;
    22    (iii)  be  subject to the terms and conditions generally applicable to
    23  benefits under the evidence of coverage under the health care plan;

    24    (iv) be binding on the plan and the enrollee; and
    25    (v) be admissible in any court proceeding.
    26    § 25. The financial services law is amended by adding a new article  7
    27  to read as follows:
    28                                   ARTICLE 7
    29                         EMERGENCY MEDICAL SERVICES
    30  Section 701. Definitions.
    31          702. Prohibition of excessive charges for emergency services.
    32          703. Dispute resolution.
    33          704. Criteria for determining excessive charges.
    34    § 701. Definitions. For the purposes of this article:
    35    (a) "Emergency condition" means a medical or behavioral condition that
    36  manifests  itself  by  acute  symptoms of sufficient severity, including

    37  severe pain, such that a prudent layperson, possessing an average  know-
    38  ledge  of  medicine  and  health, could reasonably expect the absence of
    39  immediate medical attention to result in (1) placing the health  of  the
    40  person afflicted with such condition in serious jeopardy, or in the case
    41  of a behavioral condition placing the health of such person or others in
    42  serious  jeopardy;  (2) serious impairment to such person's bodily func-
    43  tions; (3) serious dysfunction of any  bodily  organ  or  part  of  such
    44  person;  (4)  serious  disfigurement  of such person; or (5) a condition
    45  described in clause (i), (ii) or (iii) of section 1867(e)(1)(A)  of  the
    46  social security act.
    47    (b)  "Emergency  services"  means, with respect to an emergency condi-

    48  tion: (1) a medical screening examination as required under section 1867
    49  of the social security act, 42 U.S.C. §  1395dd,  which  is  within  the
    50  capability  of  the emergency department of a hospital, including ancil-
    51  lary services routinely available to the emergency department to  evalu-
    52  ate such emergency medical condition; and (2) within the capabilities of
    53  the staff and facilities available at the hospital, such further medical
    54  examination  and  treatment  as  are  required under section 1867 of the
    55  social security act, 42 U.S.C.  § 1395dd, to stabilize the patient.

        S. 2551                            13
 
     1    (c) "Excessive fee" means a fee that is in excess of an amount  deter-

     2  mined in accordance with section seven hundred four of this article.
     3    (d)  "Health  care  plan"  means a health insurer including an insurer
     4  licensed to write accident and health insurance subject to article thir-
     5  ty-two of the insurance law; a corporation organized pursuant to article
     6  forty-three of the insurance law; a municipal cooperative health benefit
     7  plan certified pursuant to article forty-seven of the insurance  law;  a
     8  health maintenance organization certified pursuant to article forty-four
     9  of  the  public  health  law;  or a self-funded employee welfare benefit
    10  plan.
    11    (e) "Insured" means a patient covered under a policy or contract  with
    12  a health care plan.

    13    (f)  "Patient"  means a person who receives emergency services in this
    14  state.
    15    (g) "Usual and customary cost" means the eightieth percentile  of  all
    16  charges  for  the particular health care service performed by a provider
    17  in the same or similar specialty and provided in the  same  geographical
    18  area  as  reported  in a benchmarking database maintained by a nonprofit
    19  organization specified by the superintendent. The nonprofit organization
    20  shall not be affiliated with an insurer, a corporation subject to  arti-
    21  cle  forty-three  of  the  insurance law, a municipal cooperative health
    22  benefit plan certified pursuant to article forty-seven of the  insurance
    23  law,  or a health maintenance organization certified pursuant to article

    24  forty-four of the public health law.
    25    § 702. Prohibition of excessive charges for emergency services.  (a) A
    26  physician who provides health care services  in  this  state  shall  not
    27  charge  an  excessive  fee based on the criteria for providing emergency
    28  services in section seven hundred three of this article.
    29    (b) This article shall not apply to emergency services where  provider
    30  fees  are  subject  to schedules or other monetary limitations under any
    31  other law, including the workers' compensation law and article fifty-one
    32  of the insurance law, and shall not preempt any such law.
    33    § 703. Dispute resolution.  (a) A health care plan or a patient alleg-
    34  ing that a physician has charged an excessive fee for providing emergen-

    35  cy services may submit the dispute for review to an independent  dispute
    36  resolution  entity,  in  accordance  with regulations promulgated by the
    37  superintendent, if the physician's charge exceeds the usual and  custom-
    38  ary cost of the health care services.
    39    (b)  A  patient  shall  not  be required to pay the physician's fee in
    40  order to be eligible to submit the dispute for review to the independent
    41  dispute resolution entity.
    42    § 704. Criteria for determining excessive charges.  (a) (1) The  inde-
    43  pendent  dispute  resolution entity shall decide whether the fee charged
    44  by the physician for the services rendered is excessive. In making  such
    45  a determination the independent dispute resolution entity shall consider

    46  all relevant factors including:
    47    (i)  Whether there is a gross disparity between the fee charged by the
    48  physician for services rendered as compared to: (A)  fees  paid  by  the
    49  health  care  plan  to  reimburse similarly qualified physicians for the
    50  same services in the same region who do not participate with the  health
    51  care  plan;  and  (B)  fees  paid to the involved physician for the same
    52  services rendered by the physician to patients in health care  plans  in
    53  which the physician does not participate;
    54    (ii) The level of training, education and experience of the physician;

        S. 2551                            14
 
     1    (iii) The physician's usual charge for comparable services with regard

     2  to patients in health care plans in which the physician does not partic-
     3  ipate;
     4    (iv)  The circumstances and complexity of the particular case, includ-
     5  ing time and place of the service;
     6    (v) Individual patient characteristics; and
     7    (vi) The usual and customary cost of the service.
     8    (2) If the independent dispute resolution entity determines  that  the
     9  fee charged is excessive, then the independent dispute resolution entity
    10  shall  determine  a  reasonable fee for the services based upon the same
    11  conditions and factors set forth in this subdivision,  which  fee  shall
    12  not  be  less  than the usual and customary cost for such services.  The
    13  physician shall return to the health care plan any portion  of  the  fee

    14  paid  by  the  health care plan in excess of the amount determined to be
    15  reasonable by the independent dispute resolution entity.
    16    (b) The determination of  an  independent  dispute  resolution  entity
    17  shall  be  binding  on  the health care plan, physician and patient, and
    18  shall be admissible in any court  proceeding  between  the  health  care
    19  plan,  physician or patient, or in any administrative proceeding between
    20  this state and the physician.
    21    (c) The superintendent shall promulgate regulations to establish stan-
    22  dards for the dispute resolution process including standards for  estab-
    23  lishing  which  party  shall  be  responsible for payment of the dispute
    24  resolution process.

    25    § 26. This act shall take effect January 1, 2014,  provided,  however,
    26  that:
    27    1.  for  policies  renewed  on and after such date this act shall take
    28  effect on the renewal date;
    29    2. sections twelve, sixteen, twenty-one and twenty-five  of  this  act
    30  shall  apply to health care services provided on and after such date and
    31  section twenty-five of this act shall  expire  and  be  deemed  repealed
    32  January 1, 2016; and
    33    3.  sections  eleven, thirteen, fourteen, fifteen, twenty, twenty-two,
    34  twenty-three and twenty-four of this act shall apply to  denials  issued
    35  on and after such date.
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