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

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

---

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

---

                STATE OF NEW YORK
        ________________________________________________________________________
                                         7611--B
                                                                Cal. No. 534
                               2017-2018 Regular Sessions
                   IN ASSEMBLY
                                       May 3, 2017
                                       ___________
        Introduced  by  M.  of  A.  CAHILL, COLTON, ARROYO, JEAN-PIERRE, TAYLOR,
          McDONOUGH -- 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 delivered to the Senate, recalled from
          the  Senate,  vote  reconsidered,  bill  amended,  ordered  reprinted,
          retaining its place on the order of third reading -- passed by  Assem-
          bly and delivered to the Senate, recalled from the Senate, vote recon-
          sidered,  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
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD09770-07-8
        A. 7611--B                          2
     1  a health care plan submits a dispute regarding a fee for  payment  of  a
     2  non-participating  hospital's  emergency  services, the health care plan
     3  shall, after the initial payment, pay any additional amounts  it  deter-
     4  mines is reasonable directly to the non-participating hospital.
     5    (3)  The  independent  dispute resolution entity shall make a determi-
     6  nation within thirty days of receipt of the dispute for review.
     7    (4) In determining a reasonable fee  for  the  services  rendered,  an
     8  independent  dispute  resolution  entity  shall select either the health
     9  care plan's payment or the non-participating physician's  or  hospital's
    10  fee.  The  independent  dispute  resolution entity shall determine which
    11  amount to select based upon the conditions  and  factors  set  forth  in
    12  section  six  hundred  four  of  this article. If an independent dispute
    13  resolution entity determines, based on the health  care  plan's  payment
    14  and  the non-participating physician's or hospital's fee, that a settle-
    15  ment between the health care plan  and  non-participating  physician  or
    16  hospital  is  reasonably  likely,  or  that  both the health care plan's
    17  payment and the non-participating physician's or hospital's  fee  repre-
    18  sent  unreasonable  extremes,  then  the  independent dispute resolution
    19  entity may direct both parties to attempt a good faith  negotiation  for
    20  settlement.  The  health  care  plan  and non-participating physician or
    21  hospital may be granted up to ten business days  for  this  negotiation,
    22  which  shall  run  concurrently  with  the thirty day period for dispute
    23  resolution.
    24    (b) Emergency services for a patient that is not  an  insured.  (1)  A
    25  patient  that  is not an insured or the patient's physician may submit a
    26  dispute regarding a fee for emergency services for review  to  an  inde-
    27  pendent dispute resolution entity upon approval of the superintendent.
    28    (2) An independent dispute resolution entity shall determine a reason-
    29  able fee for the services based upon the same conditions and factors set
    30  forth in section six hundred four of this article.
    31    (3)  A patient that is not an insured shall not be required to pay the
    32  physician's or hospital's fee in order to  be  eligible  to  submit  the
    33  dispute for review to an independent dispute resolution entity.
    34    (c)  The  determination  of  an  independent dispute resolution entity
    35  shall be binding on the health care  plan,  physician  or  hospital  and
    36  patient,  and  shall  be  admissible in any court proceeding between the
    37  health care plan, physician or hospital or patient, or in  any  adminis-
    38  trative proceeding between this state and the physician or hospital.
    39    §  2. Subdivision (a) of section 608 of the financial services law, as
    40  added by section 26 of part H of chapter 60 of  the  laws  of  2014,  is
    41  amended to read as follows:
    42    (a)  For  disputes  involving an insured, when the independent dispute
    43  resolution entity determines the health care plan's payment  is  reason-
    44  able,  payment for the dispute resolution process shall be the responsi-
    45  bility of the non-participating physician or hospital.   When the  inde-
    46  pendent  dispute  resolution  entity  determines  the  non-participating
    47  physician's or hospital's fee is reasonable,  payment  for  the  dispute
    48  resolution  process shall be the responsibility of the health care plan.
    49  When a good faith negotiation directed by the independent dispute resol-
    50  ution entity pursuant to paragraph four of subsection (a) of section six
    51  hundred five of this article, or paragraph  six  of  subsection  (a)  of
    52  section  six  hundred  seven  of  this  article  results in a settlement
    53  between the health care plan and non-participating physician, the health
    54  care plan and the non-participating physician or hospital  shall  evenly
    55  divide and share the prorated cost for dispute resolution.
        A. 7611--B                          3
     1    § 3. Section 604 of the financial services law, as added by section 26
     2  of  part  H  of  chapter  60  of the laws of 2014, is amended to read as
     3  follows:
     4    §  604.  Criteria for determining a reasonable fee. In determining the
     5  appropriate amount to pay for a  health  care  service,  an  independent
     6  dispute  resolution  entity shall consider all relevant factors, includ-
     7  ing:
     8    (a) whether there is a gross disparity between the fee charged by  the
     9  [physician] health care provider for services rendered as compared to:
    10    (1) fees paid to the involved [physician] health care provider for the
    11  same  services rendered by the [physician] health care provider to other
    12  patients in health care plans  in  which  the  [physician]  health  care
    13  provider is not participating, and
    14    (2)  in  the case of a dispute involving a health care plan, fees paid
    15  by the health care plan to reimburse  similarly  qualified  [physicians]
    16  health  care  providers for the same services in the same region who are
    17  not participating with the health care plan;
    18    (b) the level of training, education and experience of the [physician]
    19  health care provider;
    20    (c) the [physician's] health care provider's usual charge for compara-
    21  ble services with regard to patients in health care plans in  which  the
    22  [physician] health care provider is not participating;
    23    (d) the circumstances and complexity of the particular case, including
    24  time and place of the service;
    25    (e) individual patient characteristics; and, where applicable,
    26    (f) the usual and customary cost of the service.
    27    § 4. This act shall take effect immediately.