S T A T E O F N E W Y O R K
________________________________________________________________________
264--B
2019-2020 Regular Sessions
I N A S S E M B L Y
(PREFILED)
January 9, 2019
___________
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:
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:
§ 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,
INCLUDING A BILL FOR INPATIENT SERVICES WHICH FOLLOW AN EMERGENCY ROOM
VISIT, 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 twenty-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 thou-
sand 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
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD03101-05-9
A. 264--B 2
NON-PARTICIPATING HOSPITAL'S EMERGENCY SERVICES, THE HEALTH CARE PLAN
SHALL, AFTER THE INITIAL PAYMENT, PAY ANY ADDITIONAL AMOUNTS IT DETER-
MINES 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
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.
(D) THE PROVISIONS OF THIS SECTION SHALL NOT APPLY TO HOSPITALS THAT
HAD AT LEAST SIXTY PERCENT OF INPATIENT DISCHARGES ANNUALLY WHICH
CONSISTED OF MEDICAID, UNINSURED, AND DUAL ELIGIBLE INDIVIDUALS AS
DETERMINED BY THE DEPARTMENT OF HEALTH IN ITS DETERMINATION OF SAFETY
NET HOSPITALS.
§ 2. Subsection (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 (a) of section six
hundred five of this article, or paragraph six of subsection (a) of
section six hundred seven of this article results in a settlement
A. 264--B 3
between the health care plan and non-participating physician OR
HOSPITAL, the health care plan and the non-participating physician OR
HOSPITAL shall evenly divide and share the prorated cost for dispute
resolution.
§ 3. Section 604 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:
§ 604. Criteria for determining a reasonable fee. In determining the
appropriate amount to pay for a health care service, an independent
dispute resolution entity shall consider all relevant factors, includ-
ing:
(a) whether there is a gross disparity between the fee charged by the
[physician] HEALTH CARE PROVIDER for services rendered as compared to:
(1) fees paid to the involved [physician] HEALTH CARE PROVIDER for the
same services rendered by the [physician] HEALTH CARE PROVIDER to other
patients in health care plans in which the [physician] HEALTH CARE
PROVIDER is not participating, and
(2) in the case of a dispute involving a health care plan, fees paid
by the health care plan to reimburse similarly qualified [physicians]
HEALTH CARE PROVIDERS for the same services in the same region who are
not participating with the health care plan;
(b) the level of training, education and experience of the [physician]
HEALTH CARE PROVIDER;
(c) the [physician's] HEALTH CARE PROVIDER'S usual charge for compara-
ble services with regard to patients in health care plans in which the
[physician] HEALTH CARE PROVIDER is not participating;
(d) the circumstances and complexity of the particular case, including
time and place of the service;
(e) individual patient characteristics; and, WITH REGARD TO PHYSICIAN
SERVICES,
(f) the usual and customary cost of the service.
§ 4. This act shall take effect immediately.