Bill Text: NY A07611 | 2017-2018 | General Assembly | Amended

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.

Spectrum: Moderate Partisan Bill (Democrat 7-1)

Status: (Engrossed - Dead) 2018-06-12 - COMMITTED TO RULES [A07611 Detail]

Download: New_York-2017-A07611-Amended.html

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                STATE OF NEW YORK
        ________________________________________________________________________
                                         7611--A
                                                                Cal. No. 561
                               2017-2018 Regular Sessions
                   IN ASSEMBLY
                                       May 3, 2017
                                       ___________
        Introduced  by  M.  of A. CAHILL, SEPULVEDA -- read once and referred to
          the Committee on Insurance -- reported and referred to  the  Committee
          on Codes -- advanced to a third reading, passed by Assembly and deliv-
          ered  to the Senate, recalled from the Senate, vote reconsidered, bill
          amended, ordered reprinted, retaining its place on 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.
    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
    19  a  health  care  plan submits a dispute regarding a fee for payment of a
    20  non-participating physician or hospital's emergency services, the health
    21  care plan shall, after the initial payment, pay any  additional  amounts
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD09770-05-7
        A. 7611--A                          2
     1  it  determines is reasonable directly to the non-participating physician
     2  or hospital, respectively.
     3    (3)  The  independent  dispute resolution entity shall make a determi-
     4  nation within thirty days of receipt of the dispute for review.
     5    (4) In determining a reasonable fee  for  the  services  rendered,  an
     6  independent  dispute  resolution  entity  shall select either the health
     7  care plan's payment or the non-participating physician's  or  hospital's
     8  fee.  The  independent  dispute  resolution entity shall determine which
     9  amount to select based upon the conditions  and  factors  set  forth  in
    10  section  six  hundred  four  of  this article. If an independent dispute
    11  resolution entity determines, based on the health  care  plan's  payment
    12  and  the non-participating physician's or hospital's fee, that a settle-
    13  ment between the health care plan  and  non-participating  physician  or
    14  hospital  is  reasonably  likely,  or  that  both the health care plan's
    15  payment and the non-participating physician's or hospital's  fee  repre-
    16  sent  unreasonable  extremes,  then  the  independent dispute resolution
    17  entity may direct both parties to attempt a good faith  negotiation  for
    18  settlement.  The  health  care  plan  and non-participating physician or
    19  hospital may be granted up to ten business days  for  this  negotiation,
    20  which  shall  run  concurrently  with  the thirty day period for dispute
    21  resolution.
    22    (b) Emergency services for a patient that is not  an  insured.  (1)  A
    23  patient  that  is not an insured or the patient's physician may submit a
    24  dispute regarding a fee for emergency services for review  to  an  inde-
    25  pendent dispute resolution entity upon approval of the superintendent.
    26    (2) An independent dispute resolution entity shall determine a reason-
    27  able fee for the services based upon the same conditions and factors set
    28  forth in section six hundred four of this article.
    29    (3)  A patient that is not an insured shall not be required to pay the
    30  physician's or hospital's fee in order to  be  eligible  to  submit  the
    31  dispute for review to an independent dispute resolution entity.
    32    (c)  The  determination  of  an  independent dispute resolution entity
    33  shall be binding on the health care  plan,  physician  or  hospital  and
    34  patient,  and  shall  be  admissible in any court proceeding between the
    35  health care plan, physician or hospital or patient, or in  any  adminis-
    36  trative proceeding between this state and the physician or hospital.
    37    §  2. Subdivision (a) of section 608 of the financial services law, as
    38  added by section 26 of part H of chapter 60 of  the  laws  of  2014,  is
    39  amended to read as follows:
    40    (a)  For  disputes  involving an insured, when the independent dispute
    41  resolution entity determines the health care plan's payment  is  reason-
    42  able,  payment for the dispute resolution process shall be the responsi-
    43  bility of the non-participating physician or hospital.   When the  inde-
    44  pendent  dispute  resolution  entity  determines  the  non-participating
    45  physician's or hospital's fee is reasonable,  payment  for  the  dispute
    46  resolution  process shall be the responsibility of the health care plan.
    47  When a good faith negotiation directed by the independent dispute resol-
    48  ution entity pursuant to paragraph four of subsection (a) of section six
    49  hundred five of this article, or paragraph  six  of  subsection  (a)  of
    50  section  six  hundred  seven  of  this  article  results in a settlement
    51  between the health care plan and non-participating physician, the health
    52  care plan and the non-participating physician or hospital  shall  evenly
    53  divide and share the prorated cost for dispute resolution.
    54    § 3. Section 604 of the financial services law, as added by section 26
    55  of  part  H  of  chapter  60  of the laws of 2014, is amended to read as
    56  follows:
        A. 7611--A                          3
     1    § 604. Criteria for determining a reasonable fee. In  determining  the
     2  appropriate  amount  to  pay  for  a health care service, an independent
     3  dispute resolution entity shall consider all relevant  factors,  includ-
     4  ing:
     5    (a)  whether there is a gross disparity between the fee charged by the
     6  [physician] health care provider for services rendered as compared to:
     7    (1) fees paid to the involved [physician] health care provider for the
     8  same services rendered by the [physician] health care provider to  other
     9  patients  in  health  care  plans  in  which the [physician] health care
    10  provider is not participating, and
    11    (2) in the case of a dispute involving a health care plan,  fees  paid
    12  by  the  health  care plan to reimburse similarly qualified [physicians]
    13  health care providers for the same services in the same region  who  are
    14  not participating with the health care plan;
    15    (b) the level of training, education and experience of the [physician]
    16  health care provider;
    17    (c) the [physician's] health care provider's usual charge for compara-
    18  ble  services  with regard to patients in health care plans in which the
    19  [physician] health care provider is not participating;
    20    (d) the circumstances and complexity of the particular case, including
    21  time and place of the service;
    22    (e) individual patient characteristics; and, where applicable,
    23    (f) the usual and customary cost of the service.
    24    § 4. This act shall take effect immediately.