STATE OF NEW YORK
________________________________________________________________________
5638
2023-2024 Regular Sessions
IN SENATE
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:
1 Section 1. Subsection (c) of section 603 of the financial services
2 law, as added by section 26 of part H of chapter 60 of the laws of 2014,
3 is amended to read as follows:
4 (c) "Health care plan" means an insurer licensed to write accident and
5 health insurance pursuant to article thirty-two of the insurance law; a
6 corporation organized pursuant to article forty-three of the insurance
7 law; a municipal cooperative health benefit plan certified pursuant to
8 article forty-seven of the insurance law; a health maintenance organiza-
9 tion certified pursuant to article forty-four of the public health law;
10 [or] a student health plan established or maintained pursuant to section
11 one thousand one hundred twenty-four of the insurance law; or any
12 provision of health benefits under section one hundred sixty-two of the
13 civil service law.
14 § 2. Section 604 of the financial services law, as amended by section
15 4 of subpart A of part AA of chapter 57 of the laws of 2022, is amended
16 to read as follows:
17 § 604. Criteria for determining a reasonable fee. In determining the
18 appropriate amount to pay for a health care service, an independent
19 dispute resolution entity shall consider all relevant factors, includ-
20 ing:
21 (a) whether there is a gross disparity between the fee charged by the
22 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 (1) fees paid to the involved provider for the same services rendered
2 by the provider to other patients in health care plans in which the
3 provider is not participating, and
4 (2) in the case of a dispute involving a health care plan, fees paid
5 by the health care plan to reimburse similarly qualified providers for
6 the same services in the same region who are not participating with the
7 health care plan;
8 (b) the level of training, education and experience of the health care
9 professional, and in the case of a hospital, the teaching staff, scope
10 of services and case mix;
11 (c) the provider's usual charge for comparable services with regard to
12 patients in health care plans in which the provider is not participat-
13 ing;
14 (d) the circumstances and complexity of the particular case, including
15 time and place of the service;
16 (e) individual patient characteristics; and
17 (f) [the median of the rate recognized by the health care plan to
18 reimburse similarly qualified providers for the same or similar services
19 in the same region that are participating with the health care plan; and
20 (g)] with regard to physician services, the usual and customary cost
21 of the service.
22 § 3. This act shall take effect immediately.