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

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Establishes protections from excess hospital charges.

Spectrum: Partisan Bill (Democrat 3-0)

Status: (Passed) 2019-10-17 - SIGNED CHAP.377 [S06544 Detail]

Download: New_York-2019-S06544-Introduced.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                          6544

                               2019-2020 Regular Sessions

                    IN SENATE

                                      June 15, 2019
                                       ___________

        Introduced  by  Sen. KRUEGER -- read twice and ordered printed, and when
          printed to be committed to the Committee on Rules

        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
    20  services  provided  by such non-participating hospital, the non-partici-
    21  pating hospital may bill the health care plan for the emergency services

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD03101-09-9
        S. 6544                             2

     1  rendered. Upon receipt of the bill, the health care plan shall  pay  the
     2  non-participating hospital the amount prescribed by this section and any
     3  subsequent  amount  determined to be owed to the hospital in relation to
     4  the emergency services provided.  To the extent that a non-participating
     5  hospital opts to send the bill to a patient in addition to or in lieu of
     6  the  health  care  plan, such bill must state in bold, large conspicuous
     7  print on the top of the bill a notation that the patient is not  respon-
     8  sible for the payment of the bill, other than the deductible, copayments
     9  or other cost sharing obligations of the patient.
    10    (2)  A  non-participating  physician or hospital or a health care plan
    11  may submit a dispute regarding a fee or payment for  emergency  services
    12  for review to an independent dispute resolution entity.  [In cases where
    13  a  health  care  plan submits a dispute regarding a fee for payment of a
    14  non-participating hospital's emergency services, the  health  care  plan
    15  shall,  after  the initial payment, pay any additional amounts it deter-
    16  mines is reasonable directly to the non-participating hospital.]
    17    (3) The independent dispute resolution entity shall  make  a  determi-
    18  nation within thirty days of receipt of the dispute for review.
    19    (4)  In  determining  a  reasonable  fee for the services rendered, an
    20  independent dispute resolution entity shall  select  either  the  health
    21  care  plan's  payment or the non-participating physician's or hospital's
    22  fee. The independent dispute resolution  entity  shall  determine  which
    23  amount  to  select  based  upon  the conditions and factors set forth in
    24  section six hundred four of this  article.  If  an  independent  dispute
    25  resolution  entity  determines,  based on the health care plan's payment
    26  and the non-participating physician's or hospital's fee, that a  settle-
    27  ment  between  the  health  care plan and non-participating physician or
    28  hospital is reasonably likely, or  that  both  the  health  care  plan's
    29  payment  and  the non-participating physician's or hospital's fee repre-
    30  sent unreasonable extremes,  then  the  independent  dispute  resolution
    31  entity  may  direct both parties to attempt a good faith negotiation for
    32  settlement. The health care  plan  and  non-participating  physician  or
    33  hospital  may  be  granted up to ten business days for this negotiation,
    34  which shall run concurrently with the  thirty  day  period  for  dispute
    35  resolution.
    36    (b)  Emergency  services  for  a patient that is not an insured. (1) A
    37  patient that is not an insured or the patient's physician may  submit  a
    38  dispute  regarding  a  fee for emergency services for review to an inde-
    39  pendent dispute resolution entity upon approval of the superintendent.
    40    (2) An independent dispute resolution entity shall determine a reason-
    41  able fee for the services based upon the same conditions and factors set
    42  forth in section six hundred four of this article.
    43    (3) A patient that is not an insured shall not be required to pay  the
    44  physician's  or  hospital's  fee  in  order to be eligible to submit the
    45  dispute for review to an independent dispute resolution entity.
    46    (c) The determination of  an  independent  dispute  resolution  entity
    47  shall  be  binding  on  the  health care plan, physician or hospital and
    48  patient, and shall be admissible in any  court  proceeding  between  the
    49  health  care  plan, physician or hospital or patient, or in any adminis-
    50  trative proceeding between this state and the physician or hospital.
    51    (d) The provisions of this section shall not apply to  hospitals  that
    52  had  at  least  sixty  percent  of  inpatient  discharges annually which
    53  consisted of medicaid,  uninsured,  and  dual  eligible  individuals  as
    54  determined  by  the  department of health in its determination of safety
    55  net hospitals.
        S. 6544                             3

     1    (e) For purposes of the hospital payment pursuant to subsection (a) of
     2  this section, the amount the health care plan shall pay to the  hospital
     3  shall be at least twenty-five percent greater than the amount the health
     4  care  plan  would  have  paid  for  the  claim  had the hospital been in
     5  network,  based on the most recent contract between the health care plan
     6  and the hospital. Provided however, the amount paid by the  health  care
     7  plan  pursuant  to  this  subsection shall not prejudice either party or
     8  preclude either party from submitting a dispute to  the  dispute  resol-
     9  ution  entity  relating  to  the payment to the hospital or preclude the
    10  hospital from seeking additional payment from the health care plan prior
    11  to a decision by the dispute resolution entity. To the extent the  prior
    12  contract  between the hospital and health care plan expired greater than
    13  twelve months prior to the payment of the disputed  claim,  the  payment
    14  amount  shall  be  adjusted based upon the medical consumer price index.
    15  The provisions of this subsection shall only apply  to  the  extent  the
    16  health  care plan and hospital had previously entered into a participat-
    17  ing provider agreement.
    18    § 2. Section 604 of the financial services law, as amended by a  chap-
    19  ter of the laws of 2019, amending the financial services law relating to
    20  establishing  protections  from  excess hospital charges, as proposed in
    21  legislative bills numbers S. 3171-A and A. 264-B, is amended to read  as
    22  follows:
    23    §  604.  Criteria for determining a reasonable fee. In determining the
    24  appropriate amount to pay for a  health  care  service,  an  independent
    25  dispute  resolution  entity shall consider all relevant factors, includ-
    26  ing:
    27    (a) whether there is a gross disparity between the fee charged by  the
    28  [health  care  provider]  physician or hospital for services rendered as
    29  compared to:
    30    (1) fees paid to the involved  [health  care  provider]  physician  or
    31  hospital  for  the  same services rendered by the [health care provider]
    32  physician or hospital to other patients in health care  plans  in  which
    33  the  [health  care provider] physician or hospital is not participating,
    34  and
    35    (2) in the case of a dispute involving a health care plan,  fees  paid
    36  by  the  health  care plan to reimburse similarly qualified [health care
    37  providers] physicians or hospitals for the same  services  in  the  same
    38  region who are not participating with the health care plan;
    39    (b)  the  level  of  training, education and experience of the [health
    40  care provider] physician, and in the case of a  hospital,  the  teaching
    41  staff, scope of services and case mix;
    42    (c)  the  [health  care  provider's]  physician's and hospital's usual
    43  charge for comparable services with regard to patients  in  health  care
    44  plans  in  which the [health care provider] physician or hospital is not
    45  participating;
    46    (d) the circumstances and complexity of the particular case, including
    47  time and place of the service;
    48    (e) individual patient characteristics; and, with regard to  physician
    49  services,
    50    (f) the usual and customary cost of the service.
    51    §  3.  Section  4406-c of the public health law is amended by adding a
    52  new subdivision 5-e to read as follows:
    53    5-e. At least sixty days  prior  to  the  termination  of  a  contract
    54  between  a  hospital and a health care plan, the parties shall utilize a
    55  mutually agreed upon mediator to assist  in  resolving  any  outstanding
        S. 6544                             4

     1  contractual issues. The results of the mediation shall not be binding on
     2  the parties.
     3    §  4.  Section  3217-b of the insurance law is amended by adding a new
     4  subsection (l) to read as follows:
     5    (l) At least sixty days prior to the termination of a contract between
     6  a hospital and an insurer, the parties shall utilize a  mutually  agreed
     7  upon mediator to assist in resolving any outstanding contractual issues.
     8  The results of the mediation shall not be binding on the parties.
     9    §  5.  Section  4325  of  the insurance law is amended by adding a new
    10  subsection (m) to read as follows:
    11    (m) At least sixty days prior to the termination of a contract between
    12  a hospital and an organization, the parties  shall  utilize  a  mutually
    13  agreed  upon mediator to assist in resolving any outstanding contractual
    14  issues. The results of  the  mediation  shall  not  be  binding  on  the
    15  parties.
    16    §  6.  Section 4 of a chapter of the laws of 2019, amending the finan-
    17  cial services law  relating  to  establishing  protections  from  excess
    18  hospital charges, as proposed in legislative bills numbers S. 3171-A and
    19  A. 264-B, is amended to read as follows:
    20    § 4. This act shall take effect [immediately] January 1, 2020.
    21    §  7.  This act shall take effect immediately; provided, however, that
    22  sections one, two, three, four, and five of this act shall  take  effect
    23  on  the  same  date  and  in the same manner as a chapter of the laws of
    24  2019, amending the  financial  services  law  relating  to  establishing
    25  protections  from  excess  hospital  charges, as proposed in legislative
    26  bills numbers S. 3171-A and A. 264-B, takes effect.