S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  10470

                          I N  A S S E M B L Y

                              May 27, 2016
                               ___________

Introduced by M. of A. CAHILL -- read once and referred to the Committee
  on Insurance

AN  ACT to amend the financial services law, in relation to establishing
  protections from excessive hospital 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:

  Section 1. Section 605 of the financial  services  law,  as  added  by
section  26  of  part H of chapter 60 of the laws of 2014, is amended to
read as follows:
  S 605.  Dispute  resolution  for  emergency  services.  (a)  Emergency
services for an insured. (1) When a health care plan receives a bill for
emergency  services  from a non-participating physician OR HOSPITAL, the
health care plan shall pay an amount that it  determines  is  reasonable
for  the  emergency services rendered by the non-participating physician
OR HOSPITAL, in accordance with section three thousand two hundred twen-
ty-four-a of the insurance law, except  for  the  insured's  co-payment,
coinsurance  or  deductible,  if  any, and shall ensure that the insured
shall incur no greater out-of-pocket costs for  the  emergency  services
than  the  insured would have incurred with a participating physician OR
HOSPITAL pursuant to  subsection  (c)  of  section  three  thousand  two
hundred forty-one of the insurance law.
  (2)  A  non-participating  physician OR HOSPITAL or a health care plan
may submit a dispute regarding a fee or payment for  emergency  services
for review to an independent dispute resolution entity. IN CASES WHERE A
HEALTH  CARE  PLAN  SUBMITS  A  DISPUTE REGARDING A FEE FOR PAYMENT OF A
NON-PARTICIPATING HOSPITAL'S EMERGENCY ROOM SERVICES,  THE  HEALTH  CARE
PLAN  SHALL  PAY  THE AMOUNT IT DETERMINES IS REASONABLE DIRECTLY TO THE
NON-PARTICIPATING HOSPITAL.
  (3) The independent dispute resolution entity shall  make  a  determi-
nation within thirty days of receipt of the dispute for review.
  (4)  In  determining  a  reasonable  fee for the services rendered, an
independent dispute resolution entity shall  select  either  the  health
care  plan's  payment or the non-participating physician's OR HOSPITAL'S

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
              

                                                           LBD15693-01-6

A. 10470                            2

fee. The independent dispute resolution  entity  shall  determine  which
amount  to  select  based  upon  the conditions and factors set forth in
section six hundred four of this  article.  If  an  independent  dispute
resolution  entity  determines,  based on the health care plan's payment
and the non-participating physician's OR HOSPITAL'S fee, that a  settle-
ment  between  the  health  care plan and non-participating physician OR
HOSPITAL is reasonably likely, or  that  both  the  health  care  plan's
payment  and  the non-participating physician's OR HOSPITAL'S fee repre-
sent unreasonable extremes,  then  the  independent  dispute  resolution
entity  may  direct both parties to attempt a good faith negotiation for
settlement. The health care  plan  and  non-participating  physician  OR
HOSPITAL  may  be  granted up to ten business days for this negotiation,
which shall run concurrently with the  thirty  day  period  for  dispute
resolution.
  (b)  Emergency  services  for  a patient that is not an insured. (1) A
patient that is not an insured or the patient's physician may  submit  a
dispute  regarding  a  fee for emergency services for review to an inde-
pendent dispute resolution entity upon approval of the superintendent.
  (2) An independent dispute resolution entity shall determine a reason-
able fee for the services based upon the same conditions and factors set
forth in section six hundred four of this article.
  (3) A patient that is not an insured shall not be required to pay  the
physician's  OR  HOSPITAL'S  fee  in  order to be eligible to submit the
dispute for review to an independent dispute resolution entity.
  (c) The determination of  an  independent  dispute  resolution  entity
shall  be  binding  on  the  health care plan, physician OR HOSPITAL and
patient, and shall be admissible in any  court  proceeding  between  the
health  care  plan, physician OR HOSPITAL or patient, or in any adminis-
trative proceeding between this state and the physician OR HOSPITAL.
  S 2. Subdivision (a) of section 608 of the financial services law,  as
added  by  section  26  of  part H of chapter 60 of the laws of 2014, is
amended to read as follows:
  (a) For disputes involving an insured, when  the  independent  dispute
resolution  entity  determines the health care plan's payment is reason-
able, payment for the dispute resolution process shall be the  responsi-
bility  of  the non-participating physician OR HOSPITAL.  When the inde-
pendent  dispute  resolution  entity  determines  the  non-participating
physician's  OR  HOSPITAL'S  fee  is reasonable, payment for the dispute
resolution process shall be the responsibility of the health care  plan.
When a good faith negotiation directed by the independent dispute resol-
ution  entity pursuant to paragraph four of [subsection] SUBDIVISION (a)
of section six hundred  five  of  this  article,  or  paragraph  six  of
[subsection]  SUBDIVISION (a) of section six hundred seven of this arti-
cle results in a settlement between the health care plan and  non-parti-
cipating  physician,  the  health  care  plan  and the non-participating
physician OR HOSPITAL shall evenly divide and share  the  prorated  cost
for dispute resolution.
  S  3.    A contract between a hospital or hospital system located in a
county with a population greater than 178,000 and less than 182,000  and
a  commercial  health  insurer  providing  coverage or benefits for both
fully insured and self-insured members is subject to expire or is  being
terminated  on  or  after May 31, 2016, shall automatically be extended,
under the same terms and  conditions,  for  an  additional  ninety  days
during  which  time  the parties to the contract shall engage a mutually
agreeable independent and qualified third party to mediate the financial

A. 10470                            3

terms in dispute between the parties. In selecting the third party medi-
ator, such parties shall act reasonably and in good faith.
  S  4.  This  act  shall take effect immediately; provided that section
three of this act shall expire and be  deemed  repealed  on  January  1,
2017.