S T A T E O F N E W Y O R K
________________________________________________________________________
8836--C
2009-2010 Regular Sessions
I N A S S E M B L Y
June 11, 2009
___________
Introduced by M. of A. ORTIZ -- Multi-Sponsored by -- M. of A. CRESPO --
read once and referred to the Committee on Health -- committee
discharged, bill amended, ordered reprinted as amended and recommitted
to said committee -- recommitted to the Committee on Health in accord-
ance with Assembly Rule 3, sec. 2 -- committee discharged, bill
amended, ordered reprinted as amended and recommitted to said commit-
tee -- again reported from said committee with amendments, ordered
reprinted as amended and recommitted to said committee
AN ACT to amend the public health law and the insurance law, in relation
to providing access to diagnostic laboratories by patients in health
maintenance organizations
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Section 4406 of the public health law is amended by adding
a new subdivision 6 to read as follows:
6. NOTWITHSTANDING ANY OTHER PROVISION OF LAW, IF AN ENROLLEE IS
REFERRED BY AN IN-PLAN PROVIDER TO A PROVIDER OF CLINICAL LABORATORY
SERVICES NOT PARTICIPATING IN THE PLAN (A "NON-PARTICIPATING PROVIDER"),
ANY SERVICE PROVIDED BY A NON-PARTICIPATING PROVIDER THAT WOULD OTHER-
WISE BE PAID FOR BY THE PLAN TO OTHER NON-PARTICIPATING PROVIDERS SHALL
BE PAID FOR BY THE PLAN, AND THE PLAN SHALL BE RESPONSIBLE FOR PAYMENT
DIRECTLY TO THE NON-PARTICIPATING PROVIDER FOR THAT SERVICE IN ACCORD-
ANCE WITH THE TIME FRAME FOR SUCH PAYMENTS SET FORTH IN SECTION THREE
THOUSAND TWO HUNDRED TWENTY-FOUR-A OF THE INSURANCE LAW; PROVIDED,
HOWEVER, THAT THE ENROLLEE SHALL BE RESPONSIBLE FOR ANY APPLICABLE
COPAY, COINSURANCE OR DEDUCTIBLE FOR SUCH SERVICES. CLINICAL LABORATO-
RIES SEEKING REIMBURSEMENT PURSUANT TO THIS ARTICLE FOR SERVICES
RENDERED SHALL DIRECTLY BILL THE PLAN WHOSE ENROLLEE RECEIVED THE
SERVICES. ANY PAYMENT MADE BY A PLAN DIRECTLY TO THE ENROLLEE RATHER
THAN TO THE CLINICAL LABORATORY SEEKING REIMBURSEMENT SHALL NOT SATISFY
THE PLAN'S PAYMENT OBLIGATION TO THE CLINICAL LABORATORY.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD14273-14-0
A. 8836--C 2
S 2. Section 4406-c of the public health law is amended by adding two
new subdivisions 4-a and 4-b to read as follows:
4-A. NO HEALTH CARE PLAN, NOT-FOR-PROFIT OR FOR-PROFIT HEALTH MAINTE-
NANCE ORGANIZATION, PREFERRED PROVIDER ORGANIZATION, POINT OF SERVICE
PLAN, GOVERNMENT SUBSIDIZED HEALTH CARE PLAN OR SELF INSURED PLAN
(COLLECTIVELY, "PLAN") SHALL EXCLUDE FROM PARTICIPATING WITHIN ITS
NETWORK ANY PROVIDER OF CLINICAL LABORATORY SERVICES THAT MEETS THE
FOLLOWING REQUIREMENTS: (A) SUCH PROVIDER IS LICENSED AS A MEDICARE
PROVIDER BY THE UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES;
(B) SUCH PROVIDER IS EITHER ACCREDITED BY THE COLLEGE OF AMERICAN
PATHOLOGISTS, OR LICENSED BY THE NEW YORK STATE DEPARTMENT OF HEALTH;
AND (C) SUCH PROVIDER SUBMITS ELECTRONIC CLAIMS TO THE PLAN FOR THE
PAYMENT OF CLINICAL LABORATORY SERVICES RENDERED TO ENROLLEES. EACH PLAN
SHALL DIRECTLY PAY FOR CLINICAL LABORATORY SERVICES RENDERED TO ENROL-
LEES BY ANY PROVIDER OF CLINICAL LABORATORY SERVICES PRACTICING WITHIN
ITS NETWORK IN ACCORDANCE WITH THE TIME FRAME FOR SUCH PAYMENTS SET
FORTH IN SECTION THREE THOUSAND TWO HUNDRED TWENTY-FOUR-A OF THE INSUR-
ANCE LAW; PROVIDED, HOWEVER, THAT THE ENROLLEE SHALL BE RESPONSIBLE FOR
ANY APPLICABLE COPAY, COINSURANCE OR DEDUCTIBLE FOR SUCH SERVICES.
4-B. NOTWITHSTANDING ANY OTHER PROVISION OF LAW, IN NO EVENT SHALL ANY
PLAN: (A) REIMBURSE ANY IN-PLAN PROVIDER OF CLINICAL LABORATORY SERVICES
FOR A PARTICULAR LABORATORY TEST BUT NOT REIMBURSE ANOTHER IN-PLAN
PROVIDER OF CLINICAL LABORATORY SERVICES FOR THAT LABORATORY TEST; (B)
ASSIGN PREFERENTIAL STATUS NOR PROVIDE PREFERENTIAL TREATMENT TO A
PROVIDER OF CLINICAL LABORATORY SERVICES PRACTICING WITHIN ITS NETWORK.
SUCH PROHIBITED PREFERENTIAL TREATMENT SHALL INCLUDE, BUT IS NOT LIMITED
TO, MAINTAINING A SUBSTANTIALLY DIFFERENT RATE OF PAYMENT OR FEES FOR
SIMILAR PRODUCTS AND SERVICES PROVIDED BY ONE IN-PLAN PROVIDER OVER
THOSE OF OTHER IN-PLAN PROVIDERS, OR ESTABLISHING A PAYMENT PROCEDURE
WITH ONE IN-PLAN PROVIDER AS OPPOSED TO OTHER IN-PLAN PROVIDERS KNOWN TO
LIKELY RESULT IN THE LOSS OF PAYMENT FOR SUCH IN-PLAN PROVIDERS; (C)
ESTABLISH DIFFERENT PERFORMANCE MEASURES OR REQUIREMENTS FOR ONE IN-PLAN
PROVIDER OVER THOSE OF OTHER IN-PLAN PROVIDERS OF CLINICAL LABORATORY
SERVICES, INCLUDING BUT NOT LIMITED TO, THE NUMBER OF PATIENT SERVICE
CENTERS REQUIRED TO BE OPERATED IN A COVERED AREA OR FLUCTUATING REPORT-
ING GUIDELINES AND REQUIREMENTS; (D) SUBCONTRACT THE MANAGEMENT OF THE
NETWORK TO AN IN-PLAN LABORATORY THAT COLLECTS A MANAGEMENT FEE FOR SUCH
MANAGEMENT SERVICES; OR (E) TREAT ANY ENROLLEE UTILIZING THE SERVICES OF
ANY PROVIDER OF CLINICAL LABORATORY SERVICES PRACTICING WITHIN ITS
NETWORK IN A MANNER WHICH IS NOT THE SAME AS OR SIMILAR IN ALL MATERIAL
RESPECTS TO THE MANNER IN WHICH ALL OTHER ENROLLEES UTILIZING THE
SERVICES OF ANY PROVIDER OF CLINICAL LABORATORY SERVICES PRACTICING
WITHIN ITS NETWORK ARE TREATED.
S 3. Section 4804 of the insurance law is amended by adding a new
subsection (g) to read as follows:
(G) NOTWITHSTANDING ANY OTHER PROVISION OF LAW, IF AN INSURED IS
REFERRED BY AN IN-PLAN PROVIDER TO A PROVIDER OF CLINICAL LABORATORY
SERVICES NOT PARTICIPATING IN THE PLAN (A "NON-PARTICIPATING PROVIDER"),
ANY SERVICE THAT WOULD OTHERWISE BE COVERED AS AN IN-PLAN SERVICE UNDER
THE PLAN THAT IS PROVIDED BY THE NON-PARTICIPATING PROVIDER SHALL BE
COVERED, AND THE ORGANIZATION SHALL BE RESPONSIBLE FOR PAYMENT DIRECTLY
TO THE NON-PARTICIPATING PROVIDER FOR THOSE SERVICES IN ACCORDANCE WITH
THE TIME FRAME FOR SUCH PAYMENTS SET FORTH IN SECTION THREE THOUSAND TWO
HUNDRED TWENTY-FOUR-A OF THIS CHAPTER; PROVIDED, HOWEVER, THAT THE
INSURED SHALL BE RESPONSIBLE FOR ANY APPLICABLE COPAY, COINSURANCE OR
DEDUCTIBLE FOR SUCH SERVICES. CLINICAL LABORATORIES SEEKING REIMBURSE-
A. 8836--C 3
MENT PURSUANT TO THIS ARTICLE FOR SERVICES RENDERED SHALL DIRECTLY BILL
THE ORGANIZATION WHOSE INSURED RECEIVED THE SERVICES. ANY PAYMENT MADE
BY AN ORGANIZATION DIRECTLY TO THE INSURED RATHER THAN TO THE CLINICAL
LABORATORY SEEKING REIMBURSEMENT SHALL NOT SATISFY THE ORGANIZATION'S
PAYMENT OBLIGATION TO THE CLINICAL LABORATORY.
S 4. This act shall take effect immediately.