Bill Text: NY S07868 | 2015-2016 | General Assembly | Introduced

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

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Bill Title: Relates to establishing protections from excessive hospital emergency charges; includes hospital charges; extends coverage for members in certain counties.

Spectrum: Partisan Bill (Republican 2-0)

Status: (Introduced - Dead) 2016-06-03 - PRINT NUMBER 7868A [S07868 Detail]

Download: New_York-2015-S07868-Introduced.html

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                STATE OF NEW YORK
        ________________________________________________________________________
                                          7868
                    IN SENATE
                                      May 18, 2016
                                       ___________
        Introduced  by  Sen.  SEWARD -- 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  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.
    16    (2)  A  non-participating  physician or hospital or a health care plan
    17  may submit a dispute regarding a fee or payment for  emergency  services
    18  for review to an independent dispute resolution entity. In cases where a
    19  health  care  plan  submits  a  dispute regarding a fee for payment of a
    20  non-participating hospital's emergency room services,  the  health  care
    21  plan  shall  pay  the amount it determines is reasonably directly to the
    22  non-participating hospital.
    23    (3) The independent dispute resolution entity shall  make  a  determi-
    24  nation within thirty days of receipt of the dispute for review.
    25    (4)  In  determining  a  reasonable  fee for the services rendered, an
    26  independent dispute resolution entity shall  select  either  the  health
    27  care  plan's  payment or the non-participating physician's or hospital's
    28  fee. The independent dispute resolution  entity  shall  determine  which
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD15486-01-6
        S. 7868                             2
     1  amount  to  select  based  upon  the conditions and factors set forth in
     2  section six hundred four of this  article.  If  an  independent  dispute
     3  resolution  entity  determines,  based on the health care plan's payment
     4  and  the non-participating physician's or hospital's fee, that a settle-
     5  ment between the health care plan  and  non-participating  physician  or
     6  hospital  is  reasonably  likely,  or  that  both the health care plan's
     7  payment and the non-participating physician's or hospital's  fee  repre-
     8  sent  unreasonable  extremes,  then  the  independent dispute resolution
     9  entity may direct both parties to attempt a good faith  negotiation  for
    10  settlement.  The  health  care  plan  and non-participating physician or
    11  hospital may be granted up to ten business days  for  this  negotiation,
    12  which  shall  run  concurrently  with  the thirty day period for dispute
    13  resolution.
    14    (b) Emergency services for a patient that is not  an  insured.  (1)  A
    15  patient  that  is not an insured or the patient's physician may submit a
    16  dispute regarding a fee for emergency services for review  to  an  inde-
    17  pendent dispute resolution entity upon approval of the superintendent.
    18    (2) An independent dispute resolution entity shall determine a reason-
    19  able fee for the services based upon the same conditions and factors set
    20  forth in section six hundred four of this article.
    21    (3)  A patient that is not an insured shall not be required to pay the
    22  physician's or hospital's fee in order to  be  eligible  to  submit  the
    23  dispute for review to an independent dispute resolution entity.
    24    (c)  The  determination  of  an  independent dispute resolution entity
    25  shall be binding on the health care  plan,  physician  or  hospital  and
    26  patient,  and  shall  be  admissible in any court proceeding between the
    27  health care plan, physician or hospital or patient, or in  any  adminis-
    28  trative proceeding between this state and the physician or hospital.
    29    §  2.  Paragraph  (a) of section 608 of the financial services law, as
    30  added by section 26 of part H of chapter 60 of  the  laws  of  2014,  is
    31  amended to read as follows:
    32    (a)  For  disputes  involving an insured, when the independent dispute
    33  resolution entity determines the health care plan's payment  is  reason-
    34  able,  payment for the dispute resolution process shall be the responsi-
    35  bility of the non-participating physician or hospital.   When the  inde-
    36  pendent  dispute  resolution  entity  determines  the  non-participating
    37  physician's or hospital's fee is reasonable,  payment  for  the  dispute
    38  resolution  process shall be the responsibility of the health care plan.
    39  When a good faith negotiation directed by the independent dispute resol-
    40  ution entity pursuant to paragraph four of subsection (a) of section six
    41  hundred five of this article, or paragraph  six  of  subsection  (a)  of
    42  section  six  hundred  seven  of  this  article  results in a settlement
    43  between the health care plan and non-participating physician, the health
    44  care plan and the non-participating physician or hospital  shall  evenly
    45  divide and share the prorated cost for dispute resolution.
    46    § 3. This act shall take effect immediately.