New York State Assembly

 
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A07611 Summary:

A07611 Actions:

A07611 Committee Votes:

Committee:INSURANCE   Chair:Cahill      
DATE:05/16/2017AYE/NAY:24/0  Action: Favorable refer to committee Codes        
Cahill
Aye
Barclay
Aye
Cook
Aye
Butler
Aye
Pretlow
Aye
Hawley
Aye
Rivera
Excused
Blankenbush
Aye
Peoples-Stokes
Aye
Curran
Aye
Cymbrowitz
Aye
Walter
Aye
Lavine
Aye
Garbarino
Aye
Moya
Aye
Hevesi
Aye
Skoufis
Aye
Steck
Aye
Crespo
Aye
Joyner
Aye
Dilan
Aye
Hunter
Aye
Simotas
Aye
Walker
Aye
Niou
Aye

Committee:CODES   Chair:Lentol      
DATE:05/23/2017AYE/NAY:20/0  Action: Favorable         
Lentol
Aye
Graf
Aye
Schimminger
Aye
Giglio
Aye
Weinstein
Aye
McKevitt
Aye
Pretlow
Aye
Montesano
Aye
Cook
Aye
Ra
Aye
Cymbrowitz
Aye
Morinello
Aye
Titus
Aye
O'Donnell
Aye
Lavine
Aye
Perry
Aye
Zebrowski
Aye
Abinanti
Aye
Weprin
Aye
Mosley
Absent
Hevesi
Excused
Fahy
Aye

A07611 Floor Votes:

A07611 Text:

 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         7611--C
                                                                Cal. No. 534
 
                               2017-2018 Regular Sessions
 
                   IN ASSEMBLY
 
                                       May 3, 2017
                                       ___________
 
        Introduced  by  M.  of  A.  CAHILL, COLTON, ARROYO, JEAN-PIERRE, TAYLOR,
          McDONOUGH -- read once and referred to the Committee on  Insurance  --
          reported and referred to the Committee on Codes -- advanced to a third
          reading, passed by Assembly and delivered to the Senate, recalled from
          the  Senate,  vote  reconsidered,  bill  amended,  ordered  reprinted,
          retaining its place on the order of third reading -- passed by  Assem-
          bly and delivered to the Senate, recalled from the Senate, vote recon-
          sidered,  bill  amended, ordered reprinted, retaining its place on the
          order of third reading -- passed by  Assembly  and  delivered  to  the
          Senate,  recalled  from  the  Senate, vote reconsidered, bill amended,
          ordered reprinted, retaining its place on the order of third reading
 
        AN ACT to amend the financial services law, in relation to  establishing
          protections from excessive hospital emergency 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, the
     7  health care plan shall pay an amount that it  determines  is  reasonable
     8  for  the  emergency services rendered by the non-participating physician
     9  or hospital, in accordance with section three thousand two hundred twen-
    10  ty-four-a of the insurance law, except  for  the  insured's  co-payment,
    11  coinsurance  or  deductible,  if  any, and shall ensure that the insured
    12  shall incur no greater out-of-pocket costs for  the  emergency  services
    13  than  the  insured would have incurred with a participating physician or
    14  hospital pursuant to  subsection  (c)  of  section  three  thousand  two
    15  hundred forty-one of the insurance law.
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD09770-08-8
        A. 7611--C                          2
 
     1    (2)  A  non-participating  physician or hospital or a health care plan
     2  may submit a dispute regarding a fee or payment for  emergency  services
     3  for  review to an independent dispute resolution entity.  In cases where
     4  a health care plan submits a dispute regarding a fee for  payment  of  a
     5  non-participating  hospital's  emergency  services, the health care plan
     6  shall, after the initial payment, pay any additional amounts  it  deter-
     7  mines is reasonable directly to the non-participating hospital.
     8    (3)  The  independent  dispute resolution entity shall make a determi-
     9  nation within thirty days of receipt of the dispute for review.
    10    (4) In determining a reasonable fee  for  the  services  rendered,  an
    11  independent  dispute  resolution  entity  shall select either the health
    12  care plan's payment or the non-participating physician's  or  hospital's
    13  fee.  The  independent  dispute  resolution entity shall determine which
    14  amount to select based upon the conditions  and  factors  set  forth  in
    15  section  six  hundred  four  of  this article. If an independent dispute
    16  resolution entity determines, based on the health  care  plan's  payment
    17  and  the non-participating physician's or hospital's fee, that a settle-
    18  ment between the health care plan  and  non-participating  physician  or
    19  hospital  is  reasonably  likely,  or  that  both the health care plan's
    20  payment and the non-participating physician's or hospital's  fee  repre-
    21  sent  unreasonable  extremes,  then  the  independent dispute resolution
    22  entity may direct both parties to attempt a good faith  negotiation  for
    23  settlement.  The  health  care  plan  and non-participating physician or
    24  hospital may be granted up to ten business days  for  this  negotiation,
    25  which  shall  run  concurrently  with  the thirty day period for dispute
    26  resolution.
    27    (b) Emergency services for a patient that is not  an  insured.  (1)  A
    28  patient  that  is not an insured or the patient's physician may submit a
    29  dispute regarding a fee for emergency services for review  to  an  inde-
    30  pendent dispute resolution entity upon approval of the superintendent.
    31    (2) An independent dispute resolution entity shall determine a reason-
    32  able fee for the services based upon the same conditions and factors set
    33  forth in section six hundred four of this article.
    34    (3)  A patient that is not an insured shall not be required to pay the
    35  physician's or hospital's fee in order to  be  eligible  to  submit  the
    36  dispute for review to an independent dispute resolution entity.
    37    (c)  The  determination  of  an  independent dispute resolution entity
    38  shall be binding on the health care  plan,  physician  or  hospital  and
    39  patient,  and  shall  be  admissible in any court proceeding between the
    40  health care plan, physician or hospital or patient, or in  any  adminis-
    41  trative proceeding between this state and the physician or hospital.
    42    §  2. Subdivision (a) of section 608 of the financial services law, as
    43  added by section 26 of part H of chapter 60 of  the  laws  of  2014,  is
    44  amended to read as follows:
    45    (a)  For  disputes  involving an insured, when the independent dispute
    46  resolution entity determines the health care plan's payment  is  reason-
    47  able,  payment for the dispute resolution process shall be the responsi-
    48  bility of the non-participating physician or hospital.   When the  inde-
    49  pendent  dispute  resolution  entity  determines  the  non-participating
    50  physician's or hospital's fee is reasonable,  payment  for  the  dispute
    51  resolution  process shall be the responsibility of the health care plan.
    52  When a good faith negotiation directed by the independent dispute resol-
    53  ution entity pursuant to paragraph four of subsection (a) of section six
    54  hundred five of this article, or paragraph  six  of  subsection  (a)  of
    55  section  six  hundred  seven  of  this  article  results in a settlement
    56  between the health care plan and non-participating physician, the health
        A. 7611--C                          3
 
     1  care plan and the non-participating physician or hospital  shall  evenly
     2  divide and share the prorated cost for dispute resolution.
     3    § 3. Section 604 of the financial services law, as added by section 26
     4  of  part  H  of  chapter  60  of the laws of 2014, is amended to read as
     5  follows:
     6    § 604. Criteria for determining a reasonable fee. In  determining  the
     7  appropriate  amount  to  pay  for  a health care service, an independent
     8  dispute resolution entity shall consider all relevant  factors,  includ-
     9  ing:
    10    (a)  whether there is a gross disparity between the fee charged by the
    11  [physician] health care provider for services rendered as compared to:
    12    (1) fees paid to the involved [physician] health care provider for the
    13  same services rendered by the [physician] health care provider to  other
    14  patients  in  health  care  plans  in  which the [physician] health care
    15  provider is not participating, and
    16    (2) in the case of a dispute involving a health care plan,  fees  paid
    17  by  the  health  care plan to reimburse similarly qualified [physicians]
    18  health care providers for the same services in the same region  who  are
    19  not participating with the health care plan;
    20    (b) the level of training, education and experience of the [physician]
    21  health care provider;
    22    (c) the [physician's] health care provider's usual charge for compara-
    23  ble  services  with regard to patients in health care plans in which the
    24  [physician] health care provider is not participating;
    25    (d) the circumstances and complexity of the particular case, including
    26  time and place of the service;
    27    (e) individual patient characteristics; and, with regard to  physician
    28  services,
    29    (f) the usual and customary cost of the service.
    30    § 4. This act shall take effect immediately.