Bill Text: NY A03167 | 2009-2010 | General Assembly | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Requires landlords to post notices in certain rental premises regarding access to the sex offender registry; provides the language for such notice; and provides such posting requirement shall only apply to multiple dwellings.

Spectrum: Partisan Bill (Democrat 30-1)

Status: (Introduced - Dead) 2011-01-24 - referred to correction [A03167 Detail]

Download: New_York-2009-A03167-Amended.html
                           S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________
                                        3167--A
                              2009-2010 Regular Sessions
                                 I N  A S S E M B L Y
                                   January 23, 2009
                                      ___________
       Introduced by M. of A. BRADLEY, DelMONTE, GUNTHER, BENEDETTO, GOTTFRIED,
         COLTON, JAFFEE, FIELDS, MAISEL, SCHIMEL -- Multi-Sponsored by -- M. of
         A.  BOYLAND, BRENNAN, CYMBROWITZ, HYER-SPENCER, MARKEY, PHEFFER, REIL-
         LY,  ROBINSON,  SWEENEY,  TITONE,  TOWNS,  WEISENBERG -- read once and
         referred to the Committee on Insurance -- committee  discharged,  bill
         amended,  ordered reprinted as amended and recommitted to said commit-
         tee
       AN ACT to amend the insurance law, in relation to standards for  prompt,
         fair  and  equitable settlement of claims for health care and payments
         for health care services
         THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
       BLY, DO ENACT AS FOLLOWS:
    1    Section  1. Subsections (a) and (b) of section 3224-a of the insurance
    2  law, as amended by chapter 666 of the laws of 1997, are amended to  read
    3  as follows:
    4    (a)  Except  in a case where the obligation of an insurer or an organ-
    5  ization or corporation licensed or certified pursuant to article  forty-
    6  three  of this chapter or article forty-four of the public health law to
    7  pay a claim submitted by a policyholder or  person  covered  under  such
    8  policy  or  make  a  payment to a health care provider is not reasonably
    9  clear, or when there is a reasonable basis supported by specific  infor-
   10  mation  available  for  review  by the superintendent that such claim or
   11  bill for health care services rendered was submitted fraudulently,  such
   12  insurer  or organization or corporation shall pay the claim to a policy-
   13  holder or covered person or make a payment to  a  health  care  provider
   14  within  [forty-five]  FIFTEEN  DAYS  OF  RECEIPT  OF A CLAIM OR BILL FOR
   15  SERVICES RENDERED WHICH IS TRANSMITTED ELECTRONICALLY OR  WITHIN  THIRTY
   16  days  of  receipt  of  a  claim  or  bill for services rendered WHICH IS
   17  SUBMITTED BY OTHER MEANS, SUCH  AS  PAPER  OR  FACSIMILE.  THE  INSURER,
   18  ORGANIZATION  OR  CORPORATION  SHALL  NOT  DENY  PAYMENT FOR A CLAIM FOR
   19  MEDICALLY NECESSARY COVERED SERVICES ON THE BASIS OF  AN  ADMINISTRATIVE
        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD03354-02-9
       A. 3167--A                          2
    1  OR  TECHNICAL  DEFECT INCLUDING A FAILURE TO OBTAIN A REFERRAL; UNTIMELY
    2  FILING OF THE CLAIM; LATE NOTIFICATION OF A HOSPITAL  ADMISSION  OR  THE
    3  PROVISION  OF SERVICES THAT THE INSURER, ORGANIZATION OR CORPORATION MAY
    4  REQUIRE;  A  FAILURE  TO PROVIDE NOTIFICATION OF A HOSPITAL ADMISSION OR
    5  PROVISION OF SERVICES THAT THE INSURER, ORGANIZATION OR CORPORATION  MAY
    6  REQUIRE;  A  FAILURE TO PROVIDE PROPER REGISTRATION OF A HOSPITAL ADMIS-
    7  SION OR PROVISION OF SERVICES THAT THE INSURER, ORGANIZATION  OR  CORPO-
    8  RATION  MAY  REQUIRE;  A  FAILURE  TO  REQUEST PROPER AUTHORIZATION OF A
    9  HOSPITAL ADMISSION OR PROVISION OF SERVICES THAT THE INSURER,  ORGANIZA-
   10  TION  OR CORPORATION MAY REQUIRE; OR ANY OTHER ADMINISTRATIVE OR TECHNI-
   11  CAL DEFECT AS THE SUPERINTENDENT  MAY  SPECIFY  IN  A  REGULATION  AFTER
   12  CONSULTATION  WITH  THE  COMMISSIONER OF HEALTH. NOTHING IN THIS SECTION
   13  SHALL PRECLUDE A HEALTH CARE PROVIDER AND A HEALTH PLAN FROM AGREEING TO
   14  PROVISIONS DIFFERENT FROM THOSE IN THIS SECTION; PROVIDED, HOWEVER, THAT
   15  ANY AGREEMENT THAT PURPORTS TO WAIVE, LIMIT, DISCLAIM,  OR  IN  ANY  WAY
   16  DIMINISH  THE RIGHTS OF A HEALTH CARE PROVIDER SET FORTH IN THIS SECTION
   17  SHALL BE VOID AS CONTRARY TO PUBLIC POLICY.
   18    (b) In a case where the obligation of an insurer or an organization or
   19  corporation licensed or certified pursuant  to  article  forty-three  of
   20  this  chapter  or  article  forty-four of the public health law to pay a
   21  claim or make a payment for health care services rendered is not reason-
   22  ably clear due to a good faith dispute regarding the  eligibility  of  a
   23  person  for coverage, the liability of another insurer or corporation or
   24  organization for all or part of the claim, the amount of the claim,  the
   25  benefits  covered  under a contract or agreement, or the manner in which
   26  services were accessed or provided, an insurer or organization or corpo-
   27  ration shall pay any undisputed portion of the claim in accordance  with
   28  this  subsection  and  notify  the policyholder, covered person [or] AND
   29  health care provider in writing within  FIFTEEN  CALENDAR  DAYS  OF  THE
   30  RECEIPT OF THE CLAIM TRANSMITTED ELECTRONICALLY, OR thirty calendar days
   31  of  the  receipt of the claim SUBMITTED BY OTHER MEANS, SUCH AS PAPER OR
   32  FACSIMILE:
   33    (1) that it is not obligated to pay the  claim  or  make  the  medical
   34  payment, stating the specific reasons why it is not liable; or
   35    (2)  to  request  [all]  additional  information  needed  to determine
   36  liability to pay the claim or make the health  care  payment;  PROVIDED,
   37  HOWEVER,  IN RESPONSE TO ITS RECEIPT OF A SPECIFIC CLAIM FOR SERVICES AN
   38  INSURER, ORGANIZATION OR CORPORATION SHALL NOT GENERATE AND  TRANSMIT  A
   39  QUESTIONNAIRE  IN ORDER TO DETERMINE WHETHER THE POLICYHOLDER OR COVERED
   40  PERSON IS COVERED FOR ALL OR PART  OF  THE  CLAIM  BY  ANOTHER  INSURER,
   41  CORPORATION  OR  ORGANIZATION.  NOTHING  IN THIS SECTION SHALL OTHERWISE
   42  PRECLUDE AN INSURER, ORGANIZATION OR CORPORATION FROM SENDING A  COORDI-
   43  NATION  OF  BENEFIT QUESTIONNAIRE TO A POLICYHOLDER OR COVERED PERSON AT
   44  ANOTHER TIME PROVIDED THAT IN NO EVENT SHALL THE  INSURER,  ORGANIZATION
   45  OR  CORPORATION  DELAY OR DENY PAYMENT OF A CLAIM WHEN A POLICYHOLDER OR
   46  COVERED PERSON DOES NOT COMPLETE AND RETURN SUCH COORDINATION  OF  BENE-
   47  FITS QUESTIONNAIRE.
   48    Upon  receipt  of  the  information requested in paragraph two of this
   49  subsection or an appeal of a claim or  bill  for  health  care  services
   50  denied  pursuant  to  paragraph  one  of  this subsection, an insurer or
   51  organization or corporation licensed OR CERTIFIED  pursuant  to  article
   52  forty-three  of  this chapter or article forty-four of the public health
   53  law shall comply with subsection (a) of this section.
   54    S 2. Subsection (b) of section 3224-b of the insurance law,  as  added
   55  by chapter 551 of the laws of 2006, is amended to read as follows:
       A. 3167--A                          3
    1    (b) Overpayments to [physicians] HEALTH CARE PROVIDERS. (1) Other than
    2  recovery  for  duplicate  payments,  a health plan shall provide [thirty
    3  days] written notice to [physicians before engaging in additional  over-
    4  payment recovery efforts seeking] HEALTH CARE PROVIDERS OF ITS INTENTION
    5  TO  SEEK  recovery  of  the  overpayment  of claims to such [physicians]
    6  HEALTH CARE PROVIDERS. Such notice shall state the patient name, service
    7  date, payment amount, proposed adjustment,  and  a  reasonably  specific
    8  explanation  of  the  proposed  adjustment. A HEALTH PLAN SHALL NOT SEEK
    9  RECOVERY FROM A HEALTH CARE PROVIDER UNLESS: THE  HEALTH  CARE  PROVIDER
   10  AGREES  TO  THE  RECOVERY  IN WRITING; THE HEALTH CARE PROVIDER FAILS TO
   11  SEND ITS WRITTEN CHALLENGE OF THE  HEALTH  PLAN'S  OVERPAYMENT  RECOVERY
   12  WITHIN  NINETY  DAYS  OF  RECEIPT OF THE PLAN'S NOTICE OF INTENT TO SEEK
   13  OVERPAYMENT RECOVERY;  OR  THE  OVERPAYMENT  RECOVERY  HAS  BEEN  UPHELD
   14  ACCORDING  TO PROCEDURES ESTABLISHED BY THE PARTIES IN THEIR CONTRACTUAL
   15  AGREEMENT; OR A THIRD-PARTY ARBITRATOR UPHELD THE OVERPAYMENT RECOVERY.
   16    (2) A HEALTH PLAN SHALL LIMIT OVERPAYMENT RECOVERY EFFORTS TO: BILLING
   17  AND CODING ERRORS; INCORRECT RATE PAYMENTS; INELIGIBILITY  OF  A  PERSON
   18  FOR  COVERAGE;  OR  FRAUD.  A HEALTH PLAN SHALL NOT INITIATE OVERPAYMENT
   19  RECOVERY EFFORTS FOR UTILIZATION REVIEW PURPOSES AS DEFINED  IN  ARTICLE
   20  FORTY-NINE  OF  THIS  CHAPTER OR ARTICLE FORTY-NINE OF THE PUBLIC HEALTH
   21  LAW, IF THE SERVICES WERE ALREADY  DEEMED  MEDICALLY  NECESSARY  BY  THE
   22  HEALTH  PLAN,  OR  IF  THE HEALTH PLAN PREVIOUSLY APPROVED THE MANNER IN
   23  WHICH SERVICES WERE ACCESSED OR PROVIDED.
   24    (3) A HEALTH PLAN SHALL PROVIDE A HEALTH CARE PROVIDER WITH THE OPPOR-
   25  TUNITY TO CHALLENGE THE HEALTH PLAN'S OVERPAYMENT RECOVERY DETERMINATION
   26  AND SHALL ESTABLISH WRITTEN POLICIES AND PROCEDURES, IN ACCORDANCE  WITH
   27  THIS  SECTION,  FOR  HEALTH  CARE  PROVIDERS TO CHALLENGE AN OVERPAYMENT
   28  RECOVERY.  THESE  WRITTEN  POLICIES  AND  PROCEDURES  SHALL  INCLUDE   A
   29  PROVISION  STATING  THAT  A HEALTH CARE PROVIDER SHALL HAVE NO LESS THAN
   30  NINETY DAYS FROM RECEIPT OF THE HEALTH PLAN'S WRITTEN NOTICE  OF  INTENT
   31  TO  SEEK RECOVERY TO PROVIDE DOCUMENTATION CHALLENGING THE ALLEGED OVER-
   32  PAYMENTS. ANY CHALLENGE  TO  AN  OVERPAYMENT  RECOVERY  THAT  CANNOT  BE
   33  RESOLVED  BETWEEN  THE  HEALTH  PLAN AND THE HEALTH CARE PROVIDER WITHIN
   34  THIRTY DAYS FROM THE HEALTH PLAN'S RECEIPT OF THE PROVIDER'S  DOCUMENTA-
   35  TION  SHALL  BE  RESOLVED  ACCORDING  TO  PROCEDURES  ESTABLISHED BY THE
   36  PARTIES IN THEIR CONTRACTUAL  AGREEMENT  OR  SHALL  BE  SUBMITTED  TO  A
   37  THIRD-PARTY ARBITRATOR FOR A DETERMINATION.
   38    (4) A health plan shall not initiate overpayment recovery efforts more
   39  than  twenty-four  months  after  the original payment was received by a
   40  [physician] HEALTH CARE PROVIDER.  [Provided, however, that] HOWEVER, no
   41  such time limit shall apply to overpayment recovery efforts [which] THAT
   42  are: (i) based on a reasonable belief  of  fraud  or  other  intentional
   43  misconduct,  [or abusive billing,] (ii) required by, or initiated at the
   44  request of, a self-insured plan, or (iii) required by a state or federal
   45  government program. Notwithstanding the aforementioned time limitations,
   46  in the event that a [physician] HEALTH  CARE  PROVIDER  asserts  that  a
   47  health  plan has underpaid a claim or claims, the health plan may defend
   48  or set off such assertion of underpayment based  on  overpayments  going
   49  back  in  time as far as the claimed underpayment. [For purposes of this
   50  paragraph, "abusive billing" shall be  defined  as  a  billing  practice
   51  which  results  in the submission of claims that are not consistent with
   52  sound fiscal, business, or medical practices and at such  frequency  and
   53  for such a period of time as to reflect a consistent course of conduct.
   54    (3)]  (5)  Nothing in this section shall be deemed to limit [an insur-
   55  er's] A HEALTH PLAN'S right to  pursue  recovery  of  overpayments  that
   56  occurred  prior  to the effective date of this section where the insurer
       A. 3167--A                          4
    1  has provided the [physician] HEALTH CARE PROVIDER with  notice  of  such
    2  recovery efforts prior to the effective date of this section.
    3    (6)  A  HEALTH  PLAN  SHALL  NOT  PURSUE  OVERPAYMENT RECOVERY EFFORTS
    4  AGAINST AN INSURED IF THE HEALTH PLAN IS PRECLUDED FROM  PURSUING  OVER-
    5  PAYMENT  RECOVERY  EFFORTS  AGAINST  A  HEALTH CARE PROVIDER PURSUANT TO
    6  PARAGRAPH TWO OF THIS SUBSECTION.
    7    (7) A HEALTH PLAN SHALL ASSURE ADHERENCE TO THE REQUIREMENTS STATED IN
    8  THIS SECTION BY ALL CONTRACTORS, SUBCONTRACTORS, SUBVENDORS, AGENTS  AND
    9  EMPLOYEES AFFILIATED BY CONTRACT OR OTHERWISE WITH SUCH LICENSED ENTITY.
   10  ALL CONTRACTORS, SUBCONTRACTORS, SUBVENDORS, AGENTS AND EMPLOYEES AFFIL-
   11  IATED BY CONTRACT OR OTHERWISE WITH ANY HEALTH PLAN SHALL ALSO ADHERE TO
   12  THE REQUIREMENTS OF THIS SECTION.
   13    (8)  NOTHING IN THIS SECTION SHALL PRECLUDE A HEALTH CARE PROVIDER AND
   14  A HEALTH PLAN FROM AGREEING TO PROVISIONS DIFFERENT FROM THOSE  IN  THIS
   15  SECTION;  PROVIDED,  HOWEVER, THAT ANY AGREEMENT THAT PURPORTS TO WAIVE,
   16  LIMIT, DISCLAIM, OR IN ANY WAY DIMINISH THE  RIGHTS  OF  A  HEALTH  CARE
   17  PROVIDER  SET  FORTH IN THIS SECTION SHALL BE VOID AS CONTRARY TO PUBLIC
   18  POLICY.
   19    (9) HEALTH CARE PROVIDER SHALL MEAN AN ENTITY  LICENSED  OR  CERTIFIED
   20  PURSUANT  TO  ARTICLE  TWENTY-EIGHT,  THIRTY-SIX  OR FORTY OF THE PUBLIC
   21  HEALTH  LAW,  A  FACILITY  LICENSED  PURSUANT   TO   ARTICLE   NINETEEN,
   22  TWENTY-THREE  OR THIRTY-ONE OF THE MENTAL HYGIENE LAW, AND A HEALTH CARE
   23  PROFESSIONAL LICENSED, REGISTERED OR CERTIFIED PURSUANT TO  TITLE  EIGHT
   24  OF THE EDUCATION LAW.
   25    S 3. The insurance law is amended by adding a new section 3240 to read
   26  as follows:
   27    S  3240.  COVERAGE  OF SERVICES OF PARTICIPATING PROVIDERS. AN INSURER
   28  LICENSED TO WRITE ACCIDENT AND HEALTH INSURANCE, A CORPORATION ORGANIZED
   29  PURSUANT TO ARTICLE FORTY-THREE  OF  THIS  CHAPTER,  HEALTH  MAINTENANCE
   30  ORGANIZATIONS  AND  OTHER  ORGANIZATIONS  CERTIFIED  PURSUANT TO ARTICLE
   31  FORTY-FOUR OF THE PUBLIC HEALTH LAW OR A  MUNICIPAL  COOPERATIVE  HEALTH
   32  BENEFITS  PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THIS CHAPTER
   33  (COLLECTIVELY A "HEALTH PLAN") THAT UTILIZES A NETWORK OF  PARTICIPATING
   34  PROVIDERS  IN  THE  DELIVERY  AND PROVISION OF HEALTH INSURANCE BENEFITS
   35  SHALL NOT DEEM A HEALTH CARE PROVIDER WHO IS PARTICIPATING IN THE HEALTH
   36  PLAN'S PROVIDER NETWORK AND RENDERING MEDICAL SERVICES  TO  AN  INSURED,
   37  SUBSCRIBER  OR  ENROLLEE  TO BE OUT-OF-NETWORK BECAUSE ONE OR MORE OTHER
   38  HEALTH PROVIDERS RENDERING SERVICES TO THE INSURED, SUBSCRIBER OR ENROL-
   39  LEE FOR THE SAME OR RELATED MEDICAL CONDITION, ILLNESS  OR  INJURY  DOES
   40  NOT  PARTICIPATE  IN  THE  HEALTH  PLAN'S PROVIDER NETWORK. THE INSURED,
   41  SUBSCRIBER OR ENROLLEE SHALL ONLY BE  SUBJECT  TO  THE  IN-NETWORK  COST
   42  SHARING PROVISIONS OF THE POLICY OR CERTIFICATE FOR THE SERVICES OF SUCH
   43  PARTICIPATING  PROVIDER OR PROVIDERS. FURTHER, THE HEALTH PLAN SHALL PAY
   44  A PARTICIPATING HEALTH CARE PROVIDER OR PROVIDERS  THE  CONTRACTED  RATE
   45  FOR  SERVICES  PROVIDED  BY  SUCH  PARTICIPATING  PROVIDER  OR PROVIDERS
   46  REGARDLESS OF THE NETWORK STATUS OF THE  OTHER  PROVIDERS.  HEALTH  CARE
   47  PROVIDER  SHALL MEAN AN ENTITY LICENSED OR CERTIFIED PURSUANT TO ARTICLE
   48  TWENTY-EIGHT, THIRTY-SIX OR FORTY OF THE PUBLIC HEALTH LAW,  A  FACILITY
   49  LICENSED PURSUANT TO ARTICLE NINETEEN, TWENTY-THREE OR THIRTY-ONE OF THE
   50  MENTAL  HYGIENE LAW, AND A HEALTH CARE PROFESSIONAL LICENSED, REGISTERED
   51  OR CERTIFIED PURSUANT TO TITLE EIGHT OF THE EDUCATION LAW.
   52    S 4. Section 2406 of the insurance law is  amended  by  adding  a  new
   53  subsection (a-1) to read as follows:
   54    (A-1)  (1) IF, AFTER COMPLETION OF AN INVESTIGATION INVOLVING INFORMA-
   55  TION COLLECTED FROM A SIX MONTH PERIOD, NOTICE AND HEARING,  THE  SUPER-
   56  INTENDENT FINDS THAT THE PERSON COMPLAINED OF HAS ENGAGED IN A SERIES OF
       A. 3167--A                          5
    1  ACTS  PROHIBITED  BY SECTION THREE THOUSAND TWO HUNDRED TWENTY-FOUR-A OF
    2  THIS CHAPTER THAT, TAKEN TOGETHER, CONSTITUTE A  CONSISTENT  PATTERN  OR
    3  PRACTICE,  THE  SUPERINTENDENT  IS  AUTHORIZED  TO  LEVY A CIVIL PENALTY
    4  AGAINST SUCH PERSON IN THE FOLLOWING MANNER:
    5    (A)  FOR  THE  FIRST  FINDING OF A CONSISTENT PATTERN OR PRACTICE, THE
    6  SUPERINTENDENT MAY LEVY A FINE OF NOT MORE  THAN  ONE  HUNDRED  THOUSAND
    7  DOLLARS.
    8    (B)  FOR  A  SECOND  FINDING  OF A CONSISTENT PATTERN OR PRACTICE THAT
    9  OCCURS ON OR EARLIER THAN TWO YEARS FROM THE FIRST  OFFENSE  THE  SUPER-
   10  INTENDENT  MAY  LEVY  A  FINE  OF  NOT  MORE THAN THREE HUNDRED THOUSAND
   11  DOLLARS.
   12    (C) FOR A THIRD FINDING OF  A  CONSISTENT  PATTERN  OR  PRACTICE  THAT
   13  OCCURS  ON  OR EARLIER THAN FIVE YEARS AFTER A FIRST OFFENSE, THE SUPER-
   14  INTENDENT MAY LEVY A FINE OF NOT MORE THAN ONE MILLION DOLLARS.
   15    (2) IN DETERMINING THE AMOUNT OF A FINE TO BE LEVIED WITHIN THE SPECI-
   16  FIED LIMITS, THE SUPERINTENDENT SHALL CONSIDER THE FOLLOWING FACTORS:
   17    (A) THE EXTENT AND FREQUENCY OF THE VIOLATIONS;
   18    (B) WHETHER THE VIOLATIONS WERE DUE TO CIRCUMSTANCES BEYOND THE INSUR-
   19  ER, ORGANIZATION OR CORPORATION'S CONTROL;
   20    (C) ANY REMEDIAL ACTIONS TAKEN BY THE INSURER, ORGANIZATION OR  CORPO-
   21  RATION TO PREVENT FUTURE VIOLATIONS;
   22    (D)  THE  ACTUAL  OR  POTENTIAL  HARM  TO  OTHERS  RESULTING  FROM THE
   23  VIOLATIONS;
   24    (E) IF THE INSURER, ORGANIZATION OR CORPORATION KNOWINGLY AND WILLING-
   25  LY COMMITTED THE VIOLATIONS;
   26    (F) THE INSURER, ORGANIZATION OR  CORPORATION'S  FINANCIAL  CONDITION;
   27  AND
   28    (G) ANY OTHER FACTORS THE SUPERINTENDENT CONSIDERS APPROPRIATE.
   29    S 5. This act shall take effect immediately.
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