NY State Senate Bill 2009-S6016

Archive: Last Bill Status - In Senate Committee Insurance Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

Please enter your contact information

First Name

Last Name

Email Address

A valid email address is required.

Home address is used to determine the senate district in which you reside. Your support or opposition to this bill is then shared immediately with the senator who represents you.

Optional services from the NY State Senate:

Create an account. An account allows you to officially support or oppose key legislation, sign petitions with a single click, and follow issues, committees, and bills that matter to you. When you create an account, you agree to this platform's terms of participation.

Include a custom message for your Senator? (Optional)

Enter a message to your senator. Many New Yorkers use this to share the reasoning behind their support or opposition to the bill. Others might share a personal anecdote about how the bill would affect them or people they care about.

Actions

View Actions

	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 06, 2010	referred to insurance
Jun 19, 2009	referred to rules

2009-S6016 (ACTIVE) - Details

Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd Ins L, generally; amd Pub Health L, generally; amd §20, Chap 451 of 2007

2009-S6016 (ACTIVE) - Summary

Provides enhanced consumer and provider protections limitations on denial of claims for pre-authorized health care services; relates to grievance procedures; relates to managed care health insurance contracts; relates to determinations involving urgent care by utilization review agents.

2009-S6016 (ACTIVE) - Sponsor Memo

                                 BILL NUMBER:  S6016

 TITLE OF BILL :

An act to amend the insurance law and the public health law, in
relation to providing enhanced consumer and provider protections; in
relation to referrals to specialists and grievance procedures; in
relation to credits or dividends; in relation to provider contracts
and provider credentialing; in relation to overpayment recovery; in
relation to external appeals; in relation to prompt payment of claims;
in relation to participation status of health care providers; in
relation to utilization review timeframes; and to amend chapter 451 of
the laws of 2007 amending the public health law, the social services
law and the insurance law, relating to providing enhanced consumer and
provider protections, in relation to the effectiveness thereof


 PURPOSE :

This bill enhances consumer and provider protections by instituting a
series of managed care reforms, including: (1) requiring that a
provider be given notice of an adverse reimbursement change to a
provider contract and an opportunity to cancel the contract; (2)
requiring insurers who offer comprehensive policies to offer the same
grievance procedures and provide the same access to care that is
required for health maintenance organizations (HMOs); (3) requiring

insurers and HMOs to pay electronic claims promptly and limiting their
ability to respond to claims by sending a coordination of benefits
questionnaire; (4) extending. overpayment recovery protections to all
health care providers and permitting them to challenge such
recoveries; (5) requiring insurers and HMOs who fail to meet a
loss-ratio requirement to make efforts to locate and pay dividends or
credits to former policy holders; (6) prohibiting insurers and HMOs
from treating a participating provider as a non-participating
provider; (7) permitting newly licensed providers and providers moving
to New York to be provisionally Credentialed until the final
credentialing determination is made by the insurer or HMO; (8)
shortening utilization review timeframes for determinations involving
post-hospital home health care services; (9) allowing providers to
appeal concurrent adverse determinations through the external appeal
process; and (10) establishing a new external appeal standard for rare
disease treatments. The bill also enhances efficiencies by authorizing
the Superintendent of Insurance (Superintendent) to require that
mandated submissions be filed electronically.

 SUMMARY OF PROVISIONS :

Section 1 of the bill adds a new Insurance Law § 316 to provide that
the Superintendent may promulgate regulations to require that any
submissions made by an insurer or other person or entity to the
Insurance Department be submitted by electronic means.  An affected
person or entity may request an exception upon demonstration of undue
hardship, impracticability, or good cause, subject to the approval of
the Superintendent.

Sections 2 and 5 of the bill amend Insurance Law §§ 3216(d) (1) (G)
and 3221(a) (9) to extend the time for an insured to submit a written
proof of loss to an insurer from 90 to 120 days.

Sections 3, 19 and 32 of the bill amend Insurance Law §§ 3217-b and
4325 and Public Health Law (P1-IL) § 4406-c respectively to: (1)
prohibit an insurer or HMO from implementing an adverse reimbursement
change to a contract with a health care professional unless the
insurer or HMO gives the health care professional 90 days written
notice of the change; and (2) allow the health care professional,
within 30 days of such notice, to terminate his or her contract with
the insurer or HMO effective upon the implementation date of such
adverse reimbursement change.

Sections 4 and 17 of the bill add. new Insurance Law §§ 3217-d and
4306-c respectively to require that insurers offering comprehensive
policies and policies that utilize an exclusive network of providers
without an out-of-network option establish grievance procedures and
provide access to care consistent with the requirements of Article 48
of the Insurance Law.

Section 6 of the bill amends Insurance Law §§ 3224-a(a) and (b) to
require insurers and HMOs to pay claims submitted electronically
within 30 days. Under current law, the Superintendent may provide
guidance to clarify the Insurance Department's current interpretation
that the payment time frame applies from the date the provider submits
a clean claim. section 6 further expands the type of insurers covered
by Insurance Law § 3224-a to include municipal cooperative health
benefits plans certified pursuant to Article 47 of the Insurance Law.

Section 7 of the bill adds a new Insurance Law § 3224-c to prohibit
insurers and HMOs from denying a claim on the basis that they are
coordinating benefits and another insurer, HMO or other entity is
liable for payment of the claim, unless the insurer or HMO has a
reasonable basis to believe that the insured/enrollee has other health
insurance coverage which is primary. Section 7 further provides that
when an insurer or HMO does .not have current information from an
insured/enrollee regarding other coverage, the insurer or HMO can
request such information and allow the insured/enrollee 45 days to
submit the information.

Section 8 of the bill amends Insurance Law § 3224-a(c) to provide that
where a prompt payment violation is determined as the result of the
Superintendent's own investigation, the insurer or HMO shall not be
subject to a civil penalty if the Superintendent determines that the
insurer or HMO has processed at least ninety-eight percent of the
claims submitted in a calendar year in compliance with the
requirements of this section. However, this does not apply to
violations as a result of individual complaints from providers or
insureds. Section B further provides that nothing shall limit or
exempt an insurer or HMO from payment of a claim or interest.

Section 9 of the bill adds a new Insurance Law §§ 3224-a(g) and (h) to
provide that except as otherwise permitted by law, health care claims
must be submitted by health care providers within 120 after the date
of service; provided, however, that nothing precludes the parties from
agreeing to a time period that is more favorable to the health care
provider. Section 9 further provides that the 120-day timeframe does
not abrogate any right or reduce or limit any additional time period
for claim submission provided by Regulation 178 (the "Coordination of
Benefits" regulation) that was adopted by the Insurance Department on
April 1, 2009. Thus, claims submitted consistent with the provisions
of that regulation would not be subject to the denial or reduction of
payment.provisions contained in this section.

Section 9 also provides in connection with contracts for the provision
of services pursuant to §364-j or 369-ee of the Social Services Law or
Title I-A of Article 25 of the Public Health Law that nothing
precludes the parties from agreeing to a different time period for the
submission of claims, but in no event less than 90 days, and that
existing contract provisions shall not be superseded except to the
extent that the contract provides less than 90 days.  Section 9 of the
bill further provides that an insurer or HMO shall permit a
participating health provider to request a reconsideration of a claim
that is denied as untimely. If a health care provider demonstrates
that the untimely claim was the result of an unusual occurrence and
the health care provider has a pattern or practice of timely claim
submission, an insurer or HMO may reduce reimbursement to a
participating provider for an untimely claim by a penalty of no more
than 25 percent. Section 9 also provides that participating providers
and insurers or HMOs may agree to a lesser reduction or no reduction
at all, that is, the "penalty" can be reduced even to "zero."

Section 10 of the bill amends Insurance Law § 3224-b(b) to extend
protections and timeframes relating to overpayment recovery efforts
initiated by insurers and HMOs, currently applicable to physicians, to
all providers. Section 10 also requires insurers and HMOs to allow a
provider the opportunity to challenge an overpayment recovery.

Sections 11 and 18 of the bill amend Insurance Law §§ 3231(e) and
4308(h) respectively to remove the limitation that an
insured's/enrollee's contract must be in effect as of the date a
dividend or credit is issued in the event a loss-ratio requirement is
not met, and requires the insurer or HMO to make a reasonable effort
to identify and refund former policy or contract holders.

Sections 12, 13, 14 and 31 of the bill add new Insurance Law §§
3216(i) (26), 3221(k) (15) and 4303(ff) and Public Health Law §
4406(3) to prohibit insurers and HMOs from treating a hospital that
participates within a network as a non-participating provider solely
because the health care provider admitting or rendering services to
the insured/enrollee is a non-participating provider. These sections
also prohibit insurers and HMOs from treating a health care provider
that participates within a network as a non-participating provider
solely because services are rendered in a non-participating hospital.

Section 13-a is amends the insurance law by adding a new section 3241
pertaining to network adequacy.

Sections 15 and 16 of the bill add new Insurance Law §§ 4305(1) and
4306(n) to require insurers and HMOs to provide insureds at least 120
days to submit claims.

Sections 20 and 33 of the bill amend Insurance Law § 4803(a) and PHL §
4406-d(1) respectively to require that if a newly-licensed health care
professional, or a health care professional moving to New York from
another state, joins a group practice of health care professionals
that participates in the in-network portion of an insurer's or HMO's
network, but the health care professional is not credentialed or
declined by the insurer or HMO within 90 days, the health care
professional shall be deemed "provisionally credentialed" and shall
participate in the in-network portion of an insurer's or HMO's network
until the final credentialing determination is made by the insurer or
HMO.

Sections 21 and 34 of the bill add new Insurance Law § 4900(g-7) and
PHL § 4900(7-g) respectively to define "rare disease treatment."

Sections 22 and 35 of the bill amend Insurance Law § 4903{c) and PHL §
4903(3) respectively to require utilization review agents to make
determinations involving post-hospital home health care services
within one business day of receipt of the necessary information,
instead of within three business days as would otherwise apply under
Insurance Law § 4903(b) and PHL § 4903(2). Sections 22 and 35 further
provide that when the day subsequent to the request for post-hospital
home health care services falls on a weekend or holiday, a decision
shall be made within 72 hours of receipt of the necessary information.
Sections 22 and 35 additionally state that if a request for home
health care services and all necessary information is submitted prior
to hospital discharge, a utilization review agent shall not deny
coverage for home health care services on the basis of medical
necessity or lack of prior authorization while the utilization review
agent's determination is pending.
Sections 23 and 36 of the bill amends Insurance Law § 4904{b) and PHL
§ 4904(2) to specify that home health care services following
discharge from an inpatient hospital admission shall be eligible for
an expedited appeal with a utilization review agent.

Sections 24 and 37 of the bill amend Insurance Law § 4906 and PHL §
4906 respectively to provide that a hospital and an insurer or HMO may
agree to utilize an alternative dispute resolution mechanism in lieu
of the external appeal process set forth in Article 49 of the
Insurance Law and Article 49 of the PHL.

Sections 25 and 38 of the bill amend Insurance Law § 4910(b) and PHL §
4910(2) respectively to allow providers to appeal concurrent adverse
determinations through the external appeal process.

Sections 26 and 39 of the bill amend Insurance Law §§ 4910{b) (2) (B)
and (C) and PHL §§ 4910(2) (b) (ii) and (iii) respectively to provide
that an insured/enrollee, the insured/enrollee's designee and, in
connection with retrospective adverse determinations, an
insured/enrollee's health care provider, may request an external
appeal if the insured/enrollee has a life-threatening condition and is
eligible for rare disease treatment.

Sections 27 and 40 of the bill amend Insurance Law §§ 4914(b) (2) and
(3) and PHL §§ 4914(2) (b) and (c) respectively to require an external
appeal agent to notify a provider, when appropriate, of an external
appeal determination.

Sections 28 and 41 of the bill amend Insurance Law § 4914(b) (4) (B)
(ii) (a) and PHL § 4914(2) (d) (B) (ii) (1) respectively to require
that, in determining an external appeal involving a rare disease
treatment, the external appeal agent must consider whether such
treatment is "likely to benefit" the insured/enrollee.

Sections 29 and 42 of the bill amend Insurance Law § 4914(d) and PHL §
4914(4) respectively to require a provider to pay the cost of an
external appeal of a concurrent adverse determination if the insurer's
or HMO's denial is upheld and require that the insurer or HMO and
provider evenly divide the cost of the external appeal of a concurrent
adverse determination if the denial is upheld in part.  Further, if
the superintendent determines that insurers and HMOs or providers are
experiencing hardship as a result of this division of payment, the
bill authorizes the Superintendent and the Commissioner of Health to
promulgate regulations to limit such hardship. Sections 29 and 42 also
authorize the Superintendent to confirm an insured's/enrollee's
designation of a provider to bring an external appeal on his or her
behalf and set forth procedures and timelines for situations when such
authorization is exercised. In particular, if the insured/enrollee
fails to confirm a designation, the Superintendent shall offer the
provider an opportunity to file an external appeal on its own behalf.

Sections 30 and 43 of the bill add a new Insurance Law § 4917 and PHL
§ 4917 respectively to require that when a provider's external appeal
of a concurrent adverse determination is upheld by an external appeal
agent, including in cases when the provider is acting as the designee
of the insured/enrollee, the provider shall not pursue reimbursement
from the insured/enrollee, except for any copayment, coinsurance or
deductible.

Section 44 of the bill amends Chapter 451 of the Laws of 2007 to
provide that Insurance Law § 323B(a) (1) (iii) shall expire and be
deemed repealed December 31, 2011, instead of December 31, 2009.

Sections 45, 46 and 47 of the bill are intentionally omitted.


Section 48 of the bill provides that the bill would take effect
January 1, 2010: except the amendments made by §§ 20 and 33 of the
bill, amending Insurance Law § 4B03(a) and PHL § 4406-d(1) in regard
to provisional credentialing, would take effect on October 1, 2009 and
apply only to new applications; the amendments made by §§ 3, 19 and 32
of the bill amending Insurance Law §§ 3217-b(i), 4325(i), and Public
Health Law §4406-c(5-d) shall not affect the repeal of those
subsections or subdivision; the amendments made by §§ Band 44 of the
bill, amending Insurance Law §§ 3224-a(c) and § 3238(a) (I) (iii)
shall take effect immediately; the amendments made by § 9 of the bill
amending Insurance Law § 3224-a shall apply to dates of service on or
after April 1, 2010; and the amendments made by §§ 2, 4, 5, 15, 16 and
17 of the bill amending Insurance Law §§ 3216 (d) (1) (G), 3217-d,
3221 (al (9), 4305 (1), 4306 (n) and 4306-c shall take effect January
1, 2011.

 EXISTING LAW :

Insurance Law §§ 3217-b and 4325 and PHL § 4406-c govern contracts and
relationships between insurers and HMOs and their providers and
include provisions such as a prohibition on restrictions against
complaints by providers to governmental bodies about the practices of
an insurer or HMO and a prohibition on contract provisions that
transfer financial risk from insurers or HMOs to providers.

Insurance Law §§ 3231 and 4308 address premium rates and dividends for
health insurance policies.

Insurance Law § 3224-a establishes standards for the prompt payment of
health care claims. Insurers and HMOs must pay undisputed claims
within 45 days of receipt. If a claim is disputed, the insurer or HMO
must pay the undisputed portion of the claim and notify the
insured/enrollee of the dispute within 30 days of the claim's receipt.

Insurance Law § 3224-b imposes limitations on overpayment recovery
efforts.

Insurance Law § 4801(c) defines "managed care health insurance
contract" and "managed care product."

Insurance Law § 4802 establishes a grievance procedure in connection
with managed care products.

Insurance Law § 4803 and PHL § 4406-d set forth requirements for
health care professional applications for network participation.
Insurance Law § 4804 establishes requirements for access to specialty
care.

Article 49 of the Insurance Law and Article 49 of the PHL require
insurers and HMOs to have a process for rendering utilization review
determinations and establish a right to utilization review and
external appeal for insureds/enrollees and, in cases of retrospective
adverse determinations, providers.

Insurance Law § 4900(g-6) defines an "out-of-network denial" for a
managed care product.

Insurance Law § 4906 and PHL § 4906 provide that any agreement which
purports to waive, limit, disclaim, or in any way diminish the rights
set forth in Insurance Law Article 49 or PHL Article 49, except as
provided pursuant to Insurance Law § 4910 or P1-IL § 4910, shall be
void as contrary to public policy.

Insurance Law § 4910(b) and PHL § 4910(2) permit an insured/enrollee,
the insured's/enrollee's designee and, in connection with

retrospective adverse determinations, an insured's/enrollee's health
care provider, to request an external appeal in certain circumstances.

In particular, such appeal is permitted if services have been denied
as not medically necessary or as experimental or investigational.

Insurance Law § 4914(b) (4) and PHL § 4914(2)(d) set forth the
standards by which certain external appeals shall be determined.

Insurance Law § 4914(d) and PHL § 4914(4) provide that payment for an
external appeal shall be the responsibility of the insurer/HMO.

PHL § 4406-c provides that HMOs may not prohibit providers from
disclosing information to enrollees about the availability of medical
care and the products offered by the plan, or from advocating for
particular courses of treatment, and requires that contracts between
HMOs and providers contain certain provisions.

State Technology Law § 305 states that no person shall be required to
submit or file any record electronically to any government entity
except as otherwise provided by law.

 LEGISLATIVE HISTORY :

Certain provisions contained in this bill were included in
A.11737/S.4481-A of 2007-08: which passed the Senate but not the
Assembly.

 STATEMENT IN SUPPORT :

Since the advent of managed care, legislative action has been
essential to ensure that consumers and providers receive appropriate
protection under this system of health care delivery.  Significant
steps towards this goal were taken in the 1990s with the enactment of
the Managed Care Reform Act and External Appeal Law, and again in 2007
with the enactment of additional managed care reforms.  Experience
under these statutes, however, has shown that the present legal regime
remains insufficient to provide sufficient access to health care for
consumers, ensure equal treatment, and guarantee timely payment to
providers. This bill will implement a series of necessary reforms to
New York's legal regime for managed care, and thereby take further
legislative steps towards these goals.  New York's Managed Care Reform
Act, enacted in 1996 and codified as Title I of Article 49 of both the
Insurance Law and the PHL, establishes protections for health care
professionals with respect to applications and terminations, imposes
access to care requirements, establishes a grievance process and
requires insurers and HMOs to have a process for rendering utilization
review determinations and a process for insured persons to appeal such
determinations with the insurer or HMO. Specifically, the Managed Care
Reform Act provides the insured/enrollee, the insured's/enrollee's
designee and, in the case of a retrospective adverse determination,
the insured's/enrollee's health care provider, with the right to
appeal an adverse determination with the insurer or HMO.

Building upon the Managed Care Reform Act, the External Appeal Law,
enacted in 1998 and codified as Title II of Article 49 of both the
Insurance Law and the PHL, established an additional level of appeal,
independent of the insurer or HMO, if a denial is upheld in the
insurer's or HMO's internal utilization review process. Specifically,
the External Appeal Law permits an insured/enrollee, the
insured's/enrollee's designee and, in the case of a retrospective
adverse determination, an insured's/enrollee's health care provider,
to appeal a final adverse determination issued by the insurer or HMO
to an external appeal agent.


Additional managed care protections for consumers and providers were
enacted in 2007. These protections impose limitations on when claims
for preauthorized services may be denied, establish a right to an
external appeal for certain out-of-network denials, require a
cooling-off period for terminations of contracts between hospitals and
insurers or HMOs, require the collection and dissemination of
preferred provider organization information for quality assurance
reporting purposes, and establish timeframes for out-of-network
provider claim submissions to. certain HMOs.

This bill builds upon these reforms to provide further protections to
consumers and providers. In particular, the bill provides enhanced
consumer protections by: (1) extending existing protections applicable
to HMO products, including grievance requirements and access to
specialty care protections to HMO look-alike products offered by
insurers; (2) changing the criteria for an external appeal agent's
review of a rare disease treatment to require an agent to consider
whether the treatment is likely to benefit the insured/enrollee,
rather than considering whether the treatment is more beneficial than
any standard treatment; (3) requiring utilization review agents-to use
a one business day or 72 hour utilization review timeframe for
determinations involving post-hospital home health care services and
further requiring home health care services to be covered while a
decision is pending when the request for home health care services and
all information is provided prior to hospital discharge; and (4)
removing the limitation that an insured's/enrollee's contract must be
in effect as of the date a dividend or credit is issued in the event a
loss ratio requirement is not met. These protections will ensure that
consumers are better able to access health care services, and that
consumers with similar types of health insurance coverage are able to
enjoy the same protections.

In addition, the bill establishes enhanced provider protections by:
(1) prohibiting insurers and HMOs from implementing an adverse
reimbursement change to a contract with a health care professional
without prior notification; (2) allowing the provisional credentialing
of new health care professionals; (3) allowing providers to pursue an
external appeal of a concurrent adverse determination; and (4)
prohibiting insurers and HMOs from treating hospitals and providers
that participate within a network as non-participating solely because.
one or more other providers rendering services to the insured/enrollee
for the same or related medical condition does not participate within
the insurer's or HMO's provider network. This latter provision in
particular will address concerns raised by hospitals and other
providers that participate with an insurer or HMO but are treated as
non-participating providers simply because the physician admitting the
patient to the hospital, or another health care professional that
provides services to an admitted patient, does not participate with
the insurer or HMO. In such cases, the provider may be reimbursed at
the less favorable out-of-network rate and the insured/enrollee will
bear a higher copayment, coinsurance or deductible; in other cases,
the claim. may be denied.

The bill also establishes protections to ensure the prompt processing
and payment of health care claims by: (1) shortening the timeframe for
payment of electronic claims to 30 days; (2) prohibiting insurers and
HMOs from denying payment due to coordination of benefits unless the
insurer or HMO has a reasonable basis to believe that the insured has
other coverage; and (3) extending to all providers the limitations on
overpayment recovery efforts initiated by insurers and HMOs and giving
providers the opportunity to challenge an overpayment recovery. These
prompt payment protections will ensure that insurers and HMOs make
payment for all medically necessary services in a timely manner.

 BUDGET IMPLICATIONS :

This bill will not have a fiscal impact to the State.

 EFFECTIVE DATE :
This bill takes effect January 1, 2010: except the amendments made by
§§ 20 and 31 of the bill, amending Insurance Law § 4B03(a) and PHL §
4406-d(1) in regard to provisional credentialing, would take effect on
October 1, 2009 and apply only to new applications; the amendments
made by §§ 3, 19 and 32 of the bill amending Insurance Law §§
3217-b(i), 4325(i), and public Health Law §4406-c 5-d shall not affect
the repeal of those subsections or subdivision; the amendments made by
§§ B and 44 of the bill amending §§3224-a(c) and § 3238(a) (1) (iii)
of the Insurance Law shall take effect immediately; the amendments
made by § 9 of the bill amending § 3224-a of the Insurance Law shall
apply to dates of service on or after April 1, 2010; and the
amendments made by §§ 2, 4, 5, 15, 16 and 17 of the bill amending §§
3216 (d) (1) (G), 3217-d, 3221 (a) (9), § 4305 (1), 4306 (n) and
4306-c of the Insurance Law shall take effect January 1, 2011.

2009-S6016 (ACTIVE) - Bill Text download pdf

                            
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  6016

                       2009-2010 Regular Sessions

                            I N  S E N A T E

                              June 19, 2009
                               ___________

Introduced  by  Sen. BRESLIN -- read twice and ordered printed, and when
  printed to be committed to the Committee on Rules

AN ACT to amend the insurance law and the public health law, in relation
  to providing enhanced consumer and provider protections;  in  relation
  to  referrals  to specialists and grievance procedures; in relation to
  credits or dividends; in relation to provider contracts  and  provider
  credentialing;  in  relation  to  overpayment recovery; in relation to
  external appeals; in relation to prompt payment of claims; in relation
  to participation status of  health  care  providers;  in  relation  to
  utilization review timeframes; and to amend chapter 451 of the laws of
  2007  amending  the public health law, the social services law and the
  insurance law, relating to providing enhanced  consumer  and  provider
  protections, in relation to the effectiveness thereof

  THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1.  The insurance law is amended by adding a new  section  316
to read as follows:
  S  316. ELECTRONIC FILINGS. NOTWITHSTANDING SUBDIVISION ONE OF SECTION
THREE HUNDRED FIVE OF THE STATE TECHNOLOGY LAW, THE  SUPERINTENDENT  MAY
PROMULGATE  REGULATIONS  TO REQUIRE AN INSURER OR OTHER PERSON OR ENTITY
MAKING A FILING OR SUBMISSION WITH THE SUPERINTENDENT PURSUANT  TO  THIS
CHAPTER  TO  SUBMIT  THE  FILING  OR SUBMISSION TO THE SUPERINTENDENT BY
ELECTRONIC MEANS. SHOULD THE SUPERINTENDENT REQUIRE  THAT  A  FILING  OR
SUBMISSION  BE  MADE  BY ELECTRONIC MEANS, AN INSURER OR OTHER PERSON OR
ENTITY AFFECTED THEREBY MAY SUBMIT A REQUEST TO THE  SUPERINTENDENT  FOR
AN EXEMPTION FROM THE ELECTRONIC FILING REQUIREMENT UPON A DEMONSTRATION
OF  UNDUE  HARDSHIP,  IMPRACTICABILITY,  OR  GOOD  CAUSE, SUBJECT TO THE
APPROVAL OF THE SUPERINTENDENT.
  S 2. Subparagraph (G) of paragraph 1 of subsection (d) of section 3216
of the insurance law is amended to read as follows:
  (G) PROOFS OF LOSS: Written proof of loss must  be  furnished  to  the
insurer  at  its  said  office  in case of claim for loss for which this
policy provides any periodic payment  contingent  upon  continuing  loss
within  ninety  days  after  the termination of the period for which the

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD14464-01-9

S. 6016                             2

insurer is liable and in case of claim for any other loss within  [nine-
ty]  ONE  HUNDRED  TWENTY  days  after the date of such loss. Failure to
furnish such proof within the time required  shall  not  invalidate  nor
reduce  any claim if it was not reasonably possible to give proof within
such time, provided such proof is furnished as soon as reasonably possi-
ble and in no event, except in the absence of legal capacity, later than
one year from the time proof is otherwise required.
  S 3. Subsections (g) and (h) of section 3217-b of the  insurance  law,
subsection  (g)  as  relettered  by chapter 586 of the laws of 1998, are
relettered subsections (h) and (i) and a new subsection (g) is added  to
read as follows:
  (G)(1) NO INSURER SHALL IMPLEMENT AN ADVERSE REIMBURSEMENT CHANGE TO A
CONTRACT  WITH A HEALTH CARE PROFESSIONAL THAT IS OTHERWISE PERMITTED BY
THE CONTRACT, UNLESS, PRIOR TO THE EFFECTIVE DATE  OF  THE  CHANGE,  THE
INSURER  GIVES  THE  HEALTH  CARE PROFESSIONAL WITH WHOM THE INSURER HAS
DIRECTLY CONTRACTED AND WHO IS IMPACTED  BY  THE  ADVERSE  REIMBURSEMENT
CHANGE,  AT  LEAST  NINETY  DAYS  WRITTEN  NOTICE  OF THE CHANGE. IF THE
CONTRACTING HEALTH CARE PROFESSIONAL OBJECTS TO THE CHANGE THAT  IS  THE
SUBJECT  OF THE NOTICE BY THE INSURER, THE HEALTH CARE PROFESSIONAL MAY,
WITHIN THIRTY DAYS OF THE DATE OF THE NOTICE, GIVE WRITTEN NOTICE TO THE
INSURER TO TERMINATE HIS OR HER CONTRACT WITH THE INSURER EFFECTIVE UPON
THE IMPLEMENTATION DATE OF THE ADVERSE REIMBURSEMENT CHANGE.    FOR  THE
PURPOSES  OF  THIS  SUBSECTION,  THE TERM "ADVERSE REIMBURSEMENT CHANGE"
SHALL MEAN A PROPOSED CHANGE THAT COULD REASONABLY BE EXPECTED TO HAVE A
MATERIAL ADVERSE IMPACT ON THE AGGREGATE LEVEL OF PAYMENT  TO  A  HEALTH
CARE  PROFESSIONAL, AND THE TERM "HEALTH CARE PROFESSIONAL" SHALL MEAN A
HEALTH CARE PROFESSIONAL LICENSED, REGISTERED OR CERTIFIED  PURSUANT  TO
TITLE  EIGHT  OF  THE EDUCATION LAW.   THE NOTICE PROVISIONS REQUIRED BY
THIS SUBSECTION SHALL NOT APPLY WHERE:  (A)  SUCH  CHANGE  IS  OTHERWISE
REQUIRED  BY  LAW,  REGULATION OR APPLICABLE REGULATORY AUTHORITY, OR IS
REQUIRED AS A RESULT OF CHANGES IN FEE SCHEDULES, REIMBURSEMENT  METHOD-
OLOGY  OR  PAYMENT POLICIES ESTABLISHED BY A GOVERNMENT AGENCY OR BY THE
AMERICAN MEDICAL  ASSOCIATION'S  CURRENT  PROCEDURAL  TERMINOLOGY  (CPT)
CODES,  REPORTING  GUIDELINES  AND  CONVENTIONS;  OR  (B) SUCH CHANGE IS
EXPRESSLY PROVIDED FOR UNDER THE TERMS OF THE CONTRACT BY THE  INCLUSION
OF OR REFERENCE TO A SPECIFIC FEE OR FEE SCHEDULE, REIMBURSEMENT METHOD-
OLOGY OR PAYMENT POLICY INDEXING MECHANISM.
  (2)  NOTHING IN THIS SUBSECTION SHALL CREATE A PRIVATE RIGHT OF ACTION
ON  BEHALF  OF  A  HEALTH  CARE  PROFESSIONAL  AGAINST  AN  INSURER  FOR
VIOLATIONS OF THIS SUBSECTION.
  S  4.  The  insurance law is amended by adding a new section 3217-d to
read as follows:
  S 3217-D. GRIEVANCE PROCEDURE AND ACCESS TO SPECIALTY CARE.    (A)  AN
INSURER  THAT  ISSUES  A COMPREHENSIVE POLICY THAT UTILIZES A NETWORK OF
PROVIDERS AND IS NOT A MANAGED CARE HEALTH INSURANCE CONTRACT AS DEFINED
IN SUBSECTION (C) OF SECTION FOUR THOUSAND EIGHT  HUNDRED  ONE  OF  THIS
CHAPTER  SHALL  ESTABLISH  AND MAINTAIN A GRIEVANCE PROCEDURE CONSISTENT
WITH THE REQUIREMENTS OF SECTION FOUR THOUSAND EIGHT HUNDRED TWO OF THIS
CHAPTER.
  (B) AN INSURER THAT ISSUES A COMPREHENSIVE  POLICY  THAT  UTILIZES  AN
EXCLUSIVE  NETWORK  OF PROVIDERS WITHOUT AN OUT-OF-NETWORK OPTION AND IS
NOT A MANAGED CARE HEALTH INSURANCE CONTRACT AS  DEFINED  IN  SUBSECTION
(C)  OF  SECTION  FOUR  THOUSAND EIGHT HUNDRED ONE OF THIS CHAPTER SHALL
PROVIDE ACCESS TO OUT-OF-NETWORK SERVICES CONSISTENT WITH  THE  REQUIRE-
MENTS  OF  SUBSECTION  (A)  OF SECTION FOUR THOUSAND EIGHT HUNDRED FOUR,
SUBSECTION (G-6) OF SECTION FOUR THOUSAND NINE HUNDRED, SUBSECTION (A-1)

S. 6016                             3

OF  SECTION  FOUR  THOUSAND  NINE  HUNDRED  FOUR,  PARAGRAPH  THREE   OF
SUBSECTION  (B) OF SECTION FOUR THOUSAND NINE HUNDRED TEN, AND PARAGRAPH
FOUR OF SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN OF
THIS CHAPTER.
  (C)  AN  INSURER  THAT  ISSUES  A COMPREHENSIVE POLICY THAT UTILIZES A
NETWORK OF PROVIDERS AND IS NOT A MANAGED CARE HEALTH INSURANCE CONTRACT
AS DEFINED IN SUBSECTION (C) OF SECTION FOUR THOUSAND EIGHT HUNDRED  ONE
OF THIS CHAPTER AND REQUIRES THAT SPECIALTY CARE BE PROVIDED PURSUANT TO
A  REFERRAL  FROM  A  PRIMARY CARE PROVIDER SHALL PROVIDE ACCESS TO SUCH
SPECIALTY CARE CONSISTENT WITH THE REQUIREMENTS OF SUBSECTIONS (B),  (C)
AND  (D)  OF  SECTION  FOUR THOUSAND EIGHT HUNDRED FOUR OF THIS CHAPTER;
PROVIDED HOWEVER, THAT NOTHING HEREIN SHALL BE CONSTRUED TO REQUIRE THAT
AN INSURER, OR A PRIMARY CARE PROVIDER ON BEHALF OF THE INSURER, MAKE  A
REFERRAL TO A PROVIDER THAT IS NOT IN THE INSURER'S NETWORK.
  (D)  AN  INSURER  THAT  ISSUES  A COMPREHENSIVE POLICY THAT UTILIZES A
NETWORK OF PROVIDERS AND IS NOT A MANAGED CARE HEALTH INSURANCE CONTRACT
AS DEFINED IN SUBSECTION (C) OF SECTION FOUR THOUSAND EIGHT HUNDRED  ONE
OF  THIS  CHAPTER  SHALL  PROVIDE ACCESS TO TRANSITIONAL CARE CONSISTENT
WITH THE REQUIREMENTS OF SUBSECTIONS (E) AND (F) OF SECTION  FOUR  THOU-
SAND EIGHT HUNDRED FOUR OF THIS CHAPTER.
  S  5.  Paragraph  9 of subsection (a) of section 3221 of the insurance
law is amended to read as follows:
  (9) That in the case of claim for loss of time for disability, written
proof of such loss must be furnished to the insurer within  thirty  days
after  the  commencement  of the period for which the insurer is liable,
and that subsequent written proofs of the continuance of such disability
must be furnished to the insurer at such intervals as  the  insurer  may
reasonably  require,  and  that in the case of claim for any other loss,
written proof of such loss must  be  furnished  to  the  insurer  within
[ninety] ONE HUNDRED TWENTY days after the date of such loss. Failure to
furnish  such  proof within such time shall not invalidate or reduce any
claim if it shall be shown not  to  have  been  reasonably  possible  to
furnish  such  proof within such time, provided such proof was furnished
as soon as reasonably possible.
  S 6. The opening paragraph and subsections  (a)  and  (b)  of  section
3224-a  of  the  insurance law, as amended by chapter 666 of the laws of
1997, are amended to read as follows:
  In the processing of all health care claims submitted under  contracts
or  agreements issued or entered into pursuant to THIS ARTICLE AND arti-
cles [thirty-two,] forty-two [and], forty-three AND FORTY-SEVEN of  this
chapter  and  article  forty-four of the public health law and all bills
for health care services rendered by health care providers  pursuant  to
such contracts or agreements, any insurer or organization or corporation
licensed  or certified pursuant to article forty-three OR FORTY-SEVEN of
this chapter or article forty-four of the public health law shall adhere
to the following standards:
  (a) Except in a case where the obligation of an insurer or  an  organ-
ization  or corporation licensed or certified pursuant to article forty-
three OR FORTY-SEVEN of this chapter or article forty-four of the public
health law to pay a claim submitted by a policyholder or person  covered
under  such policy ("COVERED PERSON") or make a payment to a health care
provider is not reasonably clear, or when there is  a  reasonable  basis
supported  by  specific  information  available for review by the super-
intendent that such claim or bill for health care services rendered  was
submitted  fraudulently,  such  insurer  or  organization or corporation
shall pay the claim to a  policyholder  or  covered  person  or  make  a

S. 6016                             4

payment  to  a  health  care provider within [forty-five] THIRTY days of
receipt of a claim or bill for services rendered THAT IS TRANSMITTED VIA
THE INTERNET OR ELECTRONIC MAIL, OR FORTY-FIVE  DAYS  OF  RECEIPT  OF  A
CLAIM  OR  BILL  FOR SERVICES RENDERED THAT IS SUBMITTED BY OTHER MEANS,
SUCH AS PAPER OR FACSIMILE.
  (b) In a case where the obligation of an insurer or an organization or
corporation licensed or certified pursuant  to  article  forty-three  OR
FORTY-SEVEN  of  this chapter or article forty-four of the public health
law to pay a claim or make a payment for health care  services  rendered
is not reasonably clear due to a good faith dispute regarding the eligi-
bility  of  a  person  for coverage, the liability of another insurer or
corporation or organization for all or part of the claim, the amount  of
the  claim,  the  benefits covered under a contract or agreement, or the
manner in which services were accessed or provided, an insurer or organ-
ization or corporation shall pay any undisputed portion of the claim  in
accordance  with  this  subsection  and notify the policyholder, covered
person or health care provider in writing within thirty calendar days of
the receipt of the claim:
  (1) that it is not obligated to pay the  claim  or  make  the  medical
payment, stating the specific reasons why it is not liable; or
  (2)  to request all additional information needed to determine liabil-
ity to pay the claim or make the health care payment.
  Upon receipt of the information requested in  paragraph  two  of  this
subsection  or  an  appeal  of  a claim or bill for health care services
denied pursuant to paragraph one  of  this  subsection,  an  insurer  or
organization  or  corporation  licensed OR CERTIFIED pursuant to article
forty-three OR FORTY-SEVEN of this chapter or article forty-four of  the
public health law shall comply with subsection (a) of this section.
  S  7.  The  insurance law is amended by adding a new section 3224-c to
read as follows:
  S 3224-C. COORDINATION OF BENEFITS.   AN INSURER  OR  ORGANIZATION  OR
CORPORATION  LICENSED  OR  CERTIFIED  PURSUANT TO ARTICLE FORTY-THREE OR
FORTY-SEVEN OF THIS  CHAPTER OR ARTICLE FORTY-FOUR OF THE PUBLIC  HEALTH
LAW  SHALL  NOT  DENY A CLAIM, EITHER IN  WHOLE OR IN PART, ON THE BASIS
THAT IT IS COORDINATING BENEFITS AND ANOTHER INSURER OR ORGANIZATION  OR
CORPORATION  OR  OTHER  ENTITY  IS  LIABLE FOR THE PAYMENT OF THE CLAIM,
UNLESS IT HAS A REASONABLE BASIS TO BELIEVE THAT THE INSURED  HAS  OTHER
HEALTH  INSURANCE  COVERAGE  WHICH  IS  PRIMARY  FOR THAT BENEFIT. IF AN
INSURER OR ORGANIZATION OR CORPORATION DOES NOT HAVE CURRENT INFORMATION
FROM THE INSURED REGARDING OTHER COVERAGE, AND REQUESTS SUCH INFORMATION
IN ACCORDANCE WITH SUBSECTION (B) OF SECTION THREE THOUSAND TWO  HUNDRED
TWENTY-FOUR-A  OF  THIS  ARTICLE,  AND NO INFORMATION IS RECEIVED WITHIN
FORTY-FIVE DAYS, THE CLAIM SHALL BE ADJUDICATED PROVIDED,  HOWEVER,  THE
CLAIM  SHALL  NOT  BE  DENIED  BASED  ON THE INSURER, OR ORGANIZATION OR
CORPORATION NOT HAVING RECEIVED SUCH INFORMATION.
  S 8. Subsection (c) of section 3224-a of the insurance law, as amended
by chapter 666 of the laws of 1997, is amended to read as follows:
  (c) [Each] (1) EXCEPT AS PROVIDED IN PARAGRAPH TWO OF THIS SUBSECTION,
EACH claim or bill for health care services processed  in  violation  of
this  section  shall constitute a separate violation. In addition to the
penalties provided in this  chapter,  any  insurer  or  organization  or
corporation  that  fails  to  adhere  to the standards contained in this
section shall be obligated to pay to the health care provider or  person
submitting the claim, in full settlement of the claim or bill for health
care  services,  the  amount  of  the  claim or health care payment plus
interest on the amount of such claim  or  health  care  payment  of  the

S. 6016                             5

greater  of  the rate equal to the rate set by the commissioner of taxa-
tion and finance for  corporate  taxes  pursuant  to  paragraph  one  of
subsection  (e)  of  section  one  thousand ninety-six of the tax law or
twelve  percent  per  annum,  to  be computed from the date the claim or
health care payment was required to be made. When the amount of interest
due on such a claim is less then two dollars, and insurer  or  organiza-
tion or corporation shall not be required to pay interest on such claim.
  (2) WHERE A VIOLATION OF THIS SECTION IS DETERMINED BY THE SUPERINTEN-
DENT AS A RESULT OF THE SUPERINTENDENT'S OWN INVESTIGATION, EXAMINATION,
AUDIT  OR INQUIRY, AN INSURER OR ORGANIZATION OR CORPORATION LICENSED OR
CERTIFIED PURSUANT TO ARTICLE FORTY-THREE OR FORTY-SEVEN OF THIS CHAPTER
OR ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW SHALL NOT BE SUBJECT TO A
CIVIL PENALTY PRESCRIBED IN PARAGRAPH ONE OF  THIS  SUBSECTION,  IF  THE
SUPERINTENDENT  DETERMINES  THAT  THE  INSURER OR ORGANIZATION OR CORPO-
RATION HAS OTHERWISE PROCESSED AT  LEAST  NINETY-EIGHT  PERCENT  OF  THE
CLAIMS  SUBMITTED  IN  A  CALENDAR YEAR IN COMPLIANCE WITH THIS SECTION;
PROVIDED, HOWEVER, NOTHING IN THIS PARAGRAPH SHALL  LIMIT,  PRECLUDE  OR
EXEMPT AN INSURER OR ORGANIZATION OR CORPORATION FROM PAYMENT OF A CLAIM
AND  PAYMENT OF INTEREST PURSUANT TO THIS SECTION.  THIS PARAGRAPH SHALL
NOT APPLY TO VIOLATIONS OF THIS SECTION DETERMINED BY THE SUPERINTENDENT
RESULTING FROM INDIVIDUAL COMPLAINTS SUBMITTED TO THE SUPERINTENDENT  BY
HEALTH CARE PROVIDERS OR POLICYHOLDERS.
  S  9. Section 3224-a of the insurance law is amended by adding two new
subsections (g) and (h) to read as follows:
  (G) TIME PERIOD FOR SUBMISSION OF  CLAIMS.  (1)  EXCEPT  AS  OTHERWISE
PROVIDED  BY  LAW,  HEALTH  CARE  CLAIMS  MUST BE INITIALLY SUBMITTED BY
HEALTH CARE PROVIDERS WITHIN ONE HUNDRED TWENTY DAYS AFTER THE  DATE  OF
SERVICE  TO  BE VALID AND ENFORCEABLE AGAINST AN INSURER OR ORGANIZATION
OR CORPORATION LICENSED OR CERTIFIED PURSUANT TO ARTICLE FORTY-THREE  OR
ARTICLE  FORTY-SEVEN OF THIS CHAPTER OR ARTICLE FORTY-FOUR OF THE PUBLIC
HEALTH LAW. PROVIDED, HOWEVER, THAT NOTHING  IN  THIS  SUBSECTION  SHALL
PRECLUDE THE PARTIES FROM AGREEING TO A TIME PERIOD OR OTHER TERMS WHICH
ARE  MORE  FAVORABLE TO THE HEALTH CARE PROVIDER. PROVIDED FURTHER THAT,
IN CONNECTION  WITH  CONTRACTS  BETWEEN  ORGANIZATIONS  OR  CORPORATIONS
LICENSED OR CERTIFIED PURSUANT TO ARTICLE FORTY-THREE OF THIS CHAPTER OR
ARTICLE  FORTY-FOUR  OF  THE PUBLIC HEALTH LAW AND HEALTH CARE PROVIDERS
FOR  THE  PROVISION  OF  SERVICES  PURSUANT  TO  SECTION  THREE  HUNDRED
SIXTY-FOUR-J  OR  THREE HUNDRED SIXTY-NINE-EE OF THE SOCIAL SERVICES LAW
OR TITLE I-A OF ARTICLE TWENTY-FIVE OF THE PUBLIC  HEALTH  LAW,  NOTHING
HEREIN  SHALL  BE DEEMED: (I) TO PRECLUDE THE PARTIES FROM AGREEING TO A
DIFFERENT TIME PERIOD BUT IN NO EVENT LESS THAN NINETY DAYS; OR (II)  TO
SUPERSEDE  CONTRACT  PROVISIONS IN EXISTENCE AT THE TIME THIS SUBSECTION
TAKES EFFECT EXCEPT TO THE EXTENT THAT  SUCH  CONTRACTS  IMPOSE  A  TIME
PERIOD OF LESS THAN NINETY DAYS.
  (2)  THIS  SUBSECTION  SHALL NOT ABROGATE ANY RIGHT OR REDUCE OR LIMIT
ANY ADDITIONAL TIME PERIOD FOR CLAIM SUBMISSION PROVIDED BY LAW OR REGU-
LATION SPECIFICALLY APPLICABLE TO COORDINATION  OF  BENEFITS  IN  EFFECT
PRIOR TO THE EFFECTIVE DATE OF THIS SUBSECTION.
  (H)  (1)  AN INSURER OR ORGANIZATION OR CORPORATION LICENSED OR CERTI-
FIED PURSUANT TO ARTICLE FORTY-THREE  OR  ARTICLE  FORTY-SEVEN  OF  THIS
CHAPTER  OR  ARTICLE  FORTY-FOUR OF THE PUBLIC HEALTH LAW SHALL PERMIT A
PARTICIPATING HEALTH CARE PROVIDER TO REQUEST RECONSIDERATION OF A CLAIM
THAT IS DENIED EXCLUSIVELY BECAUSE IT WAS UNTIMELY SUBMITTED PURSUANT TO
SUBSECTION (G) OF THIS SECTION. THE INSURER OR  ORGANIZATION  OR  CORPO-
RATION  SHALL PAY SUCH CLAIM PURSUANT TO THE PROVISIONS OF PARAGRAPH TWO
OF THIS SUBSECTION IF THE HEALTH  CARE  PROVIDER  CAN  DEMONSTRATE  BOTH

S. 6016                             6

THAT:  (I)  THE HEALTH CARE PROVIDER'S NON-COMPLIANCE WAS A RESULT OF AN
UNUSUAL OCCURRENCE; AND (II) THE HEALTH CARE PROVIDER HAS A  PATTERN  OR
PRACTICE  OF TIMELY SUBMITTING CLAIMS IN COMPLIANCE WITH SUBDIVISION (G)
OF THIS SECTION.
  (2)  AN  INSURER  OR ORGANIZATION OR CORPORATION LICENSED OR CERTIFIED
PURSUANT TO ARTICLE FORTY-THREE OR ARTICLE FORTY-SEVEN OF  THIS  CHAPTER
OR ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW MAY REDUCE THE REIMBURSE-
MENT  DUE TO A HEALTH CARE PROVIDER FOR AN UNTIMELY CLAIM THAT OTHERWISE
MEETS THE REQUIREMENTS OF PARAGRAPH ONE OF THIS SUBSECTION BY AN  AMOUNT
NOT  TO  EXCEED  TWENTY-FIVE  PERCENT OF THE AMOUNT THAT WOULD HAVE BEEN
PAID HAD THE CLAIM BEEN SUBMITTED IN A TIMELY MANNER; PROVIDED, HOWEVER,
THAT NOTHING IN THIS SUBSECTION SHALL PRECLUDE A  HEALTH  CARE  PROVIDER
AND  AN INSURER OR ORGANIZATION OR CORPORATION FROM AGREEING TO A LESSER
REDUCTION. THE PROVISIONS OF THIS SUBSECTION  SHALL  NOT  APPLY  TO  ANY
CLAIM SUBMITTED THREE HUNDRED SIXTY-FIVE DAYS AFTER THE DATE OF SERVICE,
IN  WHICH  CASE  THE INSURER OR ORGANIZATION OR CORPORATION MAY DENY THE
CLAIM IN FULL.
  S 10. Subsection (b) of section 3224-b of the insurance law, as  added
by chapter 551 of the laws of 2006, is amended to read as follows:
  (b)  Overpayments  to  [physicians] HEALTH CARE PROVIDERS.   (1) Other
than recovery for duplicate payments, a health plan shall provide thirty
days written notice to [physicians] HEALTH CARE PROVIDERS before  engag-
ing  in  additional overpayment recovery efforts seeking recovery of the
overpayment of claims to such [physicians] HEALTH CARE  PROVIDERS.  Such
notice  shall  state  the  patient  name,  service date, payment amount,
proposed adjustment,  and  a  reasonably  specific  explanation  of  the
proposed adjustment.
  (2) A HEALTH PLAN SHALL PROVIDE A HEALTH CARE PROVIDER WITH THE OPPOR-
TUNITY  TO  CHALLENGE  AN OVERPAYMENT RECOVERY, INCLUDING THE SHARING OF
CLAIMS INFORMATION, AND SHALL ESTABLISH WRITTEN POLICIES AND  PROCEDURES
FOR  HEALTH  CARE PROVIDERS TO FOLLOW TO CHALLENGE AN OVERPAYMENT RECOV-
ERY.  SUCH CHALLENGE SHALL SET FORTH THE SPECIFIC GROUNDS ON  WHICH  THE
PROVIDER IS CHALLENGING THE OVERPAYMENT RECOVERY.
  (3) A health plan shall not initiate overpayment recovery efforts more
than  twenty-four  months  after  the original payment was received by a
[physician] HEALTH CARE PROVIDER.  [Provided, however, that] HOWEVER, no
such time limit shall apply to overpayment recovery efforts [which] THAT
are: (i) based on a reasonable belief  of  fraud  or  other  intentional
misconduct,  or  abusive  billing, (ii) required by, or initiated at the
request of, a self-insured plan, or (iii) required OR  AUTHORIZED  by  a
state or federal government program OR COVERAGE THAT IS PROVIDED BY THIS
STATE OR A MUNICIPALITY THEREOF TO ITS RESPECTIVE EMPLOYEES, RETIREES OR
MEMBERS.  Notwithstanding  the  aforementioned  time limitations, in the
event that a [physician] HEALTH CARE PROVIDER asserts that a health plan
has underpaid a claim or claims, the health plan may defend or  set  off
such  assertion of underpayment based on overpayments going back in time
as far as the claimed underpayment.  For  purposes  of  this  paragraph,
"abusive  billing"  shall be defined as a billing practice which results
in the submission of claims that are not consistent with  sound  fiscal,
business,  or  medical  practices  and  at such frequency and for such a
period of time as to reflect a consistent course of conduct.
  (4) FOR THE PURPOSES OF THIS SUBSECTION THE TERM "HEALTH CARE  PROVID-
ER" SHALL MEAN AN ENTITY LICENSED OR CERTIFIED PURSUANT TO ARTICLE TWEN-
TY-EIGHT,  THIRTY-SIX  OR  FORTY  OF  THE  PUBLIC HEALTH LAW, A FACILITY
LICENSED PURSUANT TO ARTICLE NINETEEN, THIRTY-ONE OR THIRTY-TWO  OF  THE

S. 6016                             7

MENTAL  HYGIENE  LAW, OR A HEALTH CARE PROFESSIONAL LICENSED, REGISTERED
OR CERTIFIED PURSUANT TO TITLE EIGHT OF THE EDUCATION LAW.
  [(3)]  (5) Nothing in this section shall be deemed to limit [an insur-
er's] A HEALTH PLAN'S right to  pursue  recovery  of  overpayments  that
occurred prior to the effective date of this section where the [insurer]
HEALTH  PLAN  has  provided  the  [physician]  HEALTH CARE PROVIDER with
notice of such recovery efforts prior to  the  effective  date  of  this
section.
  S  11.  Subparagraph  (B)  of paragraph 2 of subsection (e) of section
3231 of the insurance law, as added by chapter 501 of the laws of  1992,
is amended to read as follows:
  (B) Each calendar year, an insurer shall return, in the form of aggre-
gate  benefits  for  each  policy  form  filed pursuant to the alternate
procedure set forth in this paragraph at least seventy-five  percent  of
the  aggregate premiums collected for the policy form during that calen-
dar year. Insurers shall annually report, no later  than  May  first  of
each year, the loss ratio calculated pursuant to this paragraph for each
such  policy form for the previous calendar year. In each case where the
loss ratio for a policy form  fails  to  comply  with  the  seventy-five
percent  loss  ratio  requirement, the insurer shall issue a dividend or
credit against future premiums for all policy holders with  that  policy
form  in an amount sufficient to assure that the aggregate benefits paid
in the previous calendar year plus the amount of the dividends and cred-
its shall equal seventy-five percent of the aggregate premiums collected
for the policy form in the previous calendar year. The dividend or cred-
it shall be issued to each policy HOLDER WHO HAD A POLICY which  was  in
effect  [as of December thirty-first of] AT ANY TIME DURING the applica-
ble year [and remains in effect as of the date the dividend or credit is
issued]. THE DIVIDEND OR CREDIT SHALL BE PRORATED BASED  ON  THE  DIRECT
PREMIUMS  EARNED FOR THE APPLICABLE YEAR AMONG ALL POLICY HOLDERS ELIGI-
BLE TO RECEIVE SUCH DIVIDEND OR CREDIT.  AN INSURER SHALL MAKE A REASON-
ABLE EFFORT TO IDENTIFY THE CURRENT ADDRESS OF, AND ISSUE  DIVIDENDS  OR
CREDITS  TO,  FORMER  POLICY HOLDERS ENTITLED TO THE DIVIDEND OR CREDIT.
AN INSURER SHALL, WITH RESPECT TO DIVIDENDS OR CREDITS TO  WHICH  FORMER
POLICY HOLDERS THAT THE INSURER IS UNABLE TO IDENTIFY AFTER A REASONABLE
EFFORT  WOULD OTHERWISE BE ENTITLED, HAVE THE OPTION, AS DEEMED ACCEPTA-
BLE BY THE SUPERINTENDENT, OF PROSPECTIVELY ADJUSTING PREMIUM  RATES  BY
THE  AMOUNT  OF  SUCH  DIVIDENDS  OR CREDITS, ISSUING THE AMOUNT OF SUCH
DIVIDENDS OR CREDITS TO EXISTING POLICY HOLDERS, DEPOSITING  THE  AMOUNT
OF SUCH DIVIDENDS OR CREDITS IN THE FUND ESTABLISHED PURSUANT TO SECTION
FOUR  THOUSAND  THREE HUNDRED TWENTY-TWO-A OF THIS CHAPTER, OR UTILIZING
ANY OTHER METHOD WHICH OFFSETS THE AMOUNT OF SUCH DIVIDENDS OR  CREDITS.
All  dividends and credits must be distributed by September thirtieth of
the year following the calendar year in which the  loss  ratio  require-
ments  were not satisfied.  The annual report required by this paragraph
shall include an insurer's calculation of the dividends and credits,  as
well as an explanation of the insurer's plan to issue dividends or cred-
its.  The  instructions  and  format  for calculating and reporting loss
ratios and issuing dividends or credits shall be specified by the super-
intendent by regulation. Such regulations shall include  provisions  for
the distribution of a dividend or credit in the event of cancellation or
termination by a policy holder.
  S  12.  Subsection (i) of section 3216 of the insurance law is amended
by adding a new paragraph 26 to read as follows:
  (26)(A) NO MANAGED CARE HEALTH INSURANCE POLICY THAT PROVIDES COVERAGE
FOR HOSPITAL, MEDICAL OR SURGICAL CARE SHALL PROVIDE THAT SERVICES OF  A

S. 6016                             8

PARTICIPATING HOSPITAL WILL BE COVERED AS OUT-OF-NETWORK SERVICES SOLELY
ON  THE  BASIS  THAT  THE  HEALTH  CARE  PROVIDER ADMITTING OR RENDERING
SERVICES TO THE INSURED IS NOT A PARTICIPATING PROVIDER.
  (B) NO MANAGED CARE HEALTH INSURANCE POLICY THAT PROVIDES COVERAGE FOR
HOSPITAL,  MEDICAL  OR  SURGICAL  CARE  SHALL PROVIDE THAT SERVICES OF A
PARTICIPATING HEALTH CARE PROVIDER WILL  BE  COVERED  AS  OUT-OF-NETWORK
SERVICES  SOLELY  ON  THE  BASIS  THAT  THE  SERVICES  ARE RENDERED IN A
NON-PARTICIPATING HOSPITAL.
  (C) FOR PURPOSES OF THIS PARAGRAPH, A  "HEALTH  CARE  PROVIDER"  IS  A
HEALTH  CARE  PROFESSIONAL LICENSED, REGISTERED OR CERTIFIED PURSUANT TO
TITLE EIGHT OF THE EDUCATION LAW OR A HEALTH CARE  PROFESSIONAL  COMPAR-
ABLY LICENSED, REGISTERED OR CERTIFIED BY ANOTHER STATE.
  (D)  FOR  PURPOSES OF THIS PARAGRAPH, A "MANAGED CARE HEALTH INSURANCE
POLICY" IS A POLICY THAT REQUIRES THAT SERVICES BE PROVIDED BY A PROVID-
ER PARTICIPATING IN THE INSURER'S NETWORK IN ORDER FOR  THE  INSURED  TO
RECEIVE THE MAXIMUM LEVEL OF REIMBURSEMENT UNDER THE POLICY.
  S  13.  Subsection (k) of section 3221 of the insurance law is amended
by adding a new paragraph 15 to read as follows:
  (15)(A) NO GROUP OR BLANKET MANAGED CARE HEALTH INSURANCE POLICY  THAT
PROVIDES  COVERAGE  FOR HOSPITAL, MEDICAL OR SURGICAL CARE SHALL PROVIDE
THAT  SERVICES    OF  A  PARTICIPATING  HOSPITAL  WILL  BE  COVERED   AS
OUT-OF-NETWORK SERVICES SOLELY ON THE BASIS THAT THE HEALTH CARE PROVID-
ER ADMITTING OR RENDERING SERVICES TO THE INSURED IS NOT A PARTICIPATING
PROVIDER.
  (B)  NO  GROUP  OR  BLANKET  MANAGED CARE HEALTH INSURANCE POLICY THAT
PROVIDES COVERAGE FOR HOSPITAL, MEDICAL OR SURGICAL CARE  SHALL  PROVIDE
THAT SERVICES OF A PARTICIPATING HEALTH CARE PROVIDER WILL BE COVERED AS
OUT-OF-NETWORK  SERVICES  SOLELY  ON  THE  BASIS  THAT  THE SERVICES ARE
RENDERED IN A NON-PARTICIPATING HOSPITAL.
  (C) FOR PURPOSES OF THIS PARAGRAPH, A  "HEALTH  CARE  PROVIDER"  IS  A
HEALTH  CARE  PROFESSIONAL LICENSED, REGISTERED OR CERTIFIED PURSUANT TO
TITLE EIGHT OF THE EDUCATION LAW OR A HEALTH CARE  PROFESSIONAL  COMPAR-
ABLY LICENSED, REGISTERED OR CERTIFIED BY ANOTHER STATE.
  (D)  FOR  PURPOSES OF THIS PARAGRAPH, A "MANAGED CARE HEALTH INSURANCE
POLICY" IS A POLICY THAT REQUIRES THAT SERVICES BE PROVIDED BY A PROVID-
ER PARTICIPATING IN THE INSURER'S NETWORK IN ORDER FOR  THE  INSURED  TO
RECEIVE THE MAXIMUM LEVEL OF REIMBURSEMENT UNDER THE POLICY.
  S  13-a.  The insurance law is amended by adding a new section 3241 to
read as follows:
  S 3241. NETWORK ADEQUACY. AN INSURER THAT ISSUES  A  HEALTH  INSURANCE
CONTRACT  PURSUANT  TO  THIS  ARTICLE  OR A PLAN OR CONTRACT PURSUANT TO
ARTICLE FORTY-THREE OR FORTY-SEVEN OF THIS CHAPTER, WITH  A  NETWORK  OF
HEALTH CARE PROVIDERS, SHALL ENSURE THAT THE NETWORK IS ADEQUATE TO MEET
THE  HEALTH  NEEDS  OF ITS INSUREDS AND PROVIDE AN APPROPRIATE CHOICE OF
PROVIDERS SUFFICIENT TO RENDER THE SERVICES COVERED UNDER  THE  PLAN  OR
CONTRACT.  THE  SUPERINTENDENT  SHALL  REVIEW THE NETWORK OF HEALTH CARE
PROVIDERS FOR ADEQUACY AT  THE  TIME  OF  THE  SUPERINTENDENT'S  INITIAL
APPROVAL  OF  A HEALTH INSURANCE PLAN OR CONTRACT THAT USES A NETWORK OF
PROVIDERS AND IS ISSUED PURSUANT TO THIS ARTICLE OR ARTICLE  FORTY-THREE
OR  FORTY-SEVEN  OF  THIS CHAPTER, AT LEAST EVERY THREE YEARS THEREAFTER
AND UPON APPLICATION BY THE INSURER FOR EXPANSION OF  ANY  SERVICE  AREA
ASSOCIATED WITH THE PLAN OR CONTRACT.
  S  14.  Section  4303  of the insurance law is amended by adding a new
subsection (ff) to read as follows:
  (FF) (1) NO MANAGED CARE CONTRACT ISSUED BY A  HEALTH  SERVICE  CORPO-
RATION, HOSPITAL SERVICE CORPORATION OR MEDICAL EXPENSE INDEMNITY CORPO-

S. 6016                             9

RATION  THAT  PROVIDES  COVERAGE  FOR HOSPITAL, MEDICAL OR SURGICAL CARE
SHALL PROVIDE THAT SERVICES  OF A PARTICIPATING HOSPITAL WILL BE COVERED
AS OUT-OF-NETWORK SERVICES SOLELY ON THE  BASIS  THAT  THE  HEALTH  CARE
PROVIDER ADMITTING OR RENDERING SERVICES TO THE INSURED IS NOT A PARTIC-
IPATING PROVIDER.
  (2)  NO  MANAGED CARE CONTRACT ISSUED BY A HEALTH SERVICE CORPORATION,
HOSPITAL SERVICE CORPORATION OR MEDICAL  EXPENSE  INDEMNITY  CORPORATION
THAT  PROVIDES  COVERAGE  FOR  HOSPITAL,  MEDICAL OR SURGICAL CARE SHALL
PROVIDE THAT SERVICES OF A PARTICIPATING HEALTH CARE  PROVIDER  WILL  BE
COVERED AS OUT-OF-NETWORK SERVICES SOLELY ON THE BASIS THAT THE SERVICES
ARE RENDERED IN A NON-PARTICIPATING HOSPITAL.
  (3)  FOR  PURPOSES  OF  THIS SUBSECTION, A "HEALTH CARE PROVIDER" IS A
HEALTH CARE PROFESSIONAL LICENSED, REGISTERED OR CERTIFIED  PURSUANT  TO
TITLE  EIGHT  OF THE EDUCATION LAW OR A HEALTH CARE PROFESSIONAL COMPAR-
ABLY LICENSED, REGISTERED OR CERTIFIED BY ANOTHER STATE.
  (4) FOR PURPOSES OF THIS SUBSECTION, A "MANAGED CARE  CONTRACT"  IS  A
CONTRACT  THAT  REQUIRES THAT SERVICES BE PROVIDED BY A PROVIDER PARTIC-
IPATING IN THE CORPORATION'S NETWORK IN  ORDER  FOR  THE  SUBSCRIBER  TO
RECEIVE THE MAXIMUM LEVEL OF REIMBURSEMENT UNDER THE CONTRACT.
  S  15.  Section  4305  of the insurance law is amended by adding a new
subsection (1) to read as follows:
  (1) A HEALTH CARE CLAIM FROM A SUBSCRIBER  COVERED  UNDER  A  CONTRACT
ISSUED  PURSUANT  TO  THIS SECTION SHALL BE SUBMITTED WITHIN ONE HUNDRED
TWENTY DAYS FROM THE DATE OF SERVICE; PROVIDED, HOWEVER, THAT IF IT  WAS
NOT  REASONABLY  POSSIBLE  FOR THE SUBSCRIBER TO SUBMIT THE CLAIM WITHIN
THAT TIMEFRAME, THEN THE CLAIM SHALL BE SUBMITTED AS SOON AS  REASONABLY
POSSIBLE.
  S  16.  Section  4306  of the insurance law is amended by adding a new
subsection (n) to read as follows:
  (N) A STATEMENT THAT A HEALTH CARE CLAIM FROM A  SUBSCRIBER  SHALL  BE
SUBMITTED  WITHIN  ONE  HUNDRED  TWENTY  DAYS  FROM THE DATE OF SERVICE;
PROVIDED, HOWEVER, THAT IF  IT  WAS  NOT  REASONABLY  POSSIBLE  FOR  THE
SUBSCRIBER  TO  SUBMIT  THE  CLAIM WITHIN THAT TIMEFRAME, THEN THE CLAIM
SHALL BE SUBMITTED AS SOON AS REASONABLY POSSIBLE.
  S 17. The insurance law is amended by adding a new section  4306-c  to
read as follows:
  S  4306-C.  GRIEVANCE  PROCEDURE  AND ACCESS TO SPECIALTY CARE.  (A) A
CORPORATION, INCLUDING A  MUNICIPAL  COOPERATIVE  HEALTH  BENEFITS  PLAN
CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THIS CHAPTER, THAT ISSUES A
COMPREHENSIVE CONTRACT THAT UTILIZES A NETWORK OF PROVIDERS AND IS NOT A
MANAGED  CARE  HEALTH INSURANCE CONTRACT AS DEFINED IN SUBSECTION (C) OF
SECTION FOUR THOUSAND EIGHT HUNDRED ONE OF THIS CHAPTER SHALL  ESTABLISH
AND  MAINTAIN  A GRIEVANCE PROCEDURE CONSISTENT WITH THE REQUIREMENTS OF
SECTION FOUR THOUSAND EIGHT HUNDRED TWO OF THIS CHAPTER.
  (B) A CORPORATION, INCLUDING A MUNICIPAL COOPERATIVE  HEALTH  BENEFITS
PLAN  CERTIFIED  PURSUANT  TO  ARTICLE FORTY-SEVEN OF THIS CHAPTER, THAT
ISSUES A COMPREHENSIVE CONTRACT THAT UTILIZES AN  EXCLUSIVE  NETWORK  OF
PROVIDERS  WITHOUT  AN  OUT-OF-NETWORK  OPTION AND IS NOT A MANAGED CARE
HEALTH INSURANCE CONTRACT AS DEFINED IN SUBSECTION (C) OF  SECTION  FOUR
THOUSAND  EIGHT  HUNDRED  ONE  OF  THIS CHAPTER, SHALL PROVIDE ACCESS TO
OUT-OF-NETWORK SERVICES CONSISTENT WITH THE REQUIREMENTS  OF  SUBSECTION
(A)  OF  SECTION  FOUR  THOUSAND EIGHT HUNDRED FOUR, SUBSECTION (G-6) OF
SECTION FOUR THOUSAND NINE HUNDRED OF THIS CHAPTER, SUBSECTION (A-1)  OF
SECTION  FOUR  THOUSAND NINE HUNDRED FOUR, PARAGRAPH THREE OF SUBSECTION
(B) OF SECTION FOUR THOUSAND NINE HUNDRED TEN,  AND  PARAGRAPH  FOUR  OF

S. 6016                            10

SUBSECTION  (B)  OF  SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN OF THIS
CHAPTER.
  (C)  A  CORPORATION, INCLUDING A MUNICIPAL COOPERATIVE HEALTH BENEFITS
PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN  OF  THIS  CHAPTER,  THAT
ISSUES A COMPREHENSIVE CONTRACT THAT UTILIZES A NETWORK OF PROVIDERS AND
IS NOT A MANAGED CARE HEALTH INSURANCE CONTRACT AS DEFINED IN SUBSECTION
(C)  OF  SECTION  FOUR  THOUSAND  EIGHT  HUNDRED ONE OF THIS CHAPTER AND
REQUIRES THAT SPECIALTY CARE BE PROVIDED PURSUANT TO A REFERRAL  FROM  A
PRIMARY  CARE  PROVIDER  SHALL  PROVIDE  ACCESS  TO  SUCH SPECIALTY CARE
CONSISTENT WITH THE REQUIREMENTS OF SUBSECTIONS  (B),  (C)  AND  (D)  OF
SECTION  FOUR  THOUSAND  EIGHT  HUNDRED  FOUR  OF THIS CHAPTER; PROVIDED
HOWEVER, THAT NOTHING HEREIN SHALL BE CONSTRUED TO REQUIRE THAT A CORPO-
RATION, OR A PRIMARY CARE PROVIDER ON BEHALF OF THE CORPORATION, MAKE  A
REFERRAL TO A PROVIDER THAT IS NOT IN THE CORPORATION'S NETWORK.
  (D)  A  CORPORATION, INCLUDING A MUNICIPAL COOPERATIVE HEALTH BENEFITS
PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN  OF  THIS  CHAPTER,  THAT
ISSUES A COMPREHENSIVE CONTRACT THAT UTILIZES A NETWORK OF PROVIDERS AND
IS NOT A MANAGED CARE HEALTH INSURANCE CONTRACT AS DEFINED IN SUBSECTION
(C)  OF  SECTION  FOUR  THOUSAND EIGHT HUNDRED ONE OF THIS CHAPTER SHALL
PROVIDE ACCESS TO TRANSITIONAL CARE CONSISTENT WITH THE REQUIREMENTS  OF
SUBSECTIONS  (E)  AND (F) OF SECTION FOUR THOUSAND EIGHT HUNDRED FOUR OF
THIS CHAPTER.
  S 18. Paragraph 2 of subsection (h) of section 4308 of  the  insurance
law,  as added by chapter 504 of the laws of 1995, is amended to read as
follows:
  (2) In each case where the loss ratio for a  contract  form  fails  to
comply  with  the eighty-five percent minimum loss ratio requirement for
individual direct payment contracts, or the seventy-five percent minimum
loss ratio requirement  for  small  group  and  small  group  remittance
contracts,  as set forth in paragraph one of this subsection, the corpo-
ration shall issue a dividend or credit against future premiums for  all
contract  holders  with  that  contract  form in an amount sufficient to
assure that the aggregate benefits incurred  in  the  previous  calendar
year  plus  the  amount of the dividends and credits shall equal no less
than eighty-five percent for individual  direct  payment  contracts,  or
seventy-five   percent  for  small  group  and  small  group  remittance
contracts, of the aggregate premiums earned for the contract form in the
previous calendar year. The dividend or credit shall be issued  to  each
contract  HOLDER OR SUBSCRIBER WHO HAD A CONTRACT that was in effect [as
of December thirty-first of] AT ANY TIME DURING the applicable year [and
remains in effect as of the date the dividend or credit is issued].  THE
DIVIDEND OR CREDIT SHALL BE PRORATED BASED ON THE DIRECT PREMIUMS EARNED
FOR THE APPLICABLE YEAR AMONG ALL CONTRACT HOLDERS OR SUBSCRIBERS ELIGI-
BLE TO RECEIVE SUCH DIVIDEND OR CREDIT.   A  CORPORATION  SHALL  MAKE  A
REASONABLE  EFFORT  TO  IDENTIFY THE CURRENT ADDRESS OF, AND ISSUE DIVI-
DENDS OR CREDITS TO, FORMER CONTRACT HOLDERS OR SUBSCRIBERS ENTITLED  TO
THE  DIVIDEND  OR CREDIT. A CORPORATION SHALL, WITH RESPECT TO DIVIDENDS
OR CREDITS TO WHICH FORMER CONTRACT  HOLDERS  THAT  THE  CORPORATION  IS
UNABLE  TO  IDENTIFY  AFTER A REASONABLE EFFORT WOULD OTHERWISE BE ENTI-
TLED, HAVE THE OPTION, AS DEEMED ACCEPTABLE BY  THE  SUPERINTENDENT,  OF
PROSPECTIVELY ADJUSTING PREMIUM RATES BY THE AMOUNT OF SUCH DIVIDENDS OR
CREDITS,  ISSUING  THE  AMOUNT  OF SUCH DIVIDENDS OR CREDITS TO EXISTING
CONTRACT HOLDERS, DEPOSITING THE AMOUNT OF SUCH DIVIDENDS OR CREDITS  IN
THE  FUND  ESTABLISHED  PURSUANT  TO SECTION FOUR THOUSAND THREE HUNDRED
TWENTY-TWO-A OF THIS  ARTICLE,  OR  UTILIZING  ANY  OTHER  METHOD  WHICH
OFFSETS THE AMOUNT OF SUCH DIVIDENDS OR CREDITS. All dividends and cred-

S. 6016                            11

its must be distributed by September thirtieth of the year following the
calendar  year  in which the loss ratio requirements were not satisfied.
The annual report required by paragraph one  of  this  subsection  shall
include  a  corporation's  calculation  of the dividends and credits, as
well as an explanation of the corporation's plan to issue  dividends  or
credits.  The instructions and format for calculating and reporting loss
ratios and issuing dividends or credits shall be specified by the super-
intendent by regulation. Such regulations shall include  provisions  for
the distribution of a dividend or credit in the event of cancellation or
termination by a contract holder or subscriber.
  S  19.  Subsections  (g) and (h) of section 4325 of the insurance law,
subsection (g) as relettered by chapter 586 of the  laws  of  1998,  are
relettered  subsections (h) and (i) and a new subsection (g) is added to
read as follows:
  (G)(1) NO INSURER SHALL IMPLEMENT AN ADVERSE REIMBURSEMENT CHANGE TO A
CONTRACT WITH A HEALTH CARE PROFESSIONAL THAT IS OTHERWISE PERMITTED  BY
THE  CONTRACT,  UNLESS,  PRIOR  TO THE EFFECTIVE DATE OF THE CHANGE, THE
INSURER GIVES THE HEALTH CARE PROFESSIONAL WITH  WHOM  THE  INSURER  HAS
DIRECTLY  CONTRACTED  AND  WHO  IS IMPACTED BY THE ADVERSE REIMBURSEMENT
CHANGE, AT LEAST NINETY DAYS  WRITTEN  NOTICE  OF  THE  CHANGE.  IF  THE
CONTRACTING  HEALTH  CARE PROFESSIONAL OBJECTS TO THE CHANGE THAT IS THE
SUBJECT OF THE NOTICE BY THE INSURER, THE HEALTH CARE PROFESSIONAL  MAY,
WITHIN THIRTY DAYS OF THE DATE OF THE NOTICE, GIVE WRITTEN NOTICE TO THE
INSURER TO TERMINATE HIS OR HER CONTRACT WITH THE INSURER EFFECTIVE UPON
THE  IMPLEMENTATION  DATE  OF THE ADVERSE REIMBURSEMENT CHANGE.  FOR THE
PURPOSES OF THIS SUBSECTION, THE  TERM  "ADVERSE  REIMBURSEMENT  CHANGE"
SHALL MEAN A PROPOSED CHANGE THAT COULD REASONABLY BE EXPECTED TO HAVE A
MATERIAL  ADVERSE  IMPACT  ON THE AGGREGATE LEVEL OF PAYMENT TO A HEALTH
CARE PROFESSIONAL, AND THE TERM "HEALTH CARE PROFESSIONAL" SHALL MEAN  A
HEALTH  CARE  PROFESSIONAL LICENSED, REGISTERED OR CERTIFIED PURSUANT TO
TITLE EIGHT OF THE EDUCATION LAW. THE NOTICE PROVISIONS REQUIRED BY THIS
SUBSECTION SHALL NOT APPLY WHERE: (A) SUCH CHANGE IS OTHERWISE  REQUIRED
BY LAW, REGULATION OR APPLICABLE REGULATORY AUTHORITY, OR IS REQUIRED AS
A  RESULT  OF  CHANGES  IN  FEE  SCHEDULES, REIMBURSEMENT METHODOLOGY OR
PAYMENT POLICIES ESTABLISHED BY A GOVERNMENT AGENCY OR BY  THE  AMERICAN
MEDICAL   ASSOCIATION'S  CURRENT  PROCEDURAL  TERMINOLOGY  (CPT)  CODES,
REPORTING GUIDELINES AND CONVENTIONS; OR (B) SUCH  CHANGE  IS  EXPRESSLY
PROVIDED  FOR  UNDER  THE  TERMS  OF THE CONTRACT BY THE INCLUSION OF OR
REFERENCE TO A SPECIFIC FEE OR FEE SCHEDULE,  REIMBURSEMENT  METHODOLOGY
OR PAYMENT POLICY INDEXING MECHANISM.
  (2)  NOTHING IN THIS SUBSECTION SHALL CREATE A PRIVATE RIGHT OF ACTION
ON  BEHALF  OF  A  HEALTH  CARE  PROFESSIONAL  AGAINST  AN  INSURER  FOR
VIOLATIONS OF THIS SUBSECTION.
  S  20. Subsection (a) of section 4803 of the insurance law, as amended
by chapter 551 of the laws of 2006, is amended to read as follows:
  (a) (1) An insurer which offers a managed  care  product  shall,  upon
request,  make available and disclose to health care professionals writ-
ten application procedures and minimum qualification requirements  which
a  health  care  professional must meet in order to be considered by the
insurer for participation in the  in-network  benefits  portion  of  the
insurer's  network  for  the  managed  care  product.  The insurer shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements for participation in the in-network
benefits portion of the insurer's network for the managed care  product.
An  insurer  shall  complete  review  of  the health care professional's
application to participate in the in-network portion  of  the  insurer's

S. 6016                            12

network  and,  within  ninety  days  of  receiving a health care profes-
sional's completed application to participate in the insurer's  network,
will  notify the health care professional as to [(i)]: (A) whether he or
she  is credentialed; or [(ii)] (B) whether additional time is necessary
to make a determination in  spite  of  THE  insurer's  best  efforts  or
because  of  a  failure of a third party to provide necessary documenta-
tion, or non-routine or unusual circumstances  require  additional  time
for  review.    In  such  instances  where  additional time is necessary
because of a lack of necessary  documentation,  an  insurer  shall  make
every effort to obtain such information as soon as possible.
  (2)  IF  THE  COMPLETED  APPLICATION  OF  A NEWLY-LICENSED HEALTH CARE
PROFESSIONAL OR A HEALTH CARE PROFESSIONAL WHO HAS RECENTLY RELOCATED TO
THIS STATE FROM ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED  IN  THIS
STATE,  WHO  JOINS A GROUP PRACTICE OF HEALTH CARE PROFESSIONALS EACH OF
WHOM PARTICIPATES IN THE IN-NETWORK PORTION OF AN INSURER'S NETWORK,  IS
NEITHER  APPROVED  NOR DECLINED WITHIN NINETY DAYS PURSUANT TO PARAGRAPH
ONE OF THIS SUBSECTION, SUCH HEALTH CARE PROFESSIONAL  SHALL  BE  DEEMED
"PROVISIONALLY  CREDENTIALED"  AND  MAY  PARTICIPATE  IN  THE IN-NETWORK
PORTION OF AN INSURER'S NETWORK; PROVIDED, HOWEVER, THAT A PROVISIONALLY
CREDENTIALED PHYSICIAN MAY NOT BE DESIGNATED  AS  AN  INSURED'S  PRIMARY
CARE  PHYSICIAN  UNTIL SUCH TIME AS THE PHYSICIAN HAS BEEN FULLY CREDEN-
TIALED. THE  NETWORK  PARTICIPATION  FOR  A  PROVISIONALLY  CREDENTIALED
HEALTH  CARE PROFESSIONAL SHALL BEGIN ON THE DAY FOLLOWING THE NINETIETH
DAY OF RECEIPT OF THE COMPLETED APPLICATION AND  SHALL  LAST  UNTIL  THE
FINAL  CREDENTIALING DETERMINATION IS MADE BY THE INSURER. A HEALTH CARE
PROFESSIONAL SHALL ONLY BE ELIGIBLE FOR PROVISIONAL CREDENTIALING IF THE
GROUP PRACTICE OF HEALTH CARE  PROFESSIONALS  NOTIFIES  THE  INSURER  IN
WRITING  THAT,  SHOULD  THE APPLICATION ULTIMATELY BE DENIED, THE HEALTH
CARE PROFESSIONAL OR THE GROUP PRACTICE: (A) SHALL REFUND  ANY  PAYMENTS
MADE  BY  THE  INSURER  FOR  IN-NETWORK  SERVICES PROVIDED BY THE PROVI-
SIONALLY  CREDENTIALED  HEALTH  CARE  PROFESSIONAL   THAT   EXCEED   ANY
OUT-OF-NETWORK  BENEFITS  PAYABLE  UNDER THE INSURED'S CONTRACT WITH THE
INSURER; AND (B) SHALL NOT PURSUE REIMBURSEMENT FROM THE INSURED, EXCEPT
TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD  HAVE  BEEN
PAYABLE  HAD  THE  INSURED  RECEIVED SERVICES FROM A HEALTH CARE PROFES-
SIONAL PARTICIPATING IN THE IN-NETWORK PORTION OF AN INSURER'S  NETWORK.
INTEREST  AND  PENALTIES  PURSUANT TO SECTION THREE THOUSAND TWO HUNDRED
TWENTY-FOUR-A OF THIS CHAPTER SHALL NOT BE ASSESSED BASED ON THE  DENIAL
OF A CLAIM SUBMITTED DURING THE PERIOD WHEN THE HEALTH CARE PROFESSIONAL
WAS  PROVISIONALLY  CREDENTIALED; PROVIDED, HOWEVER, THAT NOTHING HEREIN
SHALL PREVENT AN INSURER FROM PAYING A CLAIM FROM A HEALTH CARE  PROFES-
SIONAL  WHO IS PROVISIONALLY CREDENTIALED UPON SUBMISSION OF SUCH CLAIM.
AN INSURER SHALL NOT DENY, AFTER APPEAL, A CLAIM FOR  SERVICES  PROVIDED
BY  A  PROVISIONALLY CREDENTIALED HEALTH CARE PROFESSIONAL SOLELY ON THE
GROUND THAT THE CLAIM WAS NOT TIMELY FILED.
  S 21. Section 4900 of the insurance law is amended  by  adding  a  new
subsection (g-7) to read as follows:
  (G-7)  "RARE  DISEASE" MEANS A LIFE THREATENING OR DISABLING CONDITION
OR DISEASE THAT (1)(A) IS CURRENTLY OR HAS BEEN SUBJECT  TO  A  RESEARCH
STUDY  BY  THE  NATIONAL  INSTITUTES  OF  HEALTH  RARE DISEASES CLINICAL
RESEARCH NETWORK; OR (B) AFFECTS FEWER THAN TWO HUNDRED THOUSAND  UNITED
STATES  RESIDENTS  PER  YEAR;  AND  (2) FOR WHICH THERE DOES NOT EXIST A
STANDARD HEALTH SERVICE OR PROCEDURE COVERED BY  THE  HEALTH  CARE  PLAN
THAT  IS MORE CLINICALLY BENEFICIAL THAN THE REQUESTED HEALTH SERVICE OR
TREATMENT. A PHYSICIAN,  OTHER THAN THE  INSURED'S  TREATING  PHYSICIAN,
SHALL  CERTIFY  IN  WRITING  THAT  THE  CONDITION   IS A RARE DISEASE AS

S. 6016                            13

DEFINED  IN  THIS  SUBSECTION.  THE  CERTIFYING  PHYSICIAN  SHALL  BE  A
LICENSED, BOARD-CERTIFIED OR BOARD-ELIGIBLE PHYSICIAN WHO SPECIALIZES IN
THE  AREA  OF  PRACTICE APPROPRIATE TO TREAT THE INSURED'S RARE DISEASE.
THE  CERTIFICATION  SHALL  PROVIDE  EITHER:  (1) THAT THE INSURED'S RARE
DISEASE IS CURRENTLY OR HAS BEEN SUBJECT TO   A RESEARCH  STUDY  BY  THE
NATIONAL  INSTITUTES  OF HEALTH RARE DISEASES CLINICAL RESEARCH NETWORK;
OR (2) THAT THE INSURED'S RARE DISEASE AFFECTS FEWER  THAN  TWO  HUNDRED
THOUSAND  UNITED STATES RESIDENTS PER YEAR. THE CERTIFICATION SHALL RELY
ON MEDICAL AND SCIENTIFIC  EVIDENCE  TO  SUPPORT  THE  REQUESTED  HEALTH
SERVICE  OR  PROCEDURE,  IF  SUCH   EVIDENCE EXISTS, AND SHALL INCLUDE A
STATEMENT THAT, BASED ON THE PHYSICIAN'S CREDIBLE EXPERIENCE,  THERE  IS
NO STANDARD TREATMENT THAT IS LIKELY TO BE MORE CLINICALLY BENEFICIAL TO
THE  INSURED  THAN  THE  REQUESTED  HEALTH  SERVICE OR PROCEDURE AND THE
REQUESTED HEALTH SERVICE OR PROCEDURE IS LIKELY TO BENEFIT  THE  INSURED
IN THE  TREATMENT OF THE INSURED'S RARE DISEASE AND THAT SUCH BENEFIT TO
THE  INSURED    OUTWEIGHS THE RISKS OF SUCH HEALTH SERVICE OR PROCEDURE.
THE CERTIFYING  PHYSICIAN  SHALL  DISCLOSE  ANY  MATERIAL  FINANCIAL  OR
PROFESSIONAL  RELATIONSHIP  WITH  THE  PROVIDER  OF THE REQUESTED HEALTH
SERVICE OR PROCEDURE AS PART OF THE APPLICATION FOR EXTERNAL  APPEAL  OF
DENIAL  OF  A RARE DISEASE TREATMENT.  IF THE PROVISION OF THE REQUESTED
HEALTH  SERVICE OR PROCEDURE AT A HEALTH CARE  FACILITY  REQUIRES  PRIOR
APPROVAL  OF  AN  INSTITUTIONAL  REVIEW  BOARD,  AN INSURED OR INSURED'S
DESIGNEE SHALL ALSO SUBMIT SUCH  APPROVAL AS PART OF THE EXTERNAL APPEAL
APPLICATION.
  S 22. Subsection (c) of section 4903 of the insurance law, as added by
chapter 705 of the laws of 1996, is amended to read as follows:
  (c) A utilization review agent shall make  a  determination  involving
continued or extended health care services, [or] additional services for
an  insured  undergoing  a course of continued treatment prescribed by a
health care provider, OR HOME HEALTH CARE SERVICES  FOLLOWING  AN  INPA-
TIENT HOSPITAL ADMISSION, and SHALL provide notice of such determination
to  the  insured  or  the  insured's designee, which may be satisfied by
notice to the insured's health care provider, by telephone and in  writ-
ing  within  one  business  day  of receipt of the necessary information
EXCEPT, WITH RESPECT TO HOME HEALTH CARE SERVICES FOLLOWING AN INPATIENT
HOSPITAL ADMISSION, WITHIN SEVENTY-TWO HOURS OF RECEIPT OF THE NECESSARY
INFORMATION WHEN THE DAY SUBSEQUENT TO THE REQUEST FALLS ON   A  WEEKEND
OR  HOLIDAY.    Notification  of  continued  or  extended services shall
include the number of extended  services  approved,  the  new  total  of
approved  services,  the  date  of onset of services and the next review
date.  PROVIDED THAT A REQUEST FOR HOME HEALTH  CARE  SERVICES  AND  ALL
NECESSARY INFORMATION IS SUBMITTED TO THE UTILIZATION REVIEW AGENT PRIOR
TO  DISCHARGE  FROM  AN  INPATIENT  HOSPITAL  ADMISSION PURSUANT TO THIS
SUBSECTION, A UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE  BASIS  OF
MEDICAL  NECESSITY  OR  LACK  OF  PRIOR AUTHORIZATION, COVERAGE FOR HOME
HEALTH CARE SERVICES WHILE A DETERMINATION  BY  THE  UTILIZATION  REVIEW
AGENT IS PENDING.
  S 23. Subsection (b) of section 4904 of the insurance law, as added by
chapter  705  of the laws of 1996, paragraph 2 as amended by chapter 586
of the laws of 1998, is amended to read as follows:
  (b) A utilization review agent shall  establish  an  expedited  appeal
process  for  appeal of an adverse determination involving (1) continued
or extended health care services, procedures or treatments or additional
services for an insured  undergoing  a  course  of  continued  treatment
prescribed  by  a  health  care  provider  or  HOME HEALTH CARE SERVICES
FOLLOWING DISCHARGE FROM AN INPATIENT  HOSPITAL  ADMISSION  PURSUANT  TO

S. 6016                            14

SUBSECTION (C) OF SECTION FOUR THOUSAND NINE HUNDRED THREE OF THIS ARTI-
CLE  OR  (2)  an adverse determination in which the health care provider
believes an immediate  appeal  is  warranted  except  any  retrospective
determination.  Such  process  shall include mechanisms which facilitate
resolution of the appeal including but not limited  to  the  sharing  of
information  from the insured's health care provider and the utilization
review agent by telephonic means or by facsimile. The utilization review
agent shall provide reasonable access  to  its  clinical  peer  reviewer
within  one  business  day of receiving notice of the taking of an expe-
dited appeal. Expedited appeals shall be determined within two  business
days  of  receipt of necessary information to conduct such appeal. Expe-
dited appeals which do not result in a resolution  satisfactory  to  the
appealing  party  may  be  further  appealed through the standard appeal
process, or through the external appeal process pursuant to section four
thousand nine hundred fourteen of this article as applicable.
  S 24. Section 4906 of the insurance law, as amended by chapter 586  of
the laws of 1998, is amended to read as follows:
  S  4906.  Waiver.  (A)  Any  agreement which purports to waive, limit,
disclaim, or in any way diminish the rights set forth in  this  article,
except as provided pursuant to section four thousand nine hundred ten of
this article shall be void as contrary to public policy.
  (B)  NOTWITHSTANDING  SUBSECTION  (A)  OF THIS SECTION, IN LIEU OF THE
EXTERNAL APPEAL PROCESS AS SET FORTH IN THIS ARTICLE, A HEALTH CARE PLAN
AND A FACILITY LICENSED PURSUANT TO ARTICLE TWENTY-EIGHT OF  THE  PUBLIC
HEALTH  LAW  MAY AGREE TO AN ALTERNATIVE DISPUTE RESOLUTION MECHANISM TO
RESOLVE DISPUTES OTHERWISE SUBJECT TO THIS ARTICLE.
  S 25. The opening paragraph of subsection (b) of section 4910  of  the
insurance  law,  as added by chapter 586 of the laws of 1998, is amended
to read as follows:
  An insured, the insured's designee and, in connection with  CONCURRENT
AND  retrospective  adverse  determinations,  an  insured's  health care
provider, shall have the right to request an external appeal when:
  S 26. Subparagraphs (B) and (C) of paragraph 2 of  subsection  (b)  of
section  4910  of the insurance law, as added by chapter 586 of the laws
of 1998, are amended to read as follows:
  (B) the insured's attending physician has certified that  the  insured
has  a  life-threatening or disabling condition or disease (a) for which
standard health services or procedures have been ineffective or would be
medically inappropriate, or (b) for which there does not  exist  a  more
beneficial  standard  health  service or procedure covered by the health
care plan, or (c) for which  there  exists  a  clinical  trial  OR  RARE
DISEASE TREATMENT, and
  (C)  the insured's attending physician, who must be a licensed, board-
certified or board-eligible physician qualified to practice in the  area
of practice appropriate to treat the insured's life-threatening or disa-
bling  condition  or  disease, must have recommended either (a) a health
service or procedure (including  a  pharmaceutical  product  within  the
meaning  of  subparagraph  (B)  of  paragraph  two  of subsection (e) of
section four thousand nine hundred of this article) that, based  on  two
documents  from the available medical and scientific evidence, is likely
to be more beneficial to the insured than any  covered  standard  health
service  or  procedure  OR,  IN THE CASE OF A RARE DISEASE, BASED ON THE
PHYSICIAN'S CERTIFICATION REQUIRED BY SUBSECTION (G-7) OF  SECTION  FOUR
THOUSAND  NINE  HUNDRED  OF  THIS ARTICLE AND SUCH OTHER EVIDENCE AS THE
INSURED, THE INSURED'S DESIGNEE OR THE INSURED'S ATTENDING PHYSICIAN MAY
PRESENT, THAT THE REQUESTED HEALTH SERVICE OR  PROCEDURE  IS  LIKELY  TO

S. 6016                            15

BENEFIT  THE  INSURED IN THE TREATMENT OF THE INSURED'S RARE DISEASE AND
THAT SUCH BENEFIT TO THE INSURED OUTWEIGHS  THE  RISKS  OF  SUCH  HEALTH
SERVICE  OR  PROCEDURE; or (b) a clinical trial for which the insured is
eligible.  Any physician certification provided under this section shall
include a statement of the evidence relied  upon  by  the  physician  in
certifying his or her recommendation, and
  S  27.  Paragraphs  2  and  3 of subsection (b) of section 4914 of the
insurance law, as added by chapter 586 of the laws of 1998, are  amended
to read as follows:
  (2)  The  external appeal agent shall make a determination with regard
to the appeal within thirty days  of  the  receipt  of  the  [insured's]
request  therefor,  submitted  in  accordance  with the superintendent's
instructions. The external appeal agent shall have  the  opportunity  to
request  additional  information  from the insured, the insured's health
care provider and the insured's health care plan within such  thirty-day
period,  in  which case the agent shall have up to five additional busi-
ness days if necessary to make such determination. The  external  appeal
agent shall notify the insured, THE INSURED'S HEALTH CARE PROVIDER WHERE
APPROPRIATE,  and the health care plan, in writing, of the appeal deter-
mination within two business days of  the  rendering  of  such  determi-
nation.
  (3)  Notwithstanding  the provisions of paragraphs one and two of this
subsection, if the insured's attending physician states that a delay  in
providing  the  health  care  service  would pose an imminent or serious
threat to the health of  the  insured,  the  external  appeal  shall  be
completed  within  three  days  of the request therefor and the external
appeal agent shall make every reasonable attempt to  immediately  notify
the  insured,  THE INSURED'S HEALTH CARE PROVIDER WHERE APPROPRIATE, and
the health plan of its determination by telephone or facsimile, followed
immediately by written notification of such determination.
  S 28. Clause (a) of item (ii) of subparagraph (B) of  paragraph  4  of
subsection (b) of section 4914 of the insurance law, as added by chapter
586 of the laws of 1998, is amended to read as follows:
  (a) that the patient costs of the proposed health service or procedure
shall  be covered by the health care plan either: when a majority of the
panel of reviewers determines,  BASED  upon  review  of  the  applicable
medical  and  scientific evidence AND, IN CONNECTION WITH RARE DISEASES,
THE PHYSICIAN'S CERTIFICATION REQUIRED BY SUBSECTION  (G-7)  OF  SECTION
FOUR  THOUSAND  NINE  HUNDRED OF THIS ARTICLE AND SUCH OTHER EVIDENCE AS
THE INSURED, THE INSURED'S DESIGNEE OR THE INSURED'S ATTENDING PHYSICIAN
MAY PRESENT (or upon confirmation that the recommended  treatment  is  a
clinical  trial),  the insured's medical record, and any other pertinent
information, that the proposed health service or treatment (including  a
pharmaceutical  product  within the meaning of subparagraph (B) of para-
graph two of subsection (e) of section four  thousand  nine  hundred  of
this article is likely to be more beneficial than any standard treatment
or  treatments for the insured's life-threatening or disabling condition
or disease OR, FOR RARE DISEASES, THAT THE REQUESTED HEALTH  SERVICE  OR
PROCEDURE  IS  LIKELY  TO  BENEFIT  THE  INSURED IN THE TREATMENT OF THE
INSURED'S RARE DISEASE AND THAT SUCH BENEFIT TO  THE  INSURED  OUTWEIGHS
THE  RISKS  OF  SUCH  HEALTH  SERVICE OR PROCEDURE (or, in the case of a
clinical trial, is likely to benefit the insured in the treatment of the
insured's condition or disease); or when a  reviewing  panel  is  evenly
divided  as to a determination concerning coverage of the health service
or procedure, or

S. 6016                            16

  S 29. Subsection (d) of section 4914 of the insurance law, as added by
chapter 586 of the laws of 1998, is amended to read as follows:
  (d)  [Payment]  (1)  EXCEPT AS PROVIDED IN PARAGRAPHS TWO AND THREE OF
THIS SUBSECTION, PAYMENT for an external appeal shall be  the  responsi-
bility  of the health care plan. The health care plan shall make payment
to the external appeal agent within forty-five days, from the  date  the
appeal determination is received by the health care plan, and the health
care  plan  shall be obligated to pay such amount together with interest
thereon calculated at a rate which is the greater of the rate set by the
commissioner of taxation and finance for  corporate  taxes  pursuant  to
paragraph  one  of  subsection (e) of section one thousand ninety-six of
the tax law or twelve percent per annum, to be computed  from  the  date
the  bill was required to be paid, in the event that payment is not made
within such forty-five days.
  (2) IF AN INSURED'S HEALTH CARE PROVIDER REQUESTS AN  EXTERNAL  APPEAL
OF  A  CONCURRENT  ADVERSE  DETERMINATION  AND THE EXTERNAL APPEAL AGENT
UPHOLDS THE HEALTH CARE PLAN'S DETERMINATION IN WHOLE, PAYMENT  FOR  THE
EXTERNAL  APPEAL SHALL BE MADE BY THE HEALTH CARE PROVIDER IN THE MANNER
AND SUBJECT TO THE TIMEFRAMES AND REQUIREMENTS SET  FORTH  IN  PARAGRAPH
ONE OF THIS SUBSECTION.
  (3)  IF  AN INSURED'S HEALTH CARE PROVIDER REQUESTS AN EXTERNAL APPEAL
OF A CONCURRENT ADVERSE DETERMINATION  AND  THE  EXTERNAL  APPEAL  AGENT
UPHOLDS  THE  HEALTH  CARE PLAN'S DETERMINATION IN PART, PAYMENT FOR THE
EXTERNAL APPEAL SHALL BE EVENLY DIVIDED BETWEEN THE HEALTH CARE PLAN AND
THE INSURED'S HEALTH CARE PROVIDER WHO REQUESTED THE EXTERNAL APPEAL AND
SHALL BE MADE BY THE HEALTH CARE PLAN  AND  THE  INSURED'S  HEALTH  CARE
PROVIDER  IN  THE  MANNER AND SUBJECT TO THE TIMEFRAMES AND REQUIREMENTS
SET FORTH IN PARAGRAPH ONE OF THIS SUBSECTION; PROVIDED,  HOWEVER,  THAT
THE  SUPERINTENDENT  MAY, UPON A DETERMINATION THAT HEALTH CARE PLANS OR
HEALTH CARE PROVIDERS ARE  EXPERIENCING  A  SUBSTANTIAL  HARDSHIP  AS  A
RESULT OF PAYMENT FOR THE EXTERNAL APPEAL WHEN THE EXTERNAL APPEAL AGENT
UPHOLDS  THE  HEALTH  CARE PLAN'S DETERMINATION IN PART, IN CONSULTATION
WITH THE COMMISSIONER OF HEALTH, PROMULGATE REGULATIONS  TO  LIMIT  SUCH
HARDSHIP.
  (4)  IF  AN INSURED'S HEALTH CARE PROVIDER WAS ACTING AS THE INSURED'S
DESIGNEE, PAYMENT FOR THE EXTERNAL APPEAL SHALL BE MADE  BY  THE  HEALTH
CARE  PLAN.   THE EXTERNAL APPEAL AND ANY DESIGNATION SHALL BE SUBMITTED
ON A STANDARD FORM DEVELOPED BY THE SUPERINTENDENT IN CONSULTATION  WITH
THE  COMMISSIONER  OF HEALTH PURSUANT TO SUBSECTION (E) OF THIS SECTION.
THE SUPERINTENDENT SHALL HAVE THE AUTHORITY UPON RECEIPT OF AN  EXTERNAL
APPEAL TO CONFIRM THE DESIGNATION OR REQUEST OTHER INFORMATION AS NECES-
SARY,  IN  WHICH CASE THE SUPERINTENDENT SHALL MAKE AT LEAST TWO WRITTEN
REQUESTS TO THE INSURED TO CONFIRM THE DESIGNATION.  THE  INSURED  SHALL
HAVE  TWO WEEKS TO RESPOND TO EACH SUCH REQUEST. IF THE INSURED FAILS TO
RESPOND TO THE SUPERINTENDENT WITHIN THE SPECIFIED TIMEFRAME, THE SUPER-
INTENDENT SHALL MAKE TWO WRITTEN REQUESTS TO THE HEALTH CARE PROVIDER TO
FILE AN EXTERNAL APPEAL ON HIS  OR  HER  OWN  BEHALF.  THE  HEALTH  CARE
PROVIDER  SHALL  HAVE  TWO WEEKS TO RESPOND TO EACH SUCH REQUEST. IF THE
HEALTH CARE PROVIDER DOES NOT RESPOND TO THE  SUPERINTENDENT'S  REQUESTS
WITHIN  THE  SPECIFIED  TIMEFRAME,  THE  SUPERINTENDENT SHALL REJECT THE
APPEAL.  IF THE HEALTH CARE PROVIDER RESPONDS  TO  THE  SUPERINTENDENT'S
REQUESTS,  PAYMENT  FOR  THE EXTERNAL APPEAL SHALL BE MADE IN ACCORDANCE
WITH PARAGRAPHS TWO AND THREE OF THIS SUBSECTION.
  S 30. The insurance law is amended by adding a  new  section  4917  to
read as follows:

S. 6016                            17

  S  4917. HOLD HARMLESS.  A HEALTH CARE PROVIDER REQUESTING AN EXTERNAL
APPEAL OF A CONCURRENT ADVERSE DETERMINATION, INCLUDING WHEN THE  HEALTH
CARE  PROVIDER  REQUESTS  AN  EXTERNAL APPEAL AS THE INSURED'S DESIGNEE,
SHALL NOT PURSUE REIMBURSEMENT FROM THE INSURED FOR SERVICES  DETERMINED
NOT  MEDICALLY NECESSARY BY THE EXTERNAL APPEAL AGENT, EXCEPT TO COLLECT
A COPAYMENT, COINSURANCE OR DEDUCTIBLE.
  S 31. Subdivisions 3 and 4 of section 4406 of the public  health  law,
subdivision  3  as  renumbered  by  chapter 538 of the laws of 1993, are
renumbered subdivisions 4 and 5 and a new subdivision 3 is added to read
as follows:
  3. (A) NO CONTRACT ISSUED PURSUANT TO THIS SECTION SHALL PROVIDE  THAT
SERVICES  OF  A PARTICIPATING HOSPITAL WILL BE COVERED AS OUT-OF-NETWORK
SERVICES SOLELY ON THE  BASIS THAT THE HEALTH CARE PROVIDER ADMITTING OR
RENDERING SERVICES TO THE ENROLLEE IS NOT A PARTICIPATING PROVIDER.
  (B) NO CONTRACT ISSUED PURSUANT TO THIS  SECTION  SHALL  PROVIDE  THAT
SERVICES  OF  A  PARTICIPATING  HEALTH  CARE PROVIDER WILL BE COVERED AS
OUT-OF-NETWORK SERVICES SOLELY  ON  THE  BASIS  THAT  THE  SERVICES  ARE
RENDERED IN A NON-PARTICIPATING HOSPITAL.
  (C)  FOR  PURPOSES  OF THIS SUBDIVISION, A "HEALTH CARE PROVIDER" IS A
HEALTH CARE PROFESSIONAL LICENSED, REGISTERED OR CERTIFIED  PURSUANT  TO
TITLE  EIGHT  OF THE EDUCATION LAW OR A HEALTH CARE PROFESSIONAL COMPAR-
ABLY LICENSED, REGISTERED OR CERTIFIED BY ANOTHER STATE.
  S 32. Subdivision 5-c of section 4406-c of the public  health  law  is
relettered subdivision 5-d and a new subdivision 5-c is added to read as
follows:
  5-C.  (A) NO HEALTH CARE PLAN SHALL IMPLEMENT AN ADVERSE REIMBURSEMENT
CHANGE TO A CONTRACT WITH A HEALTH CARE PROFESSIONAL THAT  IS  OTHERWISE
PERMITTED  BY  THE  CONTRACT, UNLESS, PRIOR TO THE EFFECTIVE DATE OF THE
CHANGE, THE HEALTH CARE PLAN GIVES THE  HEALTH  CARE  PROFESSIONAL  WITH
WHOM THE HEALTH CARE PLAN HAS DIRECTLY CONTRACTED AND WHO IS IMPACTED BY
THE ADVERSE REIMBURSEMENT CHANGE, AT LEAST NINETY DAYS WRITTEN NOTICE OF
THE  CHANGE.  IF THE CONTRACTING HEALTH CARE PROFESSIONAL OBJECTS TO THE
CHANGE THAT IS THE SUBJECT OF THE NOTICE BY THE HEALTH  CARE  PLAN,  THE
HEALTH  CARE  PROFESSIONAL  MAY,  WITHIN  THIRTY DAYS OF THE DATE OF THE
NOTICE, GIVE WRITTEN NOTICE TO THE HEALTH CARE PLAN TO TERMINATE HIS  OR
HER CONTRACT WITH THE HEALTH CARE PLAN EFFECTIVE UPON THE IMPLEMENTATION
DATE  OF  THE  ADVERSE  REIMBURSEMENT  CHANGE.  FOR THE PURPOSES OF THIS
SUBDIVISION, THE  TERM  "ADVERSE  REIMBURSEMENT  CHANGE"  SHALL  MEAN  A
PROPOSED  CHANGE  THAT  COULD  REASONABLY BE EXPECTED TO HAVE A MATERIAL
ADVERSE IMPACT ON THE AGGREGATE  LEVEL  OF  PAYMENT  TO  A  HEALTH  CARE
PROFESSIONAL,  AND  THE  TERM  "HEALTH  CARE  PROFESSIONAL" SHALL MEAN A
HEALTH CARE PROFESSIONAL LICENSED, REGISTERED OR CERTIFIED  PURSUANT  TO
TITLE EIGHT OF THE EDUCATION LAW. THE NOTICE PROVISIONS REQUIRED BY THIS
SUBDIVISION SHALL NOT APPLY WHERE: (I) SUCH CHANGE IS OTHERWISE REQUIRED
BY LAW, REGULATION OR APPLICABLE REGULATORY AUTHORITY, OR IS REQUIRED AS
A  RESULT  OF  CHANGES  IN  FEE  SCHEDULES, REIMBURSEMENT METHODOLOGY OR
PAYMENT POLICIES ESTABLISHED BY A GOVERNMENT AGENCY OR BY  THE  AMERICAN
MEDICAL   ASSOCIATION'S  CURRENT  PROCEDURAL  TERMINOLOGY  (CPT)  CODES,
REPORTING GUIDELINES AND CONVENTIONS; OR (II) SUCH CHANGE  IS  EXPRESSLY
PROVIDED  FOR  UNDER  THE  TERMS  OF THE CONTRACT BY THE INCLUSION OF OR
REFERENCE TO A SPECIFIC FEE OR FEE SCHEDULE,  REIMBURSEMENT  METHODOLOGY
OR PAYMENT POLICY INDEXING MECHANISM.
  (B) NOTHING IN THIS SUBDIVISION SHALL CREATE A PRIVATE RIGHT OF ACTION
ON  BEHALF  OF A HEALTH CARE PROFESSIONAL AGAINST A HEALTH CARE PLAN FOR
VIOLATIONS OF THIS SUBDIVISION.

S. 6016                            18

  S 33. Subdivision 1 of section 4406-d of the  public  health  law,  as
amended  by  chapter  551  of  the  laws  of 2006, is amended to read as
follows:
  1.  (A)  A  health  care  plan shall, upon request, make available and
disclose to health care professionals written application procedures and
minimum qualification requirements which a health care professional must
meet in order to be considered by the health care plan. The  plan  shall
consult with appropriately qualified health care professionals in devel-
oping  its qualification requirements. A health care plan shall complete
review of the health care professional's application to  participate  in
the  in-network  portion  of  the  health care plan's network and shall,
within ninety days of receiving a health care  professional's  completed
application to participate in the health care plan's network, notify the
health  care  professional as to [(a)]: (I) whether he or she is creden-
tialed; or [(b)] (II) whether additional time is  necessary  to  make  a
determination in spite of the health care plan's best efforts or because
of  a  failure  of  a third party to provide necessary documentation, or
non-routine or unusual circumstances require additional time for review.
In such instances where additional time is necessary because of  a  lack
of  necessary  documentation,  a  health plan shall make every effort to
obtain such information as soon as possible.
  (B) IF THE COMPLETED  APPLICATION  OF  A  NEWLY-LICENSED  HEALTH  CARE
PROFESSIONAL OR A HEALTH CARE PROFESSIONAL WHO HAS RECENTLY RELOCATED TO
THIS  STATE  FROM ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED IN THIS
STATE, WHO JOINS A GROUP PRACTICE OF HEALTH CARE PROFESSIONALS  EACH  OF
WHOM  PARTICIPATES  IN  THE  IN-NETWORK  PORTION OF A HEALTH CARE PLAN'S
NETWORK, IS NEITHER APPROVED NOR DECLINED WITHIN NINETY DAYS PURSUANT TO
PARAGRAPH (A) OF THIS SUBDIVISION, THE HEALTH CARE PROFESSIONAL SHALL BE
DEEMED "PROVISIONALLY CREDENTIALED" AND MAY PARTICIPATE IN  THE  IN-NET-
WORK  PORTION OF THE HEALTH CARE PLAN'S NETWORK; PROVIDED, HOWEVER, THAT
A PROVISIONALLY CREDENTIALED PHYSICIAN  MAY  NOT  BE  DESIGNATED  AS  AN
ENROLLEE'S  PRIMARY  CARE PHYSICIAN UNTIL SUCH TIME AS THE PHYSICIAN HAS
BEEN FULLY CREDENTIALED. THE NETWORK PARTICIPATION FOR  A  PROVISIONALLY
CREDENTIALED  HEALTH  CARE PROFESSIONAL SHALL BEGIN ON THE DAY FOLLOWING
THE NINETIETH DAY OF RECEIPT OF THE COMPLETED APPLICATION AND SHALL LAST
UNTIL THE FINAL CREDENTIALING DETERMINATION IS MADE BY THE  HEALTH  CARE
PLAN.  A HEALTH CARE PROFESSIONAL SHALL ONLY BE ELIGIBLE FOR PROVISIONAL
CREDENTIALING IF THE GROUP PRACTICE OF HEALTH CARE  PROFESSIONALS  NOTI-
FIES  THE HEALTH CARE PLAN IN WRITING THAT, SHOULD THE APPLICATION ULTI-
MATELY BE DENIED, THE HEALTH CARE PROFESSIONAL OR  THE  GROUP  PRACTICE:
(I)  SHALL  REFUND ANY PAYMENTS MADE BY THE HEALTH CARE PLAN FOR IN-NET-
WORK SERVICES PROVIDED BY THE  PROVISIONALLY  CREDENTIALED  HEALTH  CARE
PROFESSIONAL  THAT  EXCEED ANY OUT-OF-NETWORK BENEFITS PAYABLE UNDER THE
ENROLLEE'S CONTRACT WITH THE HEALTH CARE PLAN; AND (II) SHALL NOT PURSUE
REIMBURSEMENT FROM THE ENROLLEE, EXCEPT TO COLLECT  THE  COPAYMENT  THAT
OTHERWISE  WOULD  HAVE  BEEN  PAYABLE HAD THE ENROLLEE RECEIVED SERVICES
FROM A HEALTH CARE PROFESSIONAL PARTICIPATING IN THE IN-NETWORK  PORTION
OF  A  HEALTH  CARE  PLAN'S  NETWORK. INTEREST AND PENALTIES PURSUANT TO
SECTION THREE THOUSAND TWO HUNDRED TWENTY-FOUR-A OF  THE  INSURANCE  LAW
SHALL  NOT  BE  ASSESSED BASED ON THE DENIAL OF A CLAIM SUBMITTED DURING
THE PERIOD WHEN THE HEALTH CARE PROFESSIONAL WAS  PROVISIONALLY  CREDEN-
TIALED;  PROVIDED,  HOWEVER,  THAT NOTHING HEREIN SHALL PREVENT A HEALTH
CARE PLAN FROM PAYING A CLAIM FROM A HEALTH  CARE  PROFESSIONAL  WHO  IS
PROVISIONALLY  CREDENTIALED UPON SUBMISSION OF SUCH CLAIM. A HEALTH CARE
PLAN SHALL NOT DENY, AFTER APPEAL, A CLAIM FOR SERVICES  PROVIDED  BY  A

S. 6016                            19

PROVISIONALLY CREDENTIALED HEALTH CARE PROFESSIONAL SOLELY ON THE GROUND
THAT THE CLAIM WAS NOT TIMELY FILED.
  S 34. Section 4900 of the public health law is amended by adding a new
subdivision 7-g to read as follows:
  7-G. "RARE DISEASE" MEANS A LIFE THREATENING OR DISABLING CONDITION OR
DISEASE THAT (1)(A) IS CURRENTLY OR HAS BEEN SUBJECT TO A RESEARCH STUDY
BY  THE  NATIONAL  INSTITUTES  OF HEALTH RARE DISEASES CLINICAL RESEARCH
NETWORK OR (B) AFFECTS FEWER THAN TWO  HUNDRED  THOUSAND  UNITED  STATES
RESIDENTS  PER  YEAR,  AND (2) FOR WHICH THERE DOES NOT EXIST A STANDARD
HEALTH SERVICE OR PROCEDURE COVERED BY THE HEALTH CARE PLAN THAT IS MORE
CLINICALLY BENEFICIAL THAN THE REQUESTED HEALTH SERVICE OR TREATMENT.  A
PHYSICIAN,  OTHER  THAN THE ENROLLEE'S TREATING PHYSICIAN, SHALL CERTIFY
IN WRITING THAT THE CONDITION IS A  RARE  DISEASE  AS  DEFINED  IN  THIS
SUBSECTION.  THE  CERTIFYING PHYSICIAN SHALL BE A LICENSED, BOARD-CERTI-
FIED OR BOARD-ELIGIBLE PHYSICIAN WHO SPECIALIZES IN THE AREA OF PRACTICE
APPROPRIATE TO TREAT THE  ENROLLEE'S  RARE  DISEASE.  THE  CERTIFICATION
SHALL  PROVIDE  EITHER: (1) THAT THE INSURED'S RARE DISEASE IS CURRENTLY
OR HAS BEEN SUBJECT TO A RESEARCH STUDY BY THE  NATIONAL  INSTITUTES  OF
HEALTH  RARE  DISEASES  CLINICAL  RESEARCH    NETWORK;  OR  (2) THAT THE
INSURED'S RARE DISEASE AFFECTS FEWER THAN TWO  HUNDRED  THOUSAND  UNITED
STATES  RESIDENTS  PER YEAR. THE CERTIFICATION SHALL RELY ON MEDICAL AND
SCIENTIFIC EVIDENCE TO SUPPORT THE REQUESTED HEALTH  SERVICE  OR  PROCE-
DURE, IF SUCH EVIDENCE EXISTS, AND SHALL INCLUDE A STATEMENT THAT, BASED
ON  THE  PHYSICIAN'S CREDIBLE EXPERIENCE, THERE IS NO STANDARD TREATMENT
THAT IS LIKELY TO BE MORE CLINICALLY BENEFICIAL TO THE ENROLLEE THAN THE
REQUESTED HEALTH SERVICE OR PROCEDURE AND THE REQUESTED  HEALTH  SERVICE
OR  PROCEDURE  IS LIKELY TO BENEFIT THE ENROLLEE IN THE TREATMENT OF THE
ENROLLEE'S RARE DISEASE AND THAT SUCH BENEFIT TO THE ENROLLEE  OUTWEIGHS
THE RISKS OF SUCH HEALTH SERVICE OR PROCEDURE. THE CERTIFYING  PHYSICIAN
SHALL  DISCLOSE ANY MATERIAL FINANCIAL OR PROFESSIONAL RELATIONSHIP WITH
THE PROVIDER OF THE REQUESTED HEALTH SERVICE OR PROCEDURE AS PART OF THE
APPLICATION FOR EXTERNAL APPEAL OF DENIAL OF A RARE  DISEASE  TREATMENT.
IF  THE  PROVISION  OF  THE  REQUESTED  HEALTH SERVICE OR PROCEDURE AT A
HEALTH CARE FACILITY REQUIRES PRIOR APPROVAL OF AN INSTITUTIONAL  REVIEW
BOARD,  AN  ENROLLEE  OR  ENROLLEE'S  DESIGNEE  SHALL  ALSO  SUBMIT SUCH
APPROVAL AS PART OF THE EXTERNAL APPEAL APPLICATION.
  S 35. Subdivision 3 of section 4903 of the public health law, as added
by chapter 705 of the laws of 1996, is amended to read as follows:
  3. A utilization review agent shall  make  a  determination  involving
continued or extended health care services, [or] additional services for
an  enrollee  undergoing a course of continued treatment prescribed by a
health care provider, OR HOME HEALTH CARE SERVICES  FOLLOWING  AN  INPA-
TIENT HOSPITAL ADMISSION, and SHALL provide notice of such determination
to  the  enrollee  or the enrollee's designee, which may be satisfied by
notice to the enrollee's health care provider, by telephone and in writ-
ing within one business day of  receipt  of  the  necessary  information
EXCEPT, WITH RESPECT TO HOME HEALTH CARE SERVICES FOLLOWING AN INPATIENT
HOSPITAL ADMISSION, WITHIN SEVENTY-TWO HOURS OF RECEIPT OF THE NECESSARY
INFORMATION  WHEN  THE DAY SUBSEQUENT TO THE REQUEST FALLS ON  A WEEKEND
OR HOLIDAY.   Notification  of  continued  or  extended  services  shall
include  the  number  of  extended  services  approved, the new total of
approved services, the date of onset of services  and  the  next  review
date.    PROVIDED  THAT  A REQUEST FOR HOME HEALTH CARE SERVICES AND ALL
NECESSARY INFORMATION IS SUBMITTED TO THE UTILIZATION REVIEW AGENT PRIOR
TO DISCHARGE FROM AN  INPATIENT  HOSPITAL  ADMISSION  PURSUANT  TO  THIS
SUBDIVISION, A  UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF

S. 6016                            20

MEDICAL  NECESSITY  OR  LACK  OF  PRIOR AUTHORIZATION, COVERAGE FOR HOME
HEALTH CARE SERVICES WHILE A DETERMINATION   BY THE  UTILIZATION  REVIEW
AGENT IS PENDING.
  S 36. Subdivision 2 of section 4904 of the public health law, as added
by  chapter 705 of the laws of 1996, paragraph (b) as amended by chapter
586 of the laws of 1998, is amended to read as follows:
  2. A utilization review agent  shall  establish  an  expedited  appeal
process for appeal of an adverse determination involving:
  (a)  continued  or extended health care services, procedures or treat-
ments or additional services for an  enrollee  undergoing  a  course  of
continued  treatment  prescribed  by  a health care provider HOME HEALTH
CARE SERVICES FOLLOWING DISCHARGE FROM AN INPATIENT  HOSPITAL  ADMISSION
PURSUANT  TO  SUBDIVISION  THREE  OF SECTION FORTY-NINE HUNDRED THREE OF
THIS ARTICLE; or
  (b) an  adverse  determination  in  which  the  health  care  provider
believes  an  immediate  appeal  is  warranted  except any retrospective
determination.  Such process shall include mechanisms  which  facilitate
resolution  of  the  appeal  including but not limited to the sharing of
information from the enrollee's health care provider and the utilization
review agent by telephonic means or by facsimile. The utilization review
agent shall provide reasonable access  to  its  clinical  peer  reviewer
within  one  business  day of receiving notice of the taking of an expe-
dited appeal.  Expedited appeals shall be determined within two business
days of receipt of necessary information to conduct such  appeal.  Expe-
dited  appeals  which  do not result in a resolution satisfactory to the
appealing party may be further  appealed  through  the  standard  appeal
process,  or  through  the  external  appeal process pursuant to section
forty-nine hundred fourteen of this article as applicable.
  S 37. Section 4906 of the public health law, as amended by chapter 586
of the laws of 1998, is amended to read as follows:
  S 4906. Waiver. 1. Any  agreement  which  purports  to  waive,  limit,
disclaim,  or  in any way diminish the rights set forth in this article,
except as provided pursuant to section four thousand nine hundred ten of
this article shall be void as contrary to public policy.
  2. NOTWITHSTANDING SUBDIVISION ONE OF THIS SECTION,  IN  LIEU  OF  THE
EXTERNAL APPEAL PROCESS AS SET FORTH IN THIS ARTICLE, A HEALTH CARE PLAN
AND A FACILITY LICENSED PURSUANT TO ARTICLE TWENTY-EIGHT OF THIS CHAPTER
MAY  AGREE  TO  AN  ALTERNATIVE  DISPUTE RESOLUTION MECHANISM TO RESOLVE
DISPUTES OTHERWISE SUBJECT TO THIS ARTICLE.
  S 38. The opening paragraph of subdivision 2 of section  4910  of  the
public  health  law,  as  added  by  chapter 586 of the laws of 1998, is
amended to read as follows:
  An enrollee, the enrollee's designee and, in connection  with  CONCUR-
RENT AND retrospective adverse determinations, an enrollee's health care
provider, shall have the right to request an external appeal when:
  S  39.  Subparagraphs (ii) and (iii) of paragraph (b) of subdivision 2
of section 4910 of the public health law, as added by chapter 586 of the
laws of 1998, are amended to read as follows:
  (ii) the enrollee's attending physician has certified that the  enrol-
lee  has  a  life-threatening  or disabling condition or disease (a) for
which standard health services or procedures have  been  ineffective  or
would  be medically inappropriate, or (b) for which there does not exist
a more beneficial standard health service or procedure  covered  by  the
health care plan, or (c) for which there exists a clinical trial OR RARE
DISEASE TREATMENT, and

S. 6016                            21

  (iii)  the  enrollee's  attending  physician,  who must be a licensed,
board-certified or board-eligible physician qualified to practice in the
area of practice appropriate to treat the enrollee's life threatening or
disabling condition or disease,  must  have  recommended  either  (a)  a
health  service  or procedure (including a pharmaceutical product within
the meaning of subparagraph (B) of paragraph [b] (B) of subdivision five
of section forty-nine hundred of this article) that, based on two  docu-
ments  from  the available medical and scientific evidence, is likely to
be more beneficial to the enrollee  than  any  covered  standard  health
service  or  procedure  OR,  IN THE CASE OF A RARE DISEASE, BASED ON THE
PHYSICIAN'S CERTIFICATION REQUIRED BY  SUBDIVISION  SEVEN-G  OF  SECTION
FORTY-NINE HUNDRED OF THIS ARTICLE AND SUCH OTHER EVIDENCE AS THE ENROL-
LEE,  THE  ENROLLEE'S DESIGNEE OR THE ENROLLEE'S ATTENDING PHYSICIAN MAY
PRESENT, THAT THE REQUESTED HEALTH SERVICE OR  PROCEDURE  IS  LIKELY  TO
BENEFIT THE ENROLLEE IN THE TREATMENT OF THE ENROLLEE'S RARE DISEASE AND
THAT  SUCH  BENEFIT  TO  THE ENROLLEE OUTWEIGHS THE RISKS OF SUCH HEALTH
SERVICE OR PROCEDURE; or (b) a clinical trial for which the enrollee  is
eligible.  Any physician certification provided under this section shall
include  a  statement  of  the  evidence relied upon by the physician in
certifying his or her recommendation, and
  S 40. Paragraphs (b) and (c) of subdivision 2 of section 4914  of  the
public  health  law,  as  added  by chapter 586 of the laws of 1998, are
amended to read as follows:
  (b) The external appeal agent shall make a determination with  respect
to  the  appeal  within  thirty  days of the receipt of the [enrollee's]
request  therefor,  submitted  in  accordance  with  the  commissioner's
instructions.    The external appeal agent shall have the opportunity to
request additional information from the enrollee, the enrollee's  health
care provider and the enrollee's health care plan within such thirty-day
period,  in  which case the agent shall have up to five additional busi-
ness days if necessary to make such determination. The  external  appeal
agent  shall  notify  the  enrollee, THE ENROLLEE'S HEALTH CARE PROVIDER
WHERE APPROPRIATE, and the health care plan, in writing, of  the  appeal
determination within two business days of the rendering of such determi-
nation.
  (c)  Notwithstanding  the provisions of paragraphs (a) and (b) of this
subdivision, if the enrollee's attending physician states that  a  delay
in  providing  the health care service would pose an imminent or serious
threat to the health of the  enrollee,  the  external  appeal  shall  be
completed  within  three  days  of the request therefor and the external
appeal agent shall make every reasonable attempt to  immediately  notify
the enrollee, THE ENROLLEE'S HEALTH CARE PROVIDER WHERE APPROPRIATE, and
the health plan of its determination by telephone or facsimile, followed
immediately by written notification of such determination.
  S  41.  Item  1 of clause (ii) of subparagraph (B) of paragraph (d) of
subdivision 2 of section 4914 of the public  health  law,  as  added  by
chapter 586 of the laws of 1998, is amended to read as follows:
  (1) that the patient costs of the proposed health service or procedure
shall  be covered by the health care plan either: when a majority of the
panel of reviewers determines,  BASED  upon  review  of  the  applicable
medical  and  scientific evidence AND, IN CONNECTION WITH RARE DISEASES,
THE PHYSICIAN'S CERTIFICATION REQUIRED BY SUBDIVISION SEVEN-G OF SECTION
FORTY-NINE HUNDRED OF THIS ARTICLE AND SUCH OTHER EVIDENCE AS THE ENROL-
LEE, THE ENROLLEE'S DESIGNEE OR THE ENROLLEE'S ATTENDING  PHYSICIAN  MAY
PRESENT  (or upon confirmation that the recommended treatment is a clin-
ical trial), the enrollee's medical  record,  and  any  other  pertinent

S. 6016                            22

information,  that the proposed health service or treatment (including a
pharmaceutical product within the meaning of subparagraph (B)  of  para-
graph  (b)  of  subdivision  five  of section forty-nine hundred of this
article)  is likely to be more beneficial than any standard treatment or
treatments for the enrollee's life-threatening or disabling condition or
disease OR, FOR RARE DISEASES, THAT  THE  REQUESTED  HEALTH  SERVICE  OR
PROCEDURE  IS  LIKELY  TO  BENEFIT  THE ENROLLEE IN THE TREATMENT OF THE
ENROLLEE'S RARE DISEASE AND THAT SUCH BENEFIT TO THE ENROLLEE  OUTWEIGHS
THE  RISKS  OF  SUCH  HEALTH  SERVICE OR PROCEDURE (or, in the case of a
clinical trial, is likely to benefit the enrollee in  the  treatment  of
the enrollee's condition or disease); or when a reviewing panel is even-
ly  divided  as  to  a  determination  concerning coverage of the health
service or procedure, or
  S 42. Subdivision 4 of section 4914 of the public health law, as added
by chapter 586 of the laws of 1998, is amended to read as follows:
  4. [Payment] (A) EXCEPT AS PROVIDED IN PARAGRAPHS (B) AND (C) OF  THIS
SUBDIVISION,  PAYMENT for an external appeal shall be the responsibility
of the health care plan. The health care plan shall make payment to  the
external  appeal  agent  within forty-five days from the date the appeal
determination is received by the health care plan, and the  health  care
plan shall be obligated to pay such amount together with interest there-
on  calculated  at  a  rate  which is the greater of the rate set by the
commissioner of taxation and finance for  corporate  taxes  pursuant  to
paragraph  one  of  subsection (e) of section one thousand ninety-six of
the tax law or twelve percent per annum, to be computed  from  the  date
the  bill was required to be paid, in the event that payment is not made
within such forty-five days.
  (B) IF AN ENROLLEE'S HEALTH CARE PROVIDER REQUESTS AN EXTERNAL  APPEAL
OF  A  CONCURRENT  ADVERSE  DETERMINATION  AND THE EXTERNAL APPEAL AGENT
UPHOLDS THE HEALTH CARE PLAN'S DETERMINATION IN WHOLE, PAYMENT  FOR  THE
EXTERNAL  APPEAL SHALL BE MADE BY THE HEALTH CARE PROVIDER IN THE MANNER
AND SUBJECT TO THE TIMEFRAMES AND REQUIREMENTS SET  FORTH  IN  PARAGRAPH
(A) OF THIS SUBDIVISION.
  (C)  IF AN ENROLLEE'S HEALTH CARE PROVIDER REQUESTS AN EXTERNAL APPEAL
OF A CONCURRENT ADVERSE DETERMINATION  AND  THE  EXTERNAL  APPEAL  AGENT
UPHOLDS  THE  HEALTH  CARE PLAN'S DETERMINATION IN PART, PAYMENT FOR THE
EXTERNAL APPEAL SHALL BE EVENLY DIVIDED BETWEEN THE HEALTH CARE PLAN AND
THE ENROLLEE'S HEALTH CARE PROVIDER WHO REQUESTED  THE  EXTERNAL  APPEAL
AND SHALL BE MADE BY THE HEALTH CARE PLAN AND THE ENROLLEE'S HEALTH CARE
PROVIDER  IN  THE  MANNER AND SUBJECT TO THE TIMEFRAMES AND REQUIREMENTS
SET FORTH IN PARAGRAPH (A) OF THIS SUBDIVISION; PROVIDED, HOWEVER,  THAT
THE  COMMISSIONER  MAY,  UPON  A  DETERMINATION BY THE SUPERINTENDENT OF
INSURANCE THAT HEALTH CARE PLANS OR HEALTH CARE PROVIDERS ARE EXPERIENC-
ING A SUBSTANTIAL HARDSHIP AS A  RESULT  OF  PAYMENT  FOR  THE  EXTERNAL
APPEAL  WHEN  THE  EXTERNAL  APPEAL AGENT UPHOLDS THE HEALTH CARE PLAN'S
DETERMINATION IN PART, IN CONSULTATION WITH THE SUPERINTENDENT,  PROMUL-
GATE REGULATIONS TO LIMIT SUCH HARDSHIP.
  (D) IF AN ENROLLEE'S HEALTH CARE PROVIDER WAS ACTING AS THE ENROLLEE'S
DESIGNEE,  PAYMENT  FOR  THE EXTERNAL APPEAL SHALL BE MADE BY THE HEALTH
CARE PLAN.  THE EXTERNAL APPEAL AND ANY DESIGNATION SHALL  BE  SUBMITTED
ON  A  STANDARD  FORM DEVELOPED BY THE COMMISSIONER IN CONSULTATION WITH
THE SUPERINTENDENT OF INSURANCE PURSUANT TO  SUBDIVISION  FIVE  OF  THIS
SECTION.   THE SUPERINTENDENT OF INSURANCE SHALL HAVE THE AUTHORITY UPON
RECEIPT OF AN EXTERNAL APPEAL TO  CONFIRM  THE  DESIGNATION  OR  REQUEST
OTHER  INFORMATION  AS  NECESSARY,  IN  WHICH CASE THE SUPERINTENDENT OF
INSURANCE SHALL MAKE AT LEAST TWO WRITTEN REQUESTS TO  THE  ENROLLEE  TO

S. 6016                            23

CONFIRM THE DESIGNATION. THE ENROLLEE SHALL HAVE TWO WEEKS TO RESPOND TO
EACH  SUCH  REQUEST. IF THE ENROLLEE FAILS TO RESPOND TO THE SUPERINTEN-
DENT OF INSURANCE WITHIN THE SPECIFIED TIMEFRAME, THE SUPERINTENDENT  OF
INSURANCE SHALL MAKE TWO WRITTEN REQUESTS TO THE HEALTH CARE PROVIDER TO
FILE  AN  EXTERNAL  APPEAL  ON  HIS  OR  HER OWN BEHALF. THE HEALTH CARE
PROVIDER SHALL HAVE TWO WEEKS TO RESPOND TO EACH SUCH  REQUEST.  IF  THE
HEALTH CARE PROVIDER DOES NOT RESPOND TO THE SUPERINTENDENT OF INSURANCE
REQUESTS WITHIN THE SPECIFIED TIMEFRAME, THE SUPERINTENDENT OF INSURANCE
SHALL  REJECT  THE APPEAL.   IF THE HEALTH CARE PROVIDER RESPONDS TO THE
SUPERINTENDENT'S REQUESTS, PAYMENT FOR THE EXTERNAL APPEAL SHALL BE MADE
IN ACCORDANCE WITH PARAGRAPHS (B) AND (C) OF THIS  SUBDIVISION.
  S 43. The public health law is amended by adding a new section 4917 to
read as follows:
  S 4917. HOLD HARMLESS. A HEALTH CARE PROVIDER REQUESTING  AN  EXTERNAL
APPEAL  OF A CONCURRENT ADVERSE DETERMINATION, INCLUDING WHEN THE HEALTH
CARE PROVIDER REQUESTS AN EXTERNAL APPEAL AS  THE  ENROLLEE'S  DESIGNEE,
SHALL NOT PURSUE REIMBURSEMENT FROM THE ENROLLEE FOR SERVICES DETERMINED
NOT  MEDICALLY NECESSARY BY THE EXTERNAL APPEAL AGENT, EXCEPT TO COLLECT
A COPAYMENT.
  S 44. Subdivision 2 of section 20 of chapter 451 of the laws of  2007,
amending  the  public health law, the social services law and the insur-
ance  law  relating  to  providing  enhanced   consumer   and   provider
protections, is amended to read as follows:
  2.  sections  two,  three  and twelve of this act shall take effect on
January 1, 2008; provided, however, that subparagraph (iii) of paragraph
(1) of subsection (a) of section 3238 of the insurance law as  added  in
section  twelve of this act shall expire and be deemed repealed December
31, [2009] 2011;
  S 45. Intentionally omitted.
  S 46. Intentionally omitted.
  S 47. Intentionally omitted.
  S 48. This act shall take effect January 1, 2010;  provided,  however,
that:
  1.  sections  twenty  and  thirty-three  of this act shall take effect
October 1, 2009, and shall apply to applications  submitted  after  that
date,  and  shall not apply to applications submitted prior to such date
if such application is resubmitted in substantially similar form  on  or
after October 1, 2009;
  2. provided, further, that the amendments to subsection (i) of section
3217-b  of the insurance law made by section three of this act shall not
affect the repeal of such subsection and shall be deemed repealed there-
with;
  3. provided, further, that the amendments to subsection (i) of section
4325 of the insurance law made by section nineteen of this act shall not
affect the repeal of such subsection and shall be deemed repealed there-
with;
  4. provided, further,  that  the  amendments  to  subdivision  5-d  of
section  4406-c  of  the public health law made by section thirty-two of
this act shall not affect the repeal of such subdivision  and  shall  be
deemed repealed therewith;
  5.  provided  further  that  sections eight and forty-four of this act
shall take effect immediately;
  6. provided further that section nine of this act shall apply to dates
of service on or after April 1, 2010; and
  7. provided further that sections two, four,  five,  fifteen,  sixteen
and seventeen of this act shall take effect January 1, 2011.

Comments

Open Legislation is a forum for New York State legislation. All comments are subject to review and community moderation is encouraged.

Comments deemed off-topic, commercial, campaign-related, self-promotional; or that contain profanity, hate or toxic speech; or that link to sites outside of the nysenate.gov domain are not permitted, and will not be published. Attempts to intimidate and silence contributors or deliberately deceive the public, including excessive or extraneous posting/posts, or coordinated activity, are prohibited and may result in the temporary or permanent banning of the user. Comment moderation is generally performed Monday through Friday. By contributing or voting you agree to the Terms of Participation and verify you are over 13.

Create an account. An account allows you to sign petitions with a single click, officially support or oppose key legislation, and follow issues, committees, and bills that matter to you. When you create an account, you agree to this platform's terms of participation.

Senate Bill S6016

Sponsored By

Archive: Last Bill Status - In Senate Committee Insurance Committee

2009-S6016 (ACTIVE) - Details

2009-S6016 (ACTIVE) - Summary

2009-S6016 (ACTIVE) - Sponsor Memo

2009-S6016 (ACTIVE) - Bill Text download pdf

Comments

Senate Bill S6016

Share this bill

Sponsored By

Neil D. Breslin

Archive: Last Bill Status - In Senate Committee Insurance Committee

2009-S6016 (ACTIVE) - Details

2009-S6016 (ACTIVE) - Summary

2009-S6016 (ACTIVE) - Sponsor Memo

2009-S6016 (ACTIVE) - Bill Text download pdf

Comments