S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   5638
 
                        2023-2024 Regular Sessions
 
                             I N  S E N A T E
 
                              March 10, 2023
                                ___________
 
 Introduced  by  Sen. JACKSON -- read twice and ordered printed, and when
   printed to be committed 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
 S. 5638                             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.