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.