S T A T E O F N E W Y O R K
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5245
2011-2012 Regular Sessions
I N A S S E M B L Y
February 14, 2011
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Introduced by M. of A. P. RIVERA -- read once and referred to the
Committee on Insurance
AN ACT to amend the social services law, the insurance law, and the
public health law, in relation to filing requirements for medical
assistance program claims and HMO claims, payment of claims for
medical care or services, electronic remittance advices, HMO creden-
tialing for health care professionals, and establishing HMO reporting
requirements
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Subdivision 2 of section 363-a of the social services law,
as amended by chapter 474 of the laws of 1996, is amended to read as
follows:
2. The department of health shall make such regulations, not incon-
sistent with law, as may be necessary to implement this title, PROVIDED
THAT NO SUCH REGULATIONS SHALL PROVIDE THAT AN OTHERWISE VALID CLAIM FOR
MEDICAL CARE, SERVICES OR SUPPLIES PURSUANT TO THE PROVISIONS OF THIS
TITLE, SHALL BE DEEMED INVALID AND THUS INELIGIBLE FOR PAYMENT BASED
SOLELY UPON THE FAILURE OF SUCH CLAIM TO BE SUBMITTED WITHIN NINETY DAYS
OF THE DATE OF SERVICE.
S 2. Section 3216 of the insurance law is amended by adding a new
subsection (m) to read as follows:
(M) NO INSURER SHALL DENY COMPENSATION TO A PARTICIPATING PROVIDER
THAT IS NOT LISTED AS A PATIENT'S PRIMARY CARE PHYSICIAN, BUT HAS
RENDERED MEDICAL CARE, SERVICES OR SUPPLIES TO AN INSURED.
S 3. Section 3221 of the insurance law is amended by adding a new
subsection (s) to read as follows:
(S) NO INSURER SHALL DENY COMPENSATION TO A PARTICIPATING PROVIDER
THAT IS NOT LISTED AS A PATIENT'S PRIMARY CARE PHYSICIAN, BUT HAS
RENDERED MEDICAL CARE, SERVICES OR SUPPLIES TO AN INSURED.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD08316-02-1
A. 5245 2
S 4. Section 4303 of the insurance law is amended by adding a new
subsection (hh) to read as follows:
(HH) NO HOSPITAL SERVICE CORPORATION, HEALTH SERVICE CORPORATION,
MEDICAL EXPENSE INDEMNITY CORPORATION, OR OTHER INSURER WHICH PROVIDES
COVERAGE FOR HOSPITAL, SURGICAL OR MEDICAL CARE SHALL DENY COMPENSATION
TO A PARTICIPATING PROVIDER THAT IS NOT LISTED AS A PATIENT'S PRIMARY
CARE PHYSICIAN, BUT HAS RENDERED MEDICAL CARE, SERVICES OR SUPPLIES TO
AN INSURED.
S 5. Subdivision 1 of section 2807-p of the public health law is
amended by adding a new paragraph (e) to read as follows:
(E) NOTWITHSTANDING ANY OTHER PROVISION OF THIS ARTICLE, IF A FACILITY
HAS MADE A GOOD FAITH EFFORT TO COMPLY WITH THE REPORTING REQUIREMENTS
SET FORTH IN THIS SECTION, AND FAILS TO SUBMIT SUCH REPORTS OR DATA BY
THE ESTABLISHED DEADLINE, SUCH FACILITY SHALL NOT BE SUBJECT TO FINAN-
CIAL PENALTY, INCLUDING A DELAY OR DISQUALIFICATION OF FINANCIAL
DISTRIBUTIONS, BASED SOLELY UPON SUCH FAILURE TO SUBMIT SUCH REPORTS OR
DATA.
S 6. The public health law is amended by adding a new section 4408-b
to read as follows:
S 4408-B. ELECTRONIC REMITTANCE ADVICES. NOTWITHSTANDING ANY OTHER
PROVISION OF THIS ARTICLE, UPON RECEIVING AN ELECTRONIC CLAIM FOR COVER-
AGE OF A PROCEDURE, TREATMENT, SUPPLY OR SERVICE, OR ANY INFORMATION
PERTAINING TO SUCH CLAIM VIA ELECTRONIC METHOD, A HEALTH MAINTENANCE
ORGANIZATION LICENSED PURSUANT TO ARTICLE FORTY-THREE OF THE INSURANCE
LAW OR CERTIFIED PURSUANT TO THIS ARTICLE, SHALL PROVIDE ELECTRONIC
REMITTANCE ADVICES TO THE ENROLLEE, THE HEALTH CARE PROVIDER AND TO ANY
NECESSARY PARTIES INVOLVED WITH SUCH CLAIM. FOR THE PURPOSES OF THIS
SECTION, "ELECTRONIC REMITTANCE ADVICE" SHALL MEAN AN ELECTRONIC VERSION
OF SUCH INFORMATION, AS DESCRIBED IN SECTION FOUR THOUSAND FOUR HUNDRED
EIGHT OF THIS ARTICLE, AND AN EXPLANATION OF ALL DETAILS CONCERNING A
HEALTH MAINTENANCE ORGANIZATION'S PAYMENT OR DENIAL OF A CLAIM.
S 7. Subdivision 1 of section 4406-d of the public health law is
amended by adding a new paragraph (c) to read as follows:
(C) IF THE COMPLETED APPLICATION OF A HEALTH CARE PROFESSIONAL WHO IS:
(I) IN COMPLIANCE WITH THE PROVISIONS OF ARTICLE ONE HUNDRED THIRTY-ONE
OF THE EDUCATION LAW, AND (II) IN COMPLIANCE AND IN GOOD STANDING WITH
ELIGIBILITY REQUIREMENTS SET FORTH BY THE MEDICAL ASSISTANCE PROGRAM
CONCERNING A HEALTH CARE PROFESSIONAL'S PARTICIPATION AS A MEDICAL
ASSISTANCE PROVIDER, THE HEALTH CARE PROFESSIONAL SHALL BE ALLOWED TO
PROVIDE MEDICAL CARE OR SERVICE AND SUBMIT CLAIMS REGARDING SUCH MEDICAL
CARE OR SERVICE PROVIDED TO ENROLLEES PARTICIPATING IN THE MEDICAL
ASSISTANCE PROGRAM.
S 8. Section 2511 of the public health law is amended by adding a new
subdivision 21 to read as follows:
21. NOTWITHSTANDING ANY OTHER LAW OR AGREEMENT TO THE CONTRARY, IF A
HEALTH CARE PROVIDER OR HEALTH CARE CENTER PROVIDES MEDICAL CARE,
SERVICES OR SUPPLIES TO AN ENROLLEE OF A HEALTH MAINTENANCE ORGANIZA-
TION, SUCH PROVIDER SHALL BE ENTITLED TO SUBMIT A CLAIM TO THE HEALTH
MAINTENANCE ORGANIZATION FOR PAYMENT FOR SUCH MEDICAL CARE OR SERVICES
AND FOR PAYMENT OF ANY "BUDGET BALANCE ACT" (BBA) OR CHILD HEALTH PLUS
(CHIP) SUBSIDY PAYMENT AMOUNTS ENTITLED TO SUCH PROVIDER. IF SUCH CLAIM
IS SUBSEQUENTLY DENIED BY THE APPROPRIATE ORGANIZATION, THE PROVIDER
SHALL BE ENTITLED TO PAYMENT FOR SUCH MEDICAL CARE OR SERVICES, PROVIDED
THAT THE PATIENT WAS AN ACTIVE PARTICIPANT OF A HEALTH INSURANCE PROGRAM
FUNDED BY THE DEPARTMENT AND THE MEDICAL CARE OR SERVICES FURNISHED BY
SUCH PROVIDER WERE VALID.
A. 5245 3
S 9. Section 4408 of the public health law is amended by adding two
new subdivisions 7 and 8 to read as follows:
7. EVERY THIRTY DAYS, A HEALTH MAINTENANCE ORGANIZATION SHALL PROVIDE
TO ALL HEALTH CARE PROVIDERS OR HEALTH CARE CENTERS TO WHOM THEIR ENROL-
LEES SEEK MEDICAL CARE OR SERVICE, A REPORT CONTAINING AN EXPLANATION OF
CHARGES, PAYMENTS AND THE TOTAL NUMBER OF PATIENTS SERVICED UNDER THE
FAMILY HEALTH PLUS PLAN, CHILD HEALTH PLUS PLAN, MEDICARE PROGRAM AND
MEDICAID PROGRAM.
8. ALL HEALTH MAINTENANCE ORGANIZATIONS SHALL PROVIDE TO HEALTH CARE
PROVIDERS AND HEALTH CARE CENTERS, AN ELECTRONIC PATIENT ROSTER CONTAIN-
ING A LIST OF CURRENT ENROLLEES ELIGIBLE TO SEEK MEDICAL TREATMENT OR
SERVICES WITH SUCH HEALTH CARE PROVIDER OR AT SUCH HEALTH CARE CENTER.
S 10. This act shall take effect immediately.