S T A T E O F N E W Y O R K
________________________________________________________________________
6544
2019-2020 Regular Sessions
I N S E N A T E
June 15, 2019
___________
Introduced by Sen. KRUEGER -- read twice and ordered printed, and when
printed to be committed to the Committee on Rules
AN ACT to amend the financial services law, the public health law and
the insurance law, in relation to establishing protections from excess
hospital charges; and to amend a chapter of the laws of 2019, amending
the financial services law relating to establishing protections from
excess hospital charges, as proposed in legislative bills numbers S.
3171-A and A. 264-B, in relation to the effectiveness 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 amended by a
chapter of the laws of 2019, amending the financial services law relat-
ing to establishing protections from excess hospital charges, as
proposed in legislative bills numbers S. 3171-A and A. 264-B, 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. IF AN INSURED ASSIGNS
BENEFITS TO A NON-PARTICIPATING HOSPITAL IN RELATION TO EMERGENCY
SERVICES PROVIDED BY SUCH NON-PARTICIPATING HOSPITAL, THE NON-PARTICI-
PATING HOSPITAL MAY BILL THE HEALTH CARE PLAN FOR THE EMERGENCY SERVICES
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD03101-09-9
S. 6544 2
RENDERED. UPON RECEIPT OF THE BILL, THE HEALTH CARE PLAN SHALL PAY THE
NON-PARTICIPATING HOSPITAL THE AMOUNT PRESCRIBED BY THIS SECTION AND ANY
SUBSEQUENT AMOUNT DETERMINED TO BE OWED TO THE HOSPITAL IN RELATION TO
THE EMERGENCY SERVICES PROVIDED. TO THE EXTENT THAT A NON-PARTICIPATING
HOSPITAL OPTS TO SEND THE BILL TO A PATIENT IN ADDITION TO OR IN LIEU OF
THE HEALTH CARE PLAN, SUCH BILL MUST STATE IN BOLD, LARGE CONSPICUOUS
PRINT ON THE TOP OF THE BILL A NOTATION THAT THE PATIENT IS NOT RESPON-
SIBLE FOR THE PAYMENT OF THE BILL, OTHER THAN THE DEDUCTIBLE, COPAYMENTS
OR OTHER COST SHARING OBLIGATIONS OF THE PATIENT.
(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 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.
S. 6544 3
(E) FOR PURPOSES OF THE HOSPITAL PAYMENT PURSUANT TO SUBSECTION (A) OF
THIS SECTION, THE AMOUNT THE HEALTH CARE PLAN SHALL PAY TO THE HOSPITAL
SHALL BE AT LEAST TWENTY-FIVE PERCENT GREATER THAN THE AMOUNT THE HEALTH
CARE PLAN WOULD HAVE PAID FOR THE CLAIM HAD THE HOSPITAL BEEN IN
NETWORK, BASED ON THE MOST RECENT CONTRACT BETWEEN THE HEALTH CARE PLAN
AND THE HOSPITAL. PROVIDED HOWEVER, THE AMOUNT PAID BY THE HEALTH CARE
PLAN PURSUANT TO THIS SUBSECTION SHALL NOT PREJUDICE EITHER PARTY OR
PRECLUDE EITHER PARTY FROM SUBMITTING A DISPUTE TO THE DISPUTE RESOL-
UTION ENTITY RELATING TO THE PAYMENT TO THE HOSPITAL OR PRECLUDE THE
HOSPITAL FROM SEEKING ADDITIONAL PAYMENT FROM THE HEALTH CARE PLAN PRIOR
TO A DECISION BY THE DISPUTE RESOLUTION ENTITY. TO THE EXTENT THE PRIOR
CONTRACT BETWEEN THE HOSPITAL AND HEALTH CARE PLAN EXPIRED GREATER THAN
TWELVE MONTHS PRIOR TO THE PAYMENT OF THE DISPUTED CLAIM, THE PAYMENT
AMOUNT SHALL BE ADJUSTED BASED UPON THE MEDICAL CONSUMER PRICE INDEX.
THE PROVISIONS OF THIS SUBSECTION SHALL ONLY APPLY TO THE EXTENT THE
HEALTH CARE PLAN AND HOSPITAL HAD PREVIOUSLY ENTERED INTO A PARTICIPAT-
ING PROVIDER AGREEMENT.
§ 2. Section 604 of the financial services law, as amended by a chap-
ter of the laws of 2019, amending the financial services law relating to
establishing protections from excess hospital charges, as proposed in
legislative bills numbers S. 3171-A and A. 264-B, 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
[health care provider] PHYSICIAN OR HOSPITAL for services rendered as
compared to:
(1) fees paid to the involved [health care provider] PHYSICIAN OR
HOSPITAL for the same services rendered by the [health care provider]
PHYSICIAN OR HOSPITAL to other patients in health care plans in which
the [health care provider] PHYSICIAN OR HOSPITAL 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 [health care
providers] PHYSICIANS OR HOSPITALS 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 [health
care provider] PHYSICIAN, AND IN THE CASE OF A HOSPITAL, THE TEACHING
STAFF, SCOPE OF SERVICES AND CASE MIX;
(c) the [health care provider's] PHYSICIAN'S AND HOSPITAL'S usual
charge for comparable services with regard to patients in health care
plans in which the [health care provider] PHYSICIAN OR HOSPITAL 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.
§ 3. Section 4406-c of the public health law is amended by adding a
new subdivision 5-e to read as follows:
5-E. AT LEAST SIXTY DAYS PRIOR TO THE TERMINATION OF A CONTRACT
BETWEEN A HOSPITAL AND A HEALTH CARE PLAN, THE PARTIES SHALL UTILIZE A
MUTUALLY AGREED UPON MEDIATOR TO ASSIST IN RESOLVING ANY OUTSTANDING
S. 6544 4
CONTRACTUAL ISSUES. THE RESULTS OF THE MEDIATION SHALL NOT BE BINDING ON
THE PARTIES.
§ 4. Section 3217-b of the insurance law is amended by adding a new
subsection (l) to read as follows:
(L) AT LEAST SIXTY DAYS PRIOR TO THE TERMINATION OF A CONTRACT BETWEEN
A HOSPITAL AND AN INSURER, THE PARTIES SHALL UTILIZE A MUTUALLY AGREED
UPON MEDIATOR TO ASSIST IN RESOLVING ANY OUTSTANDING CONTRACTUAL ISSUES.
THE RESULTS OF THE MEDIATION SHALL NOT BE BINDING ON THE PARTIES.
§ 5. Section 4325 of the insurance law is amended by adding a new
subsection (m) to read as follows:
(M) AT LEAST SIXTY DAYS PRIOR TO THE TERMINATION OF A CONTRACT BETWEEN
A HOSPITAL AND AN ORGANIZATION, THE PARTIES SHALL UTILIZE A MUTUALLY
AGREED UPON MEDIATOR TO ASSIST IN RESOLVING ANY OUTSTANDING CONTRACTUAL
ISSUES. THE RESULTS OF THE MEDIATION SHALL NOT BE BINDING ON THE
PARTIES.
§ 6. Section 4 of a chapter of the laws of 2019, amending the finan-
cial services law relating to establishing protections from excess
hospital charges, as proposed in legislative bills numbers S. 3171-A and
A. 264-B, is amended to read as follows:
§ 4. This act shall take effect [immediately] JANUARY 1, 2020.
§ 7. This act shall take effect immediately; provided, however, that
sections one, two, three, four, and five of this act shall take effect
on the same date and in the same manner as a chapter of the laws of
2019, amending the financial services law relating to establishing
protections from excess hospital charges, as proposed in legislative
bills numbers S. 3171-A and A. 264-B, takes effect.