Bill Text: NY S06544 | 2019-2020 | General Assembly | Amended


Bill Title: Establishes protections from excess hospital charges.

Spectrum: Partisan Bill (Democrat 3-0)

Status: (Engrossed) 2019-06-20 - returned to senate [S06544 Detail]

Download: New_York-2019-S06544-Amended.html



                STATE OF NEW YORK
        ________________________________________________________________________

                                         6544--A

                               2019-2020 Regular Sessions

                    IN SENATE

                                      June 15, 2019
                                       ___________

        Introduced  by  Sens. KRUEGER, RIVERA -- read twice and ordered printed,
          and when printed to be committed to the Committee on Rules --  commit-
          tee  discharged, bill amended, ordered reprinted as amended and recom-
          mitted to said committee

        AN ACT to amend the financial services law, the public  health  law  and
          the insurance law, in relation to establishing protections from excess
          hospital charges; and to amend a chapter of the laws of 2019, amending
          the  financial  services law relating to establishing protections from
          excess hospital charges, as proposed in legislative bills  numbers  S.
          3171-A and A.  264-B, in relation to the effectiveness thereof

          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 amended by  a
     2  chapter  of the laws of 2019, amending the financial services law relat-
     3  ing  to  establishing  protections  from  excess  hospital  charges,  as
     4  proposed in legislative bills numbers S. 3171-A and A. 264-B, is amended
     5  to read as follows:
     6    §  605.  Dispute  resolution  for  emergency  services.  (a) Emergency
     7  services for an insured. (1) When a health care plan receives a bill for
     8  emergency services  from  a  non-participating  physician  or  hospital,
     9  including  a  bill for inpatient services which follow an emergency room
    10  visit, the health care plan shall pay an amount that  it  determines  is
    11  reasonable  for the emergency services rendered by the non-participating
    12  physician or hospital, in accordance with  section  three  thousand  two
    13  hundred  twenty-four-a  of  the  insurance law, except for the insured's
    14  co-payment, coinsurance or deductible, if any, and shall ensure that the
    15  insured shall incur no greater out-of-pocket  costs  for  the  emergency
    16  services  than  the  insured  would  have  incurred with a participating
    17  physician or hospital pursuant to subsection (c) of section three  thou-
    18  sand  two hundred forty-one of the insurance law.  If an insured assigns
    19  benefits to  a  non-participating  hospital  in  relation  to  emergency

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD03101-12-9

        S. 6544--A                          2

     1  services  provided  by such non-participating hospital, the non-partici-
     2  pating hospital may bill the health care plan for the emergency services
     3  rendered. Upon receipt of the bill, the health care plan shall  pay  the
     4  non-participating hospital the amount prescribed by this section and any
     5  subsequent  amount  determined to be owed to the hospital in relation to
     6  the emergency services provided.
     7    (2) A non-participating physician or hospital or a  health  care  plan
     8  may  submit  a dispute regarding a fee or payment for emergency services
     9  for review to an independent dispute resolution entity.  [In cases where
    10  a health care plan submits a dispute regarding a fee for  payment  of  a
    11  non-participating  hospital's  emergency  services, the health care plan
    12  shall, after the initial payment, pay any additional amounts  it  deter-
    13  mines is reasonable directly to the non-participating hospital.]
    14    (3)  The  independent  dispute resolution entity shall make a determi-
    15  nation within thirty days of receipt of the dispute for review.
    16    (4) In determining a reasonable fee  for  the  services  rendered,  an
    17  independent  dispute  resolution  entity  shall select either the health
    18  care plan's payment or the non-participating physician's  or  hospital's
    19  fee.  The  independent  dispute  resolution entity shall determine which
    20  amount to select based upon the conditions  and  factors  set  forth  in
    21  section  six  hundred  four  of  this article. If an independent dispute
    22  resolution entity determines, based on the health  care  plan's  payment
    23  and  the non-participating physician's or hospital's fee, that a settle-
    24  ment between the health care plan  and  non-participating  physician  or
    25  hospital  is  reasonably  likely,  or  that  both the health care plan's
    26  payment and the non-participating physician's or hospital's  fee  repre-
    27  sent  unreasonable  extremes,  then  the  independent dispute resolution
    28  entity may direct both parties to attempt a good faith  negotiation  for
    29  settlement.  The  health  care  plan  and non-participating physician or
    30  hospital may be granted up to ten business days  for  this  negotiation,
    31  which  shall  run  concurrently  with  the thirty day period for dispute
    32  resolution.
    33    (b) Emergency services for a patient that is not  an  insured.  (1)  A
    34  patient  that  is not an insured or the patient's physician may submit a
    35  dispute regarding a fee for emergency services for review  to  an  inde-
    36  pendent dispute resolution entity upon approval of the superintendent.
    37    (2) An independent dispute resolution entity shall determine a reason-
    38  able fee for the services based upon the same conditions and factors set
    39  forth in section six hundred four of this article.
    40    (3)  A patient that is not an insured shall not be required to pay the
    41  physician's or hospital's fee in order to  be  eligible  to  submit  the
    42  dispute for review to an independent dispute resolution entity.
    43    (c)  The  determination  of  an  independent dispute resolution entity
    44  shall be binding on the health care  plan,  physician  or  hospital  and
    45  patient,  and  shall  be  admissible in any court proceeding between the
    46  health care plan, physician or hospital or patient, or in  any  adminis-
    47  trative proceeding between this state and the physician or hospital.
    48    (d)  The  provisions of this section shall not apply to hospitals that
    49  had at least  sixty  percent  of  inpatient  discharges  annually  which
    50  consisted  of  medicaid,  uninsured,  and  dual  eligible individuals as
    51  determined by the department of health in its  determination  of  safety
    52  net hospitals.
    53    (e) For purposes of the hospital payment pursuant to subsection (a) of
    54  this  section, the amount the health care plan shall pay to the hospital
    55  shall be at least twenty-five percent greater than the amount the health
    56  care plan would have paid  for  the  claim  had  the  hospital  been  in

        S. 6544--A                          3

     1  network,  based on the most recent contract between the health care plan
     2  and the hospital. Provided however, the amount paid by the  health  care
     3  plan  pursuant  to  this  subsection shall not prejudice either party or
     4  preclude  either  party  from submitting a dispute to the dispute resol-
     5  ution entity relating to the payment to the  hospital  or  preclude  the
     6  hospital from seeking additional payment from the health care plan prior
     7  to  a decision by the dispute resolution entity. To the extent the prior
     8  contract between the hospital and health care plan expired greater  than
     9  twelve  months  prior  to the payment of the disputed claim, the payment
    10  amount shall be adjusted based upon the medical  consumer  price  index.
    11  The  provisions  of  this  subsection shall only apply to the extent the
    12  health care plan and hospital had previously entered into a  participat-
    13  ing provider agreement.
    14    §  2. Section 604 of the financial services law, as amended by a chap-
    15  ter of the laws of 2019, amending the financial services law relating to
    16  establishing protections from excess hospital charges,  as  proposed  in
    17  legislative  bills numbers S. 3171-A and A. 264-B, is amended to read as
    18  follows:
    19    § 604. Criteria for determining a reasonable fee. In  determining  the
    20  appropriate  amount  to  pay  for  a health care service, an independent
    21  dispute resolution entity shall consider all relevant  factors,  includ-
    22  ing:
    23    (a)  whether there is a gross disparity between the fee charged by the
    24  [health care provider] physician or hospital for  services  rendered  as
    25  compared to:
    26    (1)  fees  paid  to  the  involved [health care provider] physician or
    27  hospital for the same services rendered by the  [health  care  provider]
    28  physician  or  hospital  to other patients in health care plans in which
    29  the [health care provider] physician or hospital is  not  participating,
    30  and
    31    (2)  in  the case of a dispute involving a health care plan, fees paid
    32  by the health care plan to reimburse similarly  qualified  [health  care
    33  providers]  physicians  or  hospitals  for the same services in the same
    34  region who are not participating with the health care plan;
    35    (b) the level of training, education and  experience  of  the  [health
    36  care  provider]  physician,  and in the case of a hospital, the teaching
    37  staff, scope of services and case mix;
    38    (c) the [health care  provider's]  physician's  and  hospital's  usual
    39  charge  for  comparable  services with regard to patients in health care
    40  plans in which the [health care provider] physician or hospital  is  not
    41  participating;
    42    (d) the circumstances and complexity of the particular case, including
    43  time and place of the service;
    44    (e)  individual patient characteristics; and, with regard to physician
    45  services,
    46    (f) the usual and customary cost of the service.
    47    § 3. Section 4406-c of the public health law is amended  by  adding  a
    48  new subdivision 5-e to read as follows:
    49    5-e.  At  least  sixty  days  prior  to  the termination of a contract
    50  between a hospital and a health care plan, the parties shall  utilize  a
    51  mutually  agreed  upon  mediator  to assist in resolving any outstanding
    52  contractual issues. The results of the mediation shall not be binding on
    53  the parties.
    54    § 4. Section 3217-b of the insurance law is amended by  adding  a  new
    55  subsection (l) to read as follows:

        S. 6544--A                          4

     1    (l) At least sixty days prior to the termination of a contract between
     2  a  hospital  and an insurer, the parties shall utilize a mutually agreed
     3  upon mediator to assist in resolving any outstanding contractual issues.
     4  The results of the mediation shall not be binding on the parties.
     5    §  5.  Section  4325  of  the insurance law is amended by adding a new
     6  subsection (m) to read as follows:
     7    (m) At least sixty days prior to the termination of a contract between
     8  a hospital and an organization, the parties  shall  utilize  a  mutually
     9  agreed  upon mediator to assist in resolving any outstanding contractual
    10  issues. The results of  the  mediation  shall  not  be  binding  on  the
    11  parties.
    12    §  6.  Section 4 of a chapter of the laws of 2019, amending the finan-
    13  cial services law  relating  to  establishing  protections  from  excess
    14  hospital charges, as proposed in legislative bills numbers S. 3171-A and
    15  A. 264-B, is amended to read as follows:
    16    § 4. This act shall take effect [immediately] January 1, 2020.
    17    §  7.  This act shall take effect immediately; provided, however, that
    18  sections one, two, three, four, and five of this act shall  take  effect
    19  on  the  same  date  and  in the same manner as a chapter of the laws of
    20  2019, amending the  financial  services  law  relating  to  establishing
    21  protections  from  excess  hospital  charges, as proposed in legislative
    22  bills numbers S. 3171-A and A. 264-B, takes effect.
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