Bill Text: NY A00264 | 2019-2020 | General Assembly | Amended

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Bill Title: Establishes patient protections from excessive hospital emergency charges; includes hospital charges, including hospital charges for inpatient services which follow an emergency room visit.

Spectrum: Strong Partisan Bill (Democrat 13-1)

Status: (Passed) 2019-10-17 - signed chap.375 [A00264 Detail]

Download: New_York-2019-A00264-Amended.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                         264--B

                               2019-2020 Regular Sessions

                   IN ASSEMBLY

                                       (Prefiled)

                                     January 9, 2019
                                       ___________

        Introduced  by  M.  of  A.  CAHILL, COLTON, ARROYO, JEAN-PIERRE, TAYLOR,
          McDONOUGH, JACOBSON -- Multi-Sponsored by -- M. of A. EPSTEIN --  read
          once   and  referred  to  the  Committee  on  Insurance  --  committee
          discharged, bill amended, ordered reprinted as amended and recommitted
          to said committee -- again reported from said  committee  with  amend-
          ments, ordered reprinted as amended and recommitted to said committee

        AN  ACT to amend the financial services law, in relation to establishing
          protections from excess hospital 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,
     7  including  a  bill for inpatient services which follow an emergency room
     8  visit, the health care plan shall pay an amount that  it  determines  is
     9  reasonable  for the emergency services rendered by the non-participating
    10  physician or hospital, in accordance with  section  three  thousand  two
    11  hundred  twenty-four-a  of  the  insurance law, except for the insured's
    12  co-payment, coinsurance or deductible, if any, and shall ensure that the
    13  insured shall incur no greater out-of-pocket  costs  for  the  emergency
    14  services  than  the  insured  would  have  incurred with a participating
    15  physician or hospital pursuant to subsection (c) of section three  thou-
    16  sand two hundred forty-one of the insurance law.
    17    (2)  A  non-participating  physician or hospital or a health care plan
    18  may submit a dispute regarding a fee or payment for  emergency  services
    19  for  review to an independent dispute resolution entity.  In cases where
    20  a health care plan submits a dispute regarding a fee for  payment  of  a

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD03101-05-9
        A. 264--B                           2

     1  non-participating  hospital's  emergency  services, the health care plan
     2  shall, after the initial payment, pay any additional amounts  it  deter-
     3  mines is reasonable directly to the non-participating hospital.
     4    (3)  The  independent  dispute resolution entity shall make a determi-
     5  nation within thirty days of receipt of the dispute for review.
     6    (4) In determining a reasonable fee  for  the  services  rendered,  an
     7  independent  dispute  resolution  entity  shall select either the health
     8  care plan's payment or the non-participating physician's  or  hospital's
     9  fee.  The  independent  dispute  resolution entity shall determine which
    10  amount to select based upon the conditions  and  factors  set  forth  in
    11  section  six  hundred  four  of  this article. If an independent dispute
    12  resolution entity determines, based on the health  care  plan's  payment
    13  and  the non-participating physician's or hospital's fee, that a settle-
    14  ment between the health care plan  and  non-participating  physician  or
    15  hospital  is  reasonably  likely,  or  that  both the health care plan's
    16  payment and the non-participating physician's or hospital's  fee  repre-
    17  sent  unreasonable  extremes,  then  the  independent dispute resolution
    18  entity may direct both parties to attempt a good faith  negotiation  for
    19  settlement.  The  health  care  plan  and non-participating physician or
    20  hospital may be granted up to ten business days  for  this  negotiation,
    21  which  shall  run  concurrently  with  the thirty day period for dispute
    22  resolution.
    23    (b) Emergency services for a patient that is not  an  insured.  (1)  A
    24  patient  that  is not an insured or the patient's physician may submit a
    25  dispute regarding a fee for emergency services for review  to  an  inde-
    26  pendent dispute resolution entity upon approval of the superintendent.
    27    (2) An independent dispute resolution entity shall determine a reason-
    28  able fee for the services based upon the same conditions and factors set
    29  forth in section six hundred four of this article.
    30    (3)  A patient that is not an insured shall not be required to pay the
    31  physician's or hospital's fee in order to  be  eligible  to  submit  the
    32  dispute for review to an independent dispute resolution entity.
    33    (c)  The  determination  of  an  independent dispute resolution entity
    34  shall be binding on the health care  plan,  physician  or  hospital  and
    35  patient,  and  shall  be  admissible in any court proceeding between the
    36  health care plan, physician or hospital or patient, or in  any  adminis-
    37  trative proceeding between this state and the physician or hospital.
    38    (d)  The  provisions of this section shall not apply to hospitals that
    39  had at least  sixty  percent  of  inpatient  discharges  annually  which
    40  consisted  of  medicaid,  uninsured,  and  dual  eligible individuals as
    41  determined by the department of health in its  determination  of  safety
    42  net hospitals.
    43    §  2.  Subsection (a) of section 608 of the financial services law, as
    44  added by section 26 of part H of chapter 60 of  the  laws  of  2014,  is
    45  amended to read as follows:
    46    (a)  For  disputes  involving an insured, when the independent dispute
    47  resolution entity determines the health care plan's payment  is  reason-
    48  able,  payment for the dispute resolution process shall be the responsi-
    49  bility of the non-participating physician or hospital.   When the  inde-
    50  pendent  dispute  resolution  entity  determines  the  non-participating
    51  physician's or hospital's fee is reasonable,  payment  for  the  dispute
    52  resolution  process shall be the responsibility of the health care plan.
    53  When a good faith negotiation directed by the independent dispute resol-
    54  ution entity pursuant to paragraph four of subsection (a) of section six
    55  hundred five of this article, or paragraph  six  of  subsection  (a)  of
    56  section  six  hundred  seven  of  this  article  results in a settlement
        A. 264--B                           3

     1  between  the  health  care  plan  and  non-participating  physician   or
     2  hospital,  the  health  care plan and the non-participating physician or
     3  hospital shall evenly divide and share the  prorated  cost  for  dispute
     4  resolution.
     5    § 3. Section 604 of the financial services law, as added by section 26
     6  of  part  H  of  chapter  60  of the laws of 2014, is amended to read as
     7  follows:
     8    § 604. Criteria for determining a reasonable fee. In  determining  the
     9  appropriate  amount  to  pay  for  a health care service, an independent
    10  dispute resolution entity shall consider all relevant  factors,  includ-
    11  ing:
    12    (a)  whether there is a gross disparity between the fee charged by the
    13  [physician] health care provider for services rendered as compared to:
    14    (1) fees paid to the involved [physician] health care provider for the
    15  same services rendered by the [physician] health care provider to  other
    16  patients  in  health  care  plans  in  which the [physician] health care
    17  provider is not participating, and
    18    (2) in the case of a dispute involving a health care plan,  fees  paid
    19  by  the  health  care plan to reimburse similarly qualified [physicians]
    20  health care providers for the same services in the same region  who  are
    21  not participating with the health care plan;
    22    (b) the level of training, education and experience of the [physician]
    23  health care provider;
    24    (c) the [physician's] health care provider's usual charge for compara-
    25  ble  services  with regard to patients in health care plans in which the
    26  [physician] health care provider is not participating;
    27    (d) the circumstances and complexity of the particular case, including
    28  time and place of the service;
    29    (e) individual patient characteristics; and, with regard to  physician
    30  services,
    31    (f) the usual and customary cost of the service.
    32    § 4. This act shall take effect immediately.