Bill Text: NY S04241 | 2017-2018 | General Assembly | Amended
Bill Title: Relates to establishing protections from excessive hospital emergency charges; includes hospital charges.
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2018-06-20 - COMMITTED TO RULES [S04241 Detail]
Download: New_York-2017-S04241-Amended.html
STATE OF NEW YORK ________________________________________________________________________ 4241--C Cal. No. 728 2017-2018 Regular Sessions IN SENATE February 6, 2017 ___________ Introduced by Sens. SEWARD, AMEDORE, KRUEGER, LARKIN -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance -- reported favorably from said committee, ordered to first and second report, ordered to a third reading, amended and ordered reprinted, retaining its place in the order of third reading -- recom- mitted to the Committee on Insurance in accordance with Senate Rule 6, sec. 8 -- reported favorably from said committee, ordered to first and second report, ordered to a third reading, amended and ordered reprinted, retaining its place in the order of third reading -- again amended and ordered reprinted, retaining its place in the order of third reading AN ACT to amend the financial services law, in relation to establishing protections from excessive hospital emergency charges The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Section 605 of the financial services law, as added by 2 section 26 of part H of chapter 60 of the laws of 2014, is amended to 3 read as follows: 4 § 605. Dispute resolution for emergency services. (a) Emergency 5 services for an insured. (1) When a health care plan receives a bill for 6 emergency services from a non-participating physician or hospital, the 7 health care plan shall pay an amount that it determines is reasonable 8 for the emergency services rendered by the non-participating physician 9 or hospital, in accordance with section three thousand two hundred twen- 10 ty-four-a of the insurance law, except for the insured's co-payment, 11 coinsurance or deductible, if any, and shall ensure that the insured 12 shall incur no greater out-of-pocket costs for the emergency services 13 than the insured would have incurred with a participating physician or 14 hospital pursuant to subsection (c) of section three thousand two 15 hundred forty-one of the insurance law. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD09770-09-8S. 4241--C 2 1 (2) A non-participating physician or hospital or a health care plan 2 may submit a dispute regarding a fee or payment for emergency services 3 for review to an independent dispute resolution entity. In cases where 4 a health care plan submits a dispute regarding a fee for payment of a 5 non-participating hospital's emergency services, the health care plan 6 shall, after the initial payment, pay any additional amounts it deter- 7 mines is reasonable directly to the non-participating hospital. 8 (3) The independent dispute resolution entity shall make a determi- 9 nation within thirty days of receipt of the dispute for review. 10 (4) In determining a reasonable fee for the services rendered, an 11 independent dispute resolution entity shall select either the health 12 care plan's payment or the non-participating physician's or hospital's 13 fee. The independent dispute resolution entity shall determine which 14 amount to select based upon the conditions and factors set forth in 15 section six hundred four of this article. If an independent dispute 16 resolution entity determines, based on the health care plan's payment 17 and the non-participating physician's or hospital's fee, that a settle- 18 ment between the health care plan and non-participating physician or 19 hospital is reasonably likely, or that both the health care plan's 20 payment and the non-participating physician's or hospital's fee repre- 21 sent unreasonable extremes, then the independent dispute resolution 22 entity may direct both parties to attempt a good faith negotiation for 23 settlement. The health care plan and non-participating physician or 24 hospital may be granted up to ten business days for this negotiation, 25 which shall run concurrently with the thirty day period for dispute 26 resolution. 27 (b) Emergency services for a patient that is not an insured. (1) A 28 patient that is not an insured or the patient's physician may submit a 29 dispute regarding a fee for emergency services for review to an inde- 30 pendent dispute resolution entity upon approval of the superintendent. 31 (2) An independent dispute resolution entity shall determine a reason- 32 able fee for the services based upon the same conditions and factors set 33 forth in section six hundred four of this article. 34 (3) A patient that is not an insured shall not be required to pay the 35 physician's or hospital's fee in order to be eligible to submit the 36 dispute for review to an independent dispute resolution entity. 37 (c) The determination of an independent dispute resolution entity 38 shall be binding on the health care plan, physician or hospital and 39 patient, and shall be admissible in any court proceeding between the 40 health care plan, physician or hospital or patient, or in any adminis- 41 trative proceeding between this state and the physician or hospital. 42 § 2. Subdivision (a) of section 608 of the financial services law, as 43 added by section 26 of part H of chapter 60 of the laws of 2014, is 44 amended to read as follows: 45 (a) For disputes involving an insured, when the independent dispute 46 resolution entity determines the health care plan's payment is reason- 47 able, payment for the dispute resolution process shall be the responsi- 48 bility of the non-participating physician or hospital. When the inde- 49 pendent dispute resolution entity determines the non-participating 50 physician's or hospital's fee is reasonable, payment for the dispute 51 resolution process shall be the responsibility of the health care plan. 52 When a good faith negotiation directed by the independent dispute resol- 53 ution entity pursuant to paragraph four of subsection (a) of section six 54 hundred five of this article, or paragraph six of subsection (a) of 55 section six hundred seven of this article results in a settlement 56 between the health care plan and non-participating physician, the healthS. 4241--C 3 1 care plan and the non-participating physician or hospital shall evenly 2 divide and share the prorated cost for dispute resolution. 3 § 3. Section 604 of the financial services law, as added by section 26 4 of part H of chapter 60 of the laws of 2014, is amended to read as 5 follows: 6 § 604. Criteria for determining a reasonable fee. In determining the 7 appropriate amount to pay for a health care service, an independent 8 dispute resolution entity shall consider all relevant factors, includ- 9 ing: 10 (a) whether there is a gross disparity between the fee charged by the 11 [physician] health care provider for services rendered as compared to: 12 (1) fees paid to the involved [physician] health care provider for the 13 same services rendered by the [physician] health care provider to other 14 patients in health care plans in which the [physician] health care 15 provider is not participating, and 16 (2) in the case of a dispute involving a health care plan, fees paid 17 by the health care plan to reimburse similarly qualified [physicians] 18 health care providers for the same services in the same region who are 19 not participating with the health care plan; 20 (b) the level of training, education and experience of the [physician] 21 health care provider; 22 (c) the [physician's] health care provider's usual charge for compara- 23 ble services with regard to patients in health care plans in which the 24 [physician] health care provider is not participating; 25 (d) the circumstances and complexity of the particular case, including 26 time and place of the service; 27 (e) individual patient characteristics; and, with regard to physician 28 services, 29 (f) the usual and customary cost of the service. 30 § 4. This act shall take effect immediately.
