§ 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 provider, 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, including inpatient services which follow an
emergency room visit, rendered by the non-participating provider, 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, including
inpatient services which follow an emergency room visit, than the
insured would have incurred with a participating provider. The
non-participating provider may bill the health care plan for the
services rendered. Upon receipt of the bill, the health care plan shall
pay the non-participating provider the amount prescribed by this section
and any subsequent amount determined to be owed to the provider in
relation to the emergency services provided, including inpatient
services which follow an emergency room visit.

* NB Effective until January 1, 2025 and shall remain in effect until
after the superintendent of financial services and the commissioner of
health have promulgated regulations

* (1) When a health care plan receives a bill for emergency services
from a non-participating provider, including a bill for inpatient
services which follow an emergency room visit, or a bill for services
from a mobile crisis intervention services provider licensed, certified,
or designated by the office of mental health or the office of addiction
services and supports, the health care plan shall pay an amount that it
determines is reasonable for the emergency services, including inpatient
services which follow an emergency room visit or for the mobile crisis
intervention services, rendered by the non-participating provider, 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, including
inpatient services which follow an emergency room visit or for the
mobile crisis intervention services, than the insured would have
incurred with a participating provider. The non-participating provider
may bill the health care plan for the services rendered. Upon receipt of
the bill, the health care plan shall pay the non-participating provider
the amount prescribed by this section and any subsequent amount
determined to be owed to the provider in relation to the emergency
services provided, including inpatient services which follow an
emergency room visit or for the mobile crisis intervention services.

* NB Effective January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of health
have promulgated regulations

* (2) A non-participating provider or a health care plan may submit a
dispute regarding a fee or payment for emergency services, including
inpatient services which follow an emergency room visit, for review to
an independent dispute resolution entity.

* NB Effective until January 1, 2025 and shall remain in effect until
after the superintendent of financial services and the commissioner of
health have promulgated regulations

* (2) A non-participating provider or a health care plan may submit a
dispute regarding a fee or payment for emergency services, including
inpatient services which follow an emergency room visit, or for services
rendered by a mobile crisis intervention services provider licensed,
certified, or designated by the office of mental health or the office of
addiction services and supports, for review to an independent dispute
resolution entity.

* NB Effective January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of health
have promulgated regulations

(3) The independent dispute resolution entity shall make a
determination within thirty business 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 provider'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 provider's fee, that a settlement between the health
care plan and non-participating provider is reasonably likely, or that
both the health care plan's payment and the non-participating provider's
fee represent 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
provider may be granted up to ten business days for this negotiation,
which shall run concurrently with the thirty business 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, including inpatient
services which follow an emergency room visit, for review to an
independent dispute resolution entity upon approval of the
superintendent.

(2) An independent dispute resolution entity shall determine a
reasonable 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, provider and patient, and
shall be admissible in any court proceeding between the health care
plan, provider or patient, or in any administrative proceeding between
this state and the provider.

(d) 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
resolution 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
participating provider agreement.