Bill Text: NY A08404 | 2019-2020 | General Assembly | Introduced

---

Bill Title: Establishes protections from excess hospital charges.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Passed) 2019-10-17 - SIGNED CHAP.377 [A08404 Detail]

Download: New_York-2019-A08404-Introduced.html

---

                STATE OF NEW YORK
        ________________________________________________________________________

                                          8404

                               2019-2020 Regular Sessions

                   IN ASSEMBLY

                                      June 16, 2019
                                       ___________

        Introduced by M. of A. CAHILL -- read once and referred to the Committee
          on Codes

        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.
                                                                   LBD03101-13-9
        A. 8404                             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.
     5    (2)  A  non-participating  physician or hospital or a health care plan
     6  may submit a dispute regarding a fee or payment for  emergency  services
     7  for review to an independent dispute resolution entity.  [In cases where
     8  a  health  care  plan submits a dispute regarding a fee for payment of a
     9  non-participating hospital's emergency services, the  health  care  plan
    10  shall,  after  the initial payment, pay any additional amounts it deter-
    11  mines is reasonable directly to the non-participating hospital.]
    12    (3) The independent dispute resolution entity shall  make  a  determi-
    13  nation within thirty days of receipt of the dispute for review.
    14    (4)  In  determining  a  reasonable  fee for the services rendered, an
    15  independent dispute resolution entity shall  select  either  the  health
    16  care  plan's  payment or the non-participating physician's or hospital's
    17  fee. The independent dispute resolution  entity  shall  determine  which
    18  amount  to  select  based  upon  the conditions and factors set forth in
    19  section six hundred four of this  article.  If  an  independent  dispute
    20  resolution  entity  determines,  based on the health care plan's payment
    21  and the non-participating physician's or hospital's fee, that a  settle-
    22  ment  between  the  health  care plan and non-participating physician or
    23  hospital is reasonably likely, or  that  both  the  health  care  plan's
    24  payment  and  the non-participating physician's or hospital's fee repre-
    25  sent unreasonable extremes,  then  the  independent  dispute  resolution
    26  entity  may  direct both parties to attempt a good faith negotiation for
    27  settlement. The health care  plan  and  non-participating  physician  or
    28  hospital  may  be  granted up to ten business days for this negotiation,
    29  which shall run concurrently with the  thirty  day  period  for  dispute
    30  resolution.
    31    (b)  Emergency  services  for  a patient that is not an insured. (1) A
    32  patient that is not an insured or the patient's physician may  submit  a
    33  dispute  regarding  a  fee for emergency services for review to an inde-
    34  pendent dispute resolution entity upon approval of the superintendent.
    35    (2) An independent dispute resolution entity shall determine a reason-
    36  able fee for the services based upon the same conditions and factors set
    37  forth in section six hundred four of this article.
    38    (3) A patient that is not an insured shall not be required to pay  the
    39  physician's  or  hospital's  fee  in  order to be eligible to submit the
    40  dispute for review to an independent dispute resolution entity.
    41    (c) The determination of  an  independent  dispute  resolution  entity
    42  shall  be  binding  on  the  health care plan, physician or hospital and
    43  patient, and shall be admissible in any  court  proceeding  between  the
    44  health  care  plan, physician or hospital or patient, or in any adminis-
    45  trative proceeding between this state and the physician or hospital.
    46    (d) The provisions of this section shall not apply to  hospitals  that
    47  had  at  least  sixty  percent  of  inpatient  discharges annually which
    48  consisted of medicaid,  uninsured,  and  dual  eligible  individuals  as
    49  determined  by  the  department of health in its determination of safety
    50  net hospitals.
    51    (e) For purposes of the hospital payment pursuant to subsection (a) of
    52  this section, the amount the health care plan shall pay to the  hospital
    53  shall be at least twenty-five percent greater than the amount the health
    54  care  plan  would  have  paid  for  the  claim  had the hospital been in
    55  network, based on the most recent contract between the health care  plan
    56  and  the  hospital. Provided however, the amount paid by the health care
        A. 8404                             3

     1  plan pursuant to this subsection shall not  prejudice  either  party  or
     2  preclude  either  party  from submitting a dispute to the dispute resol-
     3  ution entity relating to the payment to the  hospital  or  preclude  the
     4  hospital from seeking additional payment from the health care plan prior
     5  to  a decision by the dispute resolution entity. To the extent the prior
     6  contract between the hospital and health care plan expired greater  than
     7  twelve  months  prior  to the payment of the disputed claim, the payment
     8  amount shall be adjusted based upon the medical  consumer  price  index.
     9  The  provisions  of  this  subsection shall only apply to the extent the
    10  health care plan and hospital had previously entered into a  participat-
    11  ing provider agreement.
    12    §  2. Section 604 of the financial services law, as amended by a chap-
    13  ter of the laws of 2019, amending the financial services law relating to
    14  establishing protections from excess hospital charges,  as  proposed  in
    15  legislative  bills numbers S. 3171-A and A. 264-B, is amended to read as
    16  follows:
    17    § 604. Criteria for determining a reasonable fee. In  determining  the
    18  appropriate  amount  to  pay  for  a health care service, an independent
    19  dispute resolution entity shall consider all relevant  factors,  includ-
    20  ing:
    21    (a)  whether there is a gross disparity between the fee charged by the
    22  [health care provider] physician or hospital for  services  rendered  as
    23  compared to:
    24    (1)  fees  paid  to  the  involved [health care provider] physician or
    25  hospital for the same services rendered by the  [health  care  provider]
    26  physician  or  hospital  to other patients in health care plans in which
    27  the [health care provider] physician or hospital is  not  participating,
    28  and
    29    (2)  in  the case of a dispute involving a health care plan, fees paid
    30  by the health care plan to reimburse similarly  qualified  [health  care
    31  providers]  physicians  or  hospitals  for the same services in the same
    32  region who are not participating with the health care plan;
    33    (b) the level of training, education and  experience  of  the  [health
    34  care  provider]  physician,  and in the case of a hospital, the teaching
    35  staff, scope of services and case mix;
    36    (c) the [health care  provider's]  physician's  and  hospital's  usual
    37  charge  for  comparable  services with regard to patients in health care
    38  plans in which the [health care provider] physician or hospital  is  not
    39  participating;
    40    (d) the circumstances and complexity of the particular case, including
    41  time and place of the service;
    42    (e)  individual patient characteristics; and, with regard to physician
    43  services,
    44    (f) the usual and customary cost of the service.
    45    § 3. Section 4406-c of the public health law is amended  by  adding  a
    46  new subdivision 5-e to read as follows:
    47    5-e.  At  least  sixty  days  prior  to  the termination of a contract
    48  between a hospital and a health care plan, the parties shall  utilize  a
    49  mutually  agreed  upon  mediator  to assist in resolving any outstanding
    50  contractual issues. The results of the mediation shall not be binding on
    51  the parties.
    52    § 4. Section 3217-b of the insurance law is amended by  adding  a  new
    53  subsection (l) to read as follows:
    54    (l) At least sixty days prior to the termination of a contract between
    55  a  hospital  and an insurer, the parties shall utilize a mutually agreed
        A. 8404                             4

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