Bill Text: NY S06544 | 2019-2020 | General Assembly | Amended
Bill Title: Establishes protections from excess hospital charges.
Spectrum: Partisan Bill (Democrat 3-0)
Status: (Passed) 2019-10-17 - SIGNED CHAP.377 [S06544 Detail]
Download: New_York-2019-S06544-Amended.html
STATE OF NEW YORK ________________________________________________________________________ 6544--A 2019-2020 Regular Sessions IN SENATE June 15, 2019 ___________ Introduced by Sens. KRUEGER, RIVERA -- read twice and ordered printed, and when printed to be committed to the Committee on Rules -- commit- tee discharged, bill amended, ordered reprinted as amended and recom- mitted to said committee 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 EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD03101-12-9S. 6544--A 2 1 services provided by such non-participating hospital, the non-partici- 2 pating hospital may bill the health care plan for the emergency services 3 rendered. Upon receipt of the bill, the health care plan shall pay the 4 non-participating hospital the amount prescribed by this section and any 5 subsequent amount determined to be owed to the hospital in relation to 6 the emergency services provided. 7 (2) A non-participating physician or hospital or a health care plan 8 may submit a dispute regarding a fee or payment for emergency services 9 for review to an independent dispute resolution entity. [In cases where10a health care plan submits a dispute regarding a fee for payment of a11non-participating hospital's emergency services, the health care plan12shall, after the initial payment, pay any additional amounts it deter-13mines is reasonable directly to the non-participating hospital.] 14 (3) The independent dispute resolution entity shall make a determi- 15 nation within thirty days of receipt of the dispute for review. 16 (4) In determining a reasonable fee for the services rendered, an 17 independent dispute resolution entity shall select either the health 18 care plan's payment or the non-participating physician's or hospital's 19 fee. The independent dispute resolution entity shall determine which 20 amount to select based upon the conditions and factors set forth in 21 section six hundred four of this article. If an independent dispute 22 resolution entity determines, based on the health care plan's payment 23 and the non-participating physician's or hospital's fee, that a settle- 24 ment between the health care plan and non-participating physician or 25 hospital is reasonably likely, or that both the health care plan's 26 payment and the non-participating physician's or hospital's fee repre- 27 sent unreasonable extremes, then the independent dispute resolution 28 entity may direct both parties to attempt a good faith negotiation for 29 settlement. The health care plan and non-participating physician or 30 hospital may be granted up to ten business days for this negotiation, 31 which shall run concurrently with the thirty day period for dispute 32 resolution. 33 (b) Emergency services for a patient that is not an insured. (1) A 34 patient that is not an insured or the patient's physician may submit a 35 dispute regarding a fee for emergency services for review to an inde- 36 pendent dispute resolution entity upon approval of the superintendent. 37 (2) An independent dispute resolution entity shall determine a reason- 38 able fee for the services based upon the same conditions and factors set 39 forth in section six hundred four of this article. 40 (3) A patient that is not an insured shall not be required to pay the 41 physician's or hospital's fee in order to be eligible to submit the 42 dispute for review to an independent dispute resolution entity. 43 (c) The determination of an independent dispute resolution entity 44 shall be binding on the health care plan, physician or hospital and 45 patient, and shall be admissible in any court proceeding between the 46 health care plan, physician or hospital or patient, or in any adminis- 47 trative proceeding between this state and the physician or hospital. 48 (d) The provisions of this section shall not apply to hospitals that 49 had at least sixty percent of inpatient discharges annually which 50 consisted of medicaid, uninsured, and dual eligible individuals as 51 determined by the department of health in its determination of safety 52 net hospitals. 53 (e) For purposes of the hospital payment pursuant to subsection (a) of 54 this section, the amount the health care plan shall pay to the hospital 55 shall be at least twenty-five percent greater than the amount the health 56 care plan would have paid for the claim had the hospital been inS. 6544--A 3 1 network, based on the most recent contract between the health care plan 2 and the hospital. Provided however, the amount paid by the health care 3 plan pursuant to this subsection shall not prejudice either party or 4 preclude either party from submitting a dispute to the dispute resol- 5 ution entity relating to the payment to the hospital or preclude the 6 hospital from seeking additional payment from the health care plan prior 7 to a decision by the dispute resolution entity. To the extent the prior 8 contract between the hospital and health care plan expired greater than 9 twelve months prior to the payment of the disputed claim, the payment 10 amount shall be adjusted based upon the medical consumer price index. 11 The provisions of this subsection shall only apply to the extent the 12 health care plan and hospital had previously entered into a participat- 13 ing provider agreement. 14 § 2. Section 604 of the financial services law, as amended by a chap- 15 ter of the laws of 2019, amending the financial services law relating to 16 establishing protections from excess hospital charges, as proposed in 17 legislative bills numbers S. 3171-A and A. 264-B, is amended to read as 18 follows: 19 § 604. Criteria for determining a reasonable fee. In determining the 20 appropriate amount to pay for a health care service, an independent 21 dispute resolution entity shall consider all relevant factors, includ- 22 ing: 23 (a) whether there is a gross disparity between the fee charged by the 24 [health care provider] physician or hospital for services rendered as 25 compared to: 26 (1) fees paid to the involved [health care provider] physician or 27 hospital for the same services rendered by the [health care provider] 28 physician or hospital to other patients in health care plans in which 29 the [health care provider] physician or hospital is not participating, 30 and 31 (2) in the case of a dispute involving a health care plan, fees paid 32 by the health care plan to reimburse similarly qualified [health care33providers] physicians or hospitals for the same services in the same 34 region who are not participating with the health care plan; 35 (b) the level of training, education and experience of the [health36care provider] physician, and in the case of a hospital, the teaching 37 staff, scope of services and case mix; 38 (c) the [health care provider's] physician's and hospital's usual 39 charge for comparable services with regard to patients in health care 40 plans in which the [health care provider] physician or hospital is not 41 participating; 42 (d) the circumstances and complexity of the particular case, including 43 time and place of the service; 44 (e) individual patient characteristics; and, with regard to physician 45 services, 46 (f) the usual and customary cost of the service. 47 § 3. Section 4406-c of the public health law is amended by adding a 48 new subdivision 5-e to read as follows: 49 5-e. At least sixty days prior to the termination of a contract 50 between a hospital and a health care plan, the parties shall utilize a 51 mutually agreed upon mediator to assist in resolving any outstanding 52 contractual issues. The results of the mediation shall not be binding on 53 the parties. 54 § 4. Section 3217-b of the insurance law is amended by adding a new 55 subsection (l) to read as follows:S. 6544--A 4 1 (l) At least sixty days prior to the termination of a contract between 2 a hospital and an insurer, the parties shall utilize a mutually agreed 3 upon mediator to assist in resolving any outstanding contractual issues. 4 The results of the mediation shall not be binding on the parties. 5 § 5. Section 4325 of the insurance law is amended by adding a new 6 subsection (m) to read as follows: 7 (m) At least sixty days prior to the termination of a contract between 8 a hospital and an organization, the parties shall utilize a mutually 9 agreed upon mediator to assist in resolving any outstanding contractual 10 issues. The results of the mediation shall not be binding on the 11 parties. 12 § 6. Section 4 of a chapter of the laws of 2019, amending the finan- 13 cial services law relating to establishing protections from excess 14 hospital charges, as proposed in legislative bills numbers S. 3171-A and 15 A. 264-B, is amended to read as follows: 16 § 4. This act shall take effect [immediately] January 1, 2020. 17 § 7. This act shall take effect immediately; provided, however, that 18 sections one, two, three, four, and five of this act shall take effect 19 on the same date and in the same manner as a chapter of the laws of 20 2019, amending the financial services law relating to establishing 21 protections from excess hospital charges, as proposed in legislative 22 bills numbers S. 3171-A and A. 264-B, takes effect.
