S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   7120
 
                        2023-2024 Regular Sessions
 
                           I N  A S S E M B L Y
 
                               May 11, 2023
                                ___________
 
 Introduced by M. of A. WEPRIN -- read once and referred to the Committee
   on Insurance
 
 AN  ACT  to  amend the financial services law, in relation to preserving
   the ability of health care providers to access the independent dispute
   resolution process
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.  Subsection  (c)  of section 603 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:
   (c) "Health care plan" means an insurer licensed to write accident and
 health insurance pursuant to article thirty-two of the insurance law;  a
 corporation  organized  pursuant to article forty-three of the insurance
 law; a municipal cooperative health benefit plan certified  pursuant  to
 article forty-seven of the insurance law; a health maintenance organiza-
 tion  certified pursuant to article forty-four of the public health law;
 [or] a student health plan established or maintained pursuant to section
 one thousand one hundred  twenty-four  of  the  insurance  law;  OR  ANY
 PROVISION  OF HEALTH BENEFITS UNDER SECTION ONE HUNDRED SIXTY-TWO OF THE
 CIVIL SERVICE LAW.
   § 2. Section 604 of the financial services law, as amended by  section
 4  of subpart A of part AA of chapter 57 of the laws of 2022, 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
 provider for services rendered as compared to:
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD09745-01-3
 A. 7120                             2
 
              

   (1) fees paid to the involved provider for the same services  rendered
 by  the  provider  to  other  patients in health care plans in which the
 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  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 health care
 professional, and in the case of a hospital, the teaching  staff,  scope
 of services and case mix;
   (c) the provider's usual charge for comparable services with regard to
 patients  in  health care plans in which the provider is not participat-
 ing;
   (d) the circumstances and complexity of the particular case, including
 time and place of the service;
   (e) individual patient characteristics; AND
   (f) [the median of the rate recognized by  the  health  care  plan  to
 reimburse similarly qualified providers for the same or similar services
 in the same region that are participating with the health care plan; and
   (g)]  with  regard to physician services, the usual and customary cost
 of the service.
   § 3. This act shall take effect immediately.