Assembly Bill A7813

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

                                  7813

                       2013-2014 Regular Sessions

                          I N  A S S E M B L Y

                              June 5, 2013
                               ___________

Introduced  by  M.  of  A.  GOTTFRIED  --  read once and referred to the
  Committee on Insurance

AN ACT to amend the public health law, in relation to prohibiting exces-
  sive charges for emergency services; to amend the public  health  law,
  in  relation  to  certain  provider  disclosures;  to amend the public
  health law and  the  insurance  law,  in  relation  to  out-of-network
  services;  and providing for the repeal of certain provisions upon the
  expiration thereof

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

  Section  1.  The  public health law is amended by adding a new article
30-D to read as follows:
                              ARTICLE 30-D
                  EMERGENCY SERVICES, PROVIDER CHARGES
SECTION 3080. DEFINITIONS.
        3081. PROHIBITION OF EXCESSIVE CHARGES FOR EMERGENCY SERVICES.
        3082. DISPUTE RESOLUTION.
        3083. CRITERIA FOR DETERMINING EXCESSIVE CHARGES.
        3084. DESIGNATION OF INDEPENDENT  DISPUTE  RESOLUTION  ENTITIES;
                REGULATIONS.
  S 3080. DEFINITIONS. FOR THE PURPOSES OF THIS ARTICLE:
  1.  "EMERGENCY CONDITION" MEANS A MEDICAL OR BEHAVIORAL CONDITION THAT
MANIFESTS ITSELF BY ACUTE SYMPTOMS  OF  SUFFICIENT  SEVERITY,  INCLUDING
SEVERE  PAIN, SUCH THAT A PRUDENT LAYPERSON, POSSESSING AN AVERAGE KNOW-
LEDGE OF MEDICINE AND HEALTH, COULD REASONABLY  EXPECT  THE  ABSENCE  OF
IMMEDIATE MEDICAL ATTENTION TO RESULT IN:
  (A)  PLACING THE HEALTH OF THE PERSON AFFLICTED WITH SUCH CONDITION IN
SERIOUS JEOPARDY, OR IN THE CASE OF A BEHAVIORAL CONDITION  PLACING  THE
HEALTH OF SUCH PERSON OR OTHERS IN SERIOUS JEOPARDY;
  (B) SERIOUS IMPAIRMENT TO SUCH PERSON'S BODILY FUNCTIONS;
  (C) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART OF SUCH PERSON;

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD09441-01-3
              

A. 7813                             2

  (D) SERIOUS DISFIGUREMENT OF SUCH PERSON; OR
  (E)  A  CONDITION  DESCRIBED  IN  CLAUSE (I), (II) OR (III) OF SECTION
1867(E)(1)(A) OF THE SOCIAL SECURITY ACT.
  2. "EMERGENCY SERVICES" MEANS, WITH RESPECT TO AN EMERGENCY CONDITION:
  (A) A MEDICAL SCREENING EXAMINATION AS REQUIRED UNDER SECTION 1867  OF
THE  SOCIAL  SECURITY ACT, 42 U.S.C. S 1395DD, WHICH IS WITHIN THE CAPA-
BILITY OF THE EMERGENCY DEPARTMENT OF A  HOSPITAL,  INCLUDING  ANCILLARY
SERVICES  ROUTINELY  AVAILABLE  TO THE EMERGENCY DEPARTMENT, TO EVALUATE
SUCH EMERGENCY CONDITION, OR OTHER HEALTH CARE;
  (B) WITHIN THE CAPABILITIES OF THE STAFF AND FACILITIES  AVAILABLE  AT
THE  HOSPITAL  OR HEALTH CARE PROVIDER, SUCH FURTHER MEDICAL EXAMINATION
AND TREATMENT AS ARE REQUIRED UNDER SECTION 1867 OF THE SOCIAL  SECURITY
ACT, 42 U.S.C. S 1395DD, TO STABILIZE THE PATIENT; AND
  (C)  EMERGENCY  MEDICAL SERVICES PROVIDED UNDER ARTICLE THIRTY OF THIS
CHAPTER.
  3. "EXCESSIVE FEE" MEANS A FEE THAT IS IN EXCESS OF AN  AMOUNT  DETER-
MINED  IN  ACCORDANCE  WITH  SECTION THREE THOUSAND EIGHTY-THREE OF THIS
ARTICLE.
  4. "HEALTH CARE PLAN" MEANS A  HEALTH  INSURER  INCLUDING  AN  INSURER
LICENSED TO WRITE ACCIDENT AND HEALTH INSURANCE SUBJECT TO ARTICLE THIR-
TY-TWO OF THE INSURANCE LAW; A CORPORATION ORGANIZED PURSUANT TO ARTICLE
FORTY-THREE OF THE INSURANCE LAW; A MUNICIPAL COOPERATIVE HEALTH BENEFIT
PLAN  CERTIFIED  PURSUANT TO ARTICLE FORTY-SEVEN OF THE INSURANCE LAW; A
HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR
OF THIS CHAPTER; OR OTHER THIRD-PARTY PAYER FOR HEALTH CARE SERVICES.
  5. "HEALTH  CARE  PROVIDER"  MEANS  (I)  A  HEALTH  CARE  PROFESSIONAL
LICENSED,  CERTIFIED  OR  REGISTERED  UNDER TITLE EIGHT OF THE EDUCATION
LAW; (II) A HOSPITAL UNDER ARTICLE TWENTY-EIGHT OF THIS CHAPTER; (III) A
PROVIDER OF EMERGENCY MEDICAL SERVICES  UNDER  ARTICLE  THIRTY  OF  THIS
CHAPTER; AND (IV) ANY LAWFUL COMBINATION OF HEALTH CARE PROVIDERS.
  6.  "INDEPENDENT DISPUTE RESOLUTION ENTITY" MEANS AN ENTITY DESIGNATED
BY THE COMMISSIONER UNDER SECTION THREE  THOUSAND  EIGHTY-FOUR  OF  THIS
ARTICLE.
  7. "INSURED" MEANS A PATIENT COVERED UNDER A POLICY OR CONTRACT WITH A
HEALTH CARE PLAN.
  8.  "PATIENT"  MEANS  A PERSON WHO RECEIVES EMERGENCY SERVICES IN THIS
STATE.
  9. "USUAL AND CUSTOMARY COST" MEANS THE EIGHTIETH  PERCENTILE  OF  ALL
CHARGES  FOR  THE PARTICULAR HEALTH CARE SERVICE PERFORMED BY A PROVIDER
IN THE SAME OR SIMILAR SPECIALTY AND PROVIDED IN THE  SAME  GEOGRAPHICAL
AREA  AS  REPORTED  IN A BENCHMARKING DATABASE MAINTAINED BY A NONPROFIT
ORGANIZATION  SPECIFIED  BY  THE  COMMISSIONER,  WHERE  THE  SERVICE  IS
INCLUDED  IN  THAT  DATABASE.  THE  NONPROFIT  ORGANIZATION SHALL NOT BE
AFFILIATED WITH AN INSURER, A CORPORATION SUBJECT TO ARTICLE FORTY-THREE
OF THE INSURANCE LAW, A MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN CERTI-
FIED PURSUANT TO ARTICLE FORTY-SEVEN OF THE INSURANCE LAW, OR  A  HEALTH
MAINTENANCE  ORGANIZATION  CERTIFIED  PURSUANT  TO ARTICLE FORTY-FOUR OF
THIS CHAPTER.
  S 3081. PROHIBITION OF EXCESSIVE CHARGES FOR EMERGENCY SERVICES.  1. A
HEALTH CARE PROVIDER WHICH PROVIDES HEALTH CARE SERVICES IN  THIS  STATE
SHALL  NOT  CHARGE  AN EXCESSIVE FEE BASED ON THE CRITERIA FOR PROVIDING
EMERGENCY SERVICES IN SECTION THREE THOUSAND EIGHTY-THREE OF THIS  ARTI-
CLE.
  2.  THIS  ARTICLE  DOES NOT APPLY TO EMERGENCY SERVICES WHERE PROVIDER
FEES ARE SUBJECT TO SCHEDULES OR OTHER MONETARY  LIMITATIONS  UNDER  ANY

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OTHER LAW, INCLUDING THE WORKERS' COMPENSATION LAW AND ARTICLE FIFTY-ONE
OF THE INSURANCE LAW, AND SHALL NOT PREEMPT ANY SUCH LAW.
  S 3082. DISPUTE RESOLUTION.  1. A HEALTH CARE PLAN OR A PATIENT ALLEG-
ING THAT A HEALTH CARE PROVIDER HAS CHARGED AN EXCESSIVE FEE FOR PROVID-
ING EMERGENCY SERVICES MAY SUBMIT THE DISPUTE FOR REVIEW TO AN INDEPEND-
ENT DISPUTE RESOLUTION ENTITY.
  2.  A  PATIENT SHALL NOT BE REQUIRED TO PAY THE HEALTH CARE PROVIDER'S
FEE IN ORDER TO BE ELIGIBLE TO SUBMIT THE  DISPUTE  FOR  REVIEW  TO  THE
INDEPENDENT DISPUTE RESOLUTION ENTITY.
  S  3083. CRITERIA FOR DETERMINING EXCESSIVE CHARGES.  1. THE INDEPEND-
ENT DISPUTE RESOLUTION ENTITY SHALL DETERMINE WHETHER THE FEE CHARGED BY
THE HEALTH CARE PROVIDER FOR THE SERVICES RENDERED IS AN EXCESSIVE  FEE.
IN MAKING SUCH A DETERMINATION THE INDEPENDENT DISPUTE RESOLUTION ENTITY
SHALL CONSIDER ALL RELEVANT FACTORS INCLUDING:
  (A)  WHETHER THERE IS A GROSS DISPARITY BETWEEN THE FEE CHARGED BY THE
HEALTH CARE PROVIDER FOR SERVICES RENDERED AS COMPARED TO: (I) FEES PAID
BY THE HEALTH CARE PLAN TO REIMBURSE  SIMILARLY  QUALIFIED  HEALTH  CARE
PROVIDERS  FOR  THE  SAME SERVICES IN THE SAME REGION WHO DO NOT PARTIC-
IPATE WITH THE HEALTH CARE PLAN; (II) FEES PAID TO THE  INVOLVED  HEALTH
CARE  PROVIDER FOR THE SAME SERVICE RENDERED BY THE HEALTH CARE PROVIDER
TO PATIENTS IN HEALTH CARE PLANS IN WHICH THE HEALTH CARE PROVIDER  DOES
NOT PARTICIPATE; AND (III) FEES PAID TO THE INVOLVED HEALTH CARE PROVID-
ER  FOR  THE  SAME  SERVICES  RENDERED  BY  THE  HEALTH CARE PROVIDER TO
PATIENTS IN HEALTH CARE PLANS IN WHICH THE  HEALTH  CARE  PROVIDER  DOES
PARTICIPATE;
  (B) THE LEVEL OF TRAINING, EDUCATION AND EXPERIENCE OF THE HEALTH CARE
PROVIDER OR HEALTH CARE PROFESSIONAL INVOLVED;
  (C)  THE  HEALTH  CARE PROVIDER'S USUAL CHARGE FOR COMPARABLE SERVICES
WITH REGARD TO PATIENTS IN HEALTH CARE PLANS IN WHICH  THE  HEALTH  CARE
PROVIDER DOES NOT PARTICIPATE;
  (D) THE CIRCUMSTANCES AND COMPLEXITY OF THE PARTICULAR CASE, INCLUDING
TIME AND PLACE OF THE SERVICE;
  (E) INDIVIDUAL PATIENT CHARACTERISTICS; AND
  (F)  THE  USUAL  AND  CUSTOMARY COST OF THE SERVICE, WHERE THAT CAN BE
DETERMINED.
  2. IF THE INDEPENDENT DISPUTE RESOLUTION ENTITY  DETERMINES  THAT  THE
FEE CHARGED IS EXCESSIVE, THEN THE INDEPENDENT DISPUTE RESOLUTION ENTITY
SHALL  DETERMINE  A  REASONABLE FEE FOR THE SERVICES BASED UPON THE SAME
CONDITIONS AND FACTORS SET FORTH IN THIS SUBDIVISION,  WHICH  FEE  SHALL
NOT  BE  LESS  THAN  THE USUAL AND CUSTOMARY COST FOR SUCH SERVICES. THE
HEALTH CARE PROVIDER SHALL RETURN TO THE HEALTH CARE PLAN ANY PORTION OF
THE FEE PAID BY THE HEALTH CARE PLAN IN EXCESS OF THE AMOUNT  DETERMINED
TO BE REASONABLE BY THE INDEPENDENT DISPUTE RESOLUTION ENTITY.
  3. THE DETERMINATION OF AN INDEPENDENT DISPUTE RESOLUTION ENTITY SHALL
BE  BINDING  ON  THE HEALTH CARE PLAN, HEALTH CARE PROVIDER AND PATIENT,
AND SHALL BE ADMISSIBLE IN ANY COURT PROCEEDING BETWEEN THE HEALTH  CARE
PLAN, HEALTH CARE PROVIDER OR PATIENT, OR IN ANY ADMINISTRATIVE PROCEED-
ING BETWEEN THIS STATE AND THE HEALTH CARE PROVIDER.
  S  3084. DESIGNATION OF INDEPENDENT DISPUTE RESOLUTION ENTITIES; REGU-
LATIONS. 1. THE COMMISSIONER SHALL DESIGNATE ENTITIES TO BE  INDEPENDENT
DISPUTE  RESOLUTION  ENTITIES, UPON APPLICATION BY AN ENTITY, PAYMENT OF
AN APPROPRIATE FEE, AND A DETERMINATION BY  THE  COMMISSIONER  THAT  THE
ENTITY COMPLIES WITH THIS ARTICLE AND REGULATIONS UNDER IT.
  2.  THE  COMMISSIONER SHALL MAKE REGULATIONS TO IMPLEMENT THIS ARTICLE
AND TO ESTABLISH REQUIREMENTS AND STANDARDS FOR THE  DISPUTE  RESOLUTION
PROCESS INCLUDING:

A. 7813                             4

  (A) STANDARDS AND PROCEDURES FOR DESIGNATING AN ENTITY AS AN INDEPEND-
ENT  DISPUTE RESOLUTION ENTITY AND RENEWING, SUSPENDING OR REVOKING SUCH
A DESIGNATION; AND
  (B) STANDARDS FOR ESTABLISHING WHICH PARTY OR PARTIES SHALL BE RESPON-
SIBLE FOR PAYMENT OF THE COSTS OF THE DISPUTE RESOLUTION PROCESS.
  S  2.  The  public health law is amended by adding a new section 23 to
read as follows:
  S 23. DISCLOSURE BY HEALTH CARE PROFESSIONALS RELATING TO HEALTH  CARE
PLANS.    1.  A  HEALTH  CARE PROFESSIONAL SHALL DISCLOSE TO PATIENTS OR
PROSPECTIVE PATIENTS IN WRITING  OR  THROUGH  AN  INTERNET  WEBSITE  THE
HEALTH CARE PLANS IN WHICH THE HEALTH CARE PROFESSIONAL IS A PARTICIPAT-
ING  PROVIDER  AND THE HOSPITALS WITH WHICH THE HEALTH CARE PROFESSIONAL
IS AFFILIATED.
  2. IF A HEALTH CARE PROFESSIONAL DOES NOT PARTICIPATE IN  THE  NETWORK
OF  A  PATIENT'S  OR  PROSPECTIVE PATIENT'S HEALTH CARE PLAN, THE HEALTH
CARE PROFESSIONAL SHALL, UPON RECEIPT OF A REQUEST  FROM  A  PATIENT  OR
PROSPECTIVE  PATIENT,  DISCLOSE TO THE PATIENT OR PROSPECTIVE PATIENT IN
WRITING THE AMOUNT OR ESTIMATED AMOUNT THE HEALTH CARE PROFESSIONAL WILL
BILL THE  PATIENT  OR  PROSPECTIVE  PATIENT  FOR  HEALTH  CARE  SERVICES
PROVIDED  OR  ANTICIPATED  TO  BE PROVIDED TO THE PATIENT OR PROSPECTIVE
PATIENT.
  3. A HEALTH CARE PROFESSIONAL SHALL PROVIDE A PATIENT  OR  PROSPECTIVE
PATIENT  WITH  THE  NAME,  PRACTICE  NAME, MAILING ADDRESS AND TELEPHONE
NUMBER OF  ANY  HEALTH  CARE  PROVIDER  OF  ANESTHESIOLOGY,  LABORATORY,
PATHOLOGY,  RADIOLOGY  OR  ASSISTANT SURGEON SERVICES WHO ARE REASONABLY
EXPECTED TO BE INVOLVED IN THE  PATIENT'S  CARE  IN  THE  PROFESSIONAL'S
OFFICE OR COORDINATED OR REFERRED BY THE HEALTH CARE PROFESSIONAL.
  4.  A HEALTH CARE PROFESSIONAL SHALL, FOR A PATIENT'S SCHEDULED HOSPI-
TAL ADMISSION OR  SCHEDULED  OUTPATIENT  HOSPITAL  SERVICES,  PROVIDE  A
PATIENT  AND  THE HOSPITAL WITH THE NAME, PRACTICE NAME, MAILING ADDRESS
AND TELEPHONE NUMBER OF ANY OTHER PROFESSIONALS WHOSE SERVICES  WILL  BE
ARRANGED  BY  THE  PROFESSIONAL  AND  ARE  SCHEDULED  AT THE TIME OF THE
PRE-ADMISSION TESTING, REGISTRATION OR ADMISSION.
  5. A HOSPITAL SHALL ESTABLISH, UPDATE, MAKE PUBLIC  AND  POST  ON  THE
HOSPITAL'S  WEBSITE, A LIST OF THE HOSPITAL'S STANDARD CHARGES FOR ITEMS
AND SERVICES PROVIDED BY THE HOSPITAL, INCLUDING  FOR  DIAGNOSIS-RELATED
GROUPS  ESTABLISHED UNDER SECTION 1886(D)(4) OF THE FEDERAL SOCIAL SECU-
RITY ACT.
  6. A HOSPITAL SHALL POST ON THE HOSPITAL'S  WEBSITE:  (A)  THE  HEALTH
CARE  PLANS  IN  WHICH THE HOSPITAL IS A PARTICIPATING PROVIDER; AND (B)
THE NAME, PRACTICE NAME, MAILING ADDRESS, AND TELEPHONE  NUMBER  OF  ANY
HEALTH  CARE  PROFESSIONAL WHOSE SERVICES WILL BE PROVIDED AT THE HOSPI-
TAL, BUT WILL NOT BE BILLED AS PART OF THE HOSPITAL CHARGES.
  7. A HOSPITAL SHALL, AT THE EARLIER OF EITHER  PRE-ADMISSION  TESTING,
OUTPATIENT  REGISTRATION  OR  A  NON-EMERGENCY  HOSPITAL  ADMISSION: (A)
PROVIDE A PATIENT OR PROSPECTIVE PATIENT WITH THE NAME,  PRACTICE  NAME,
MAILING  ADDRESS  AND  TELEPHONE  NUMBER OF ANY HEALTH CARE PROFESSIONAL
WHOSE SERVICES ARE REASONABLY ANTICIPATED AT THE TIME OF THE  PRE-ADMIS-
SION  TESTING,  REGISTRATION  OR  ADMISSION  AND WILL BE PROVIDED AT THE
HOSPITAL, BUT WILL NOT BE BILLED AS PART OF THE  HOSPITAL  CHARGES;  AND
(B) DISCLOSE WHETHER THE SERVICES OF HEALTH CARE PROFESSIONALS WHO TYPI-
CALLY  PROVIDE  HOSPITAL  SERVICES SUCH AS, BUT NOT LIMITED TO, ANESTHE-
SIOLOGY, PATHOLOGY OR RADIOLOGY ARE  BILLED  AS  PART  OF  THE  HOSPITAL
CHARGES.
  8. FOR PURPOSES OF THIS SECTION:

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  (A)  "HEALTH  CARE  PLAN"  MEANS A HEALTH INSURER INCLUDING AN INSURER
LICENSED TO WRITE ACCIDENT AND HEALTH INSURANCE SUBJECT TO ARTICLE THIR-
TY-TWO OF THE INSURANCE LAW; A CORPORATION ORGANIZED PURSUANT TO ARTICLE
FORTY-THREE OF THE INSURANCE LAW; A MUNICIPAL COOPERATIVE HEALTH BENEFIT
PLAN  CERTIFIED  PURSUANT TO ARTICLE FORTY-SEVEN OF THE INSURANCE LAW; A
HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR
OF THIS CHAPTER; OR OTHER THIRD-PARTY PAYER FOR HEALTH CARE SERVICES.
  (B) "HEALTH CARE PROFESSIONAL" MEANS AN APPROPRIATELY LICENSED, REGIS-
TERED OR CERTIFIED HEALTH CARE PROFESSIONAL PURSUANT TO TITLE  EIGHT  OF
THE EDUCATION LAW.
  S 3. Paragraphs (p-1), (q) and (r) of subdivision 1 of section 4408 of
the  public  health  law,  as  added by chapter 705 of the laws of 1996,
paragraph (p-1) as added by chapter 554 of the laws of 2002, are amended
and two new paragraphs (s) and (t) are added to read as follows:
  (p-1) notice that an enrollee shall have direct access to primary  and
preventive  obstetric and gynecologic services INCLUDING ANNUAL EXAMINA-
TIONS, CARE RESULTING FROM SUCH ANNUAL EXAMINATIONS,  AND  TREATMENT  OF
ACUTE GYNECOLOGIC CONDITIONS, from a qualified provider of such services
of  her  choice from within the plan [for no fewer than two examinations
annually for such services] or [to] FOR any care related to A  pregnancy
[and that additionally, the enrollee shall have direct access to primary
and  preventive  obstetric and gynecologic services required as a result
of such annual examinations or as  a  result  of  an  acute  gynecologic
condition];
  (q)  notice of all appropriate mailing addresses and telephone numbers
to be utilized by enrollees seeking information or authorization; [and]
  (r) a listing by specialty, which may be in a separate  document  that
is  updated  annually,  of the name, address and telephone number of all
participating providers, including facilities, and, in addition, in  the
case  of physicians, board certification[.], LANGUAGES SPOKEN AND AFFIL-
IATION WITH PARTICIPATING HOSPITALS. THE LISTING SHALL ALSO BE POSTED ON
THE HEALTH MAINTENANCE ORGANIZATION'S WEBSITE AND THE HEALTH MAINTENANCE
ORGANIZATION SHALL UPDATE THE WEBSITE WITHIN FIFTEEN DAYS OF  THE  ADDI-
TION  OR TERMINATION OF A PROVIDER FROM THE HEALTH MAINTENANCE ORGANIZA-
TION'S NETWORK OR A CHANGE IN A PHYSICIAN'S HOSPITAL AFFILIATION;
  (S) WHERE APPLICABLE, A DESCRIPTION OF THE METHOD BY WHICH AN ENROLLEE
MAY SUBMIT A CLAIM FOR  HEALTH  CARE  SERVICES,  INCLUDING  THROUGH  THE
INTERNET, ELECTRONIC MAIL OR BY FACSIMILE; AND
  (T)  WHERE  APPLICABLE, WHEN A CONTRACT OFFERS OUT-OF-NETWORK COVERAGE
PURSUANT TO SUBSECTIONS (B) AND (C) OF SECTION THIRTY-TWO HUNDRED  FORTY
OF THE INSURANCE LAW: (I) A CLEAR DESCRIPTION OF THE METHODOLOGY USED BY
THE  HEALTH MAINTENANCE ORGANIZATION TO DETERMINE REIMBURSEMENT FOR OUT-
OF-NETWORK HEALTH CARE SERVICES; (II) A DESCRIPTION OF THE  AMOUNT  THAT
THE HEALTH MAINTENANCE ORGANIZATION WILL REIMBURSE UNDER THE METHODOLOGY
FOR OUT-OF-NETWORK HEALTH CARE SERVICES SET FORTH AS A PERCENTAGE OF THE
USUAL  AND  CUSTOMARY  COST FOR OUT-OF-NETWORK HEALTH CARE SERVICES; AND
(III) EXAMPLES OF ANTICIPATED OUT-OF-POCKET COSTS FOR FREQUENTLY  BILLED
OUT-OF-NETWORK HEALTH CARE SERVICES.
  S  4.  Paragraphs  (k) and (l) of subdivision 2 of section 4408 of the
public health law, as added by chapter 705 of  the  laws  of  1996,  are
amended  and  three new paragraphs (m), (n) and (o) are added to read as
follows:
  (k) provide the written application procedures and minimum  qualifica-
tion  requirements  for  health  care  providers to be considered by the
health maintenance organization; [and]

A. 7813                             6

  (l) disclose  other  information  as  required  by  the  commissioner,
provided  that  such  requirements are promulgated pursuant to the state
administrative procedure act[.];
  (M)  DISCLOSE  WHETHER  A  HEALTH CARE PROVIDER SCHEDULED TO PROVIDE A
HEALTH CARE SERVICE IS AN IN-NETWORK PROVIDER;
  (N)  WHERE  APPLICABLE,  WITH  RESPECT  TO  OUT-OF-NETWORK   COVERAGE,
DISCLOSE THE DOLLAR AMOUNT THAT THE HEALTH MAINTENANCE ORGANIZATION WILL
PAY FOR A SPECIFIC OUT-OF-NETWORK HEALTH CARE SERVICE; AND
  (O)  PROVIDE  INFORMATION  IN  WRITING AND THROUGH AN INTERNET WEBSITE
THAT REASONABLY PERMITS AN ENROLLEE OR PROSPECTIVE ENROLLEE TO DETERMINE
THE  ANTICIPATED  OUT-OF-POCKET  COST  FOR  OUT-OF-NETWORK  HEALTH  CARE
SERVICES  IN  A  GEOGRAPHICAL AREA OR ZIP CODE BASED UPON THE DIFFERENCE
BETWEEN WHAT THE HEALTH  MAINTENANCE  ORGANIZATION  WILL  REIMBURSE  FOR
OUT-OF-NETWORK HEALTH CARE SERVICES AND THE USUAL AND CUSTOMARY COST FOR
OUT-OF-NETWORK HEALTH CARE SERVICES EXPRESSED IN DOLLAR AMOUNTS.
  S  5. Section 4408 of the public health law is amended by adding a new
subdivision 7 to read as follows:
  7. FOR PURPOSES OF THIS SECTION, "USUAL AND CUSTOMARY COST" SHALL MEAN
THE EIGHTIETH PERCENTILE OF ALL CHARGES FOR THE PARTICULAR  HEALTH  CARE
SERVICE  PERFORMED  BY  A  PROVIDER IN THE SAME OR SIMILAR SPECIALTY AND
PROVIDED IN THE SAME GEOGRAPHICAL AREA AS  REPORTED  IN  A  BENCHMARKING
DATABASE  MAINTAINED BY A NONPROFIT ORGANIZATION SPECIFIED BY THE SUPER-
INTENDENT OF FINANCIAL SERVICES. THE NONPROFIT ORGANIZATION SHALL NOT BE
AFFILIATED WITH AN INSURER, A CORPORATION SUBJECT TO ARTICLE FORTY-THREE
OF THE INSURANCE LAW, A MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN CERTI-
FIED PURSUANT TO ARTICLE FORTY-SEVEN OF THE INSURANCE LAW, OR  A  HEALTH
MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO THIS ARTICLE.
  S  6.  Subdivision  7-g  of  section  4900 of the public health law is
renumbered subdivision 7-h and a new subdivision 7-g is added to read as
follows:
  7-G. "OUT-OF-NETWORK REFERRAL DENIAL" MEANS A DENIAL OF A REQUEST  FOR
AN  AUTHORIZATION OR REFERRAL TO AN OUT-OF-NETWORK PROVIDER ON THE BASIS
THAT THE HEALTH CARE PLAN HAS A HEALTH CARE PROVIDER IN  THE  IN-NETWORK
BENEFITS PORTION OF ITS NETWORK WITH APPROPRIATE TRAINING AND EXPERIENCE
TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROLLEE, AND WHO IS ABLE
TO  PROVIDE  THE  REQUESTED HEALTH SERVICE. THE NOTICE OF A DENIAL OF AN
OUT-OF-NETWORK REFERRAL PROVIDED TO AN ENROLLEE SHALL  INCLUDE  INFORMA-
TION  EXPLAINING  WHAT  INFORMATION THE ENROLLEE MUST SUBMIT IN ORDER TO
APPEAL THE DENIAL OF AN OUT-OF-NETWORK REFERRAL PURSUANT TO  SUBDIVISION
ONE-B  OF  SECTION  FOUR  THOUSAND  NINE HUNDRED FOUR OF THIS ARTICLE. A
DENIAL OF AN OUT-OF-NETWORK REFERRAL UNDER  THIS  SUBDIVISION  DOES  NOT
CONSTITUTE  AN  ADVERSE  DETERMINATION  BASED  ON  MEDICAL  NECESSITY AS
DEFINED IN THIS ARTICLE. A DENIAL OF AN  OUT-OF-NETWORK  REFERRAL  SHALL
NOT  BE  CONSTRUED  TO  INCLUDE  AN  OUT-OF-NETWORK DENIAL AS DEFINED IN
SUBDIVISION SEVEN-F OF THIS SECTION.
  S 7. Subdivision 2 of section 4903 of the public health law, as  added
by chapter 705 of the laws of 1996, is amended to read as follows:
  2. A utilization review agent shall make a utilization review determi-
nation  involving  health  care services which require pre-authorization
and provide notice of a determination  to  the  enrollee  or  enrollee's
designee  and  the  enrollee's  health care provider by telephone and in
writing within three business days of receipt of the necessary  informa-
tion.   THE NOTIFICATION SHALL IDENTIFY WHETHER THE SERVICES ARE CONSID-
ERED IN-NETWORK OR OUT-OF-NETWORK.
  S 8. Section 4904 of the public health law is amended by adding a  new
subdivision 1-b to read as follows:

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  1-B.  AN  INSURED  OR THE INSURED'S DESIGNEE MAY APPEAL A DENIAL OF AN
OUT-OF-NETWORK REFERRAL BY A HEALTH CARE PLAN BY  SUBMITTING  A  WRITTEN
STATEMENT  FROM  THE  INSURED'S  ATTENDING HEALTH CARE PROFESSIONAL, WHO
SHALL BE THE INSURED'S IN-NETWORK PRIMARY CARE PROVIDER OR A HEALTH CARE
PROFESSIONAL  QUALIFIED  TO  PRACTICE  IN THE SPECIALTY AREA OF PRACTICE
APPROPRIATE TO TREAT THE INSURED FOR THE HEALTH SERVICE SOUGHT (WHO  MAY
BE THE PROPOSED OUT-OF-NETWORK HEALTH CARE PROVIDER), THAT:
  (A)  THE  IN-NETWORK  HEALTH CARE PROVIDER OR PROVIDERS RECOMMENDED BY
THE HEALTH CARE PLAN DO NOT HAVE THE APPROPRIATE TRAINING AND EXPERIENCE
TO MEET THE PARTICULAR HEALTH CARE NEEDS OF THE INSURED FOR  THE  HEALTH
SERVICE; AND
  (B)  RECOMMENDS AN OUT-OF-NETWORK PROVIDER WITH THE APPROPRIATE TRAIN-
ING AND EXPERIENCE TO MEET THE  PARTICULAR  HEALTH  CARE  NEEDS  OF  THE
INSURED, AND WHO IS ABLE TO PROVIDE THE REQUESTED HEALTH SERVICE.
  S 9. Subdivision 2 of section 4910 of the public health law is amended
by adding a new paragraph (d) to read as follows:
  (D)(I)  THE  INSURED  HAS HAD AN OUT-OF-NETWORK REFERRAL DENIED ON THE
GROUNDS THAT THE HEALTH CARE PLAN HAS A  HEALTH  CARE  PROVIDER  IN  THE
IN-NETWORK BENEFITS PORTION OF ITS NETWORK WITH APPROPRIATE TRAINING AND
EXPERIENCE  TO  MEET THE PARTICULAR HEALTH CARE NEEDS OF AN INSURED, AND
WHO IS ABLE TO PROVIDE THE REQUESTED HEALTH SERVICE. (II) THE  INSURED'S
ATTENDING  HEALTH  CARE PROFESSIONAL, WHO SHALL BE THE INSURED'S IN-NET-
WORK PRIMARY CARE PROVIDER OR A HEALTH CARE  PROFESSIONAL  QUALIFIED  TO
PRACTICE  IN  THE  SPECIALTY  AREA  OF PRACTICE APPROPRIATE TO TREAT THE
INSURED  FOR  THE  HEALTH  SERVICE  SOUGHT  (WHO  MAY  BE  THE  PROPOSED
OUT-OF-NETWORK  HEALTH  CARE  PROVIDER),  CERTIFIES  THAT THE IN-NETWORK
HEALTH CARE PROVIDER OR PROVIDERS RECOMMENDED BY THE HEALTH CARE PLAN DO
NOT HAVE THE APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE  PARTICULAR
HEALTH  CARE  NEEDS  OF  AN  INSURED,  AND  RECOMMENDS AN OUT-OF-NETWORK
PROVIDER WHOSE APPROPRIATE TRAINING AND EXPERIENCE MEET  THE  PARTICULAR
HEALTH  CARE  NEEDS  OF  AN  INSURED,  AND  WHO  IS  ABLE TO PROVIDE THE
REQUESTED HEALTH SERVICE.
  S 10. Paragraph (d) of subdivision 2 of section  4914  of  the  public
health  law  is  amended  by  adding  a  new subparagraph (D) to read as
follows:
  (D) FOR EXTERNAL APPEALS REQUESTED PURSUANT TO PARAGRAPH (D) OF SUBDI-
VISION TWO OF SECTION FOUR THOUSAND  NINE  HUNDRED  TEN  OF  THIS  TITLE
RELATING  TO AN OUT-OF-NETWORK REFERRAL, THE EXTERNAL APPEAL AGENT SHALL
REVIEW THE UTILIZATION REVIEW AGENT'S FINAL ADVERSE  DETERMINATION  AND,
IN  ACCORDANCE  WITH THE PROVISIONS OF THIS TITLE, SHALL MAKE A DETERMI-
NATION AS TO WHETHER THE OUT-OF-NETWORK REFERRAL SHALL BE COVERED BY THE
HEALTH PLAN; PROVIDED THAT SUCH DETERMINATION SHALL:  (I)  BE  CONDUCTED
ONLY  BY ONE OR A GREATER ODD NUMBER OF CLINICAL PEER REVIEWERS; (II) BE
ACCOMPANIED BY A WRITTEN STATEMENT: (1) THAT THE OUT-OF-NETWORK REFERRAL
SHALL BE COVERED BY THE HEALTH CARE PLAN EITHER WHEN THE REVIEWER  OR  A
MAJORITY OF THE PANEL OF REVIEWERS DETERMINES, UPON REVIEW OF THE TRAIN-
ING  AND  EXPERIENCE OF THE IN-NETWORK HEALTH CARE PROVIDER OR PROVIDERS
PROPOSED BY THE PLAN, THE TRAINING AND EXPERIENCE OF THE REQUESTED  OUT-
OF-NETWORK  PROVIDER,  THE INFORMATION PROVIDED CONCERNING THE ENROLLEE,
THE ATTENDING PHYSICIAN'S RECOMMENDATION, THE ENROLLEE'S MEDICAL RECORD,
AND ANY OTHER PERTINENT INFORMATION, THAT THE HEALTH PLAN DOES NOT  HAVE
A  PROVIDER  WITH  THE  APPROPRIATE  TRAINING AND EXPERIENCE TO MEET THE
PARTICULAR HEALTH CARE NEEDS OF AN ENROLLEE WHO IS ABLE TO  PROVIDE  THE
REQUESTED  HEALTH  SERVICE, AND THAT THE OUT-OF-NETWORK PROVIDER HAS THE
APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR  HEALTH  CARE
NEEDS  OF  AN ENROLLEE, IS ABLE TO PROVIDE THE REQUESTED HEALTH SERVICE,

A. 7813                             8

AND IS LIKELY TO PRODUCE A CLINICALLY BENEFICIAL OUTCOME; OR (2) UPHOLD-
ING THE HEALTH PLAN'S DENIAL OF COVERAGE; (III) BE SUBJECT TO THE  TERMS
AND  CONDITIONS  GENERALLY  APPLICABLE TO BENEFITS UNDER THE EVIDENCE OF
COVERAGE UNDER THE HEALTH CARE PLAN; (IV) BE BINDING ON THE PLAN AND THE
ENROLLEE; AND (V) BE ADMISSIBLE IN ANY COURT PROCEEDING.
  S  11.  Paragraphs  11,  12,  13,  14,  16 and 17 of subsection (a) of
section 3217-a of the insurance law, as added by chapter 705 of the laws
of 1996, are amended and three new paragraphs 16-a, 18 and 19 are  added
to read as follows:
  (11)  where  applicable,  notice that an insured enrolled in a managed
care product OR A  COMPREHENSIVE  POLICY  THAT  UTILIZES  A  NETWORK  OF
PROVIDERS  offered by the insurer may obtain a referral to a health care
provider outside of the insurer's network or panel when the insurer does
not have a health care provider with appropriate training and experience
in the network or panel to meet the particular health care needs of  the
insured and the procedure by which the insured can obtain such referral;
  (12)  where  applicable,  notice that an insured enrolled in a managed
care product OR A  COMPREHENSIVE  POLICY  THAT  UTILIZES  A  NETWORK  OF
PROVIDERS offered by the insurer with a condition which requires ongoing
care  from  a  specialist  may  request  a  standing  referral to such a
specialist and the procedure for requesting and obtaining such a  stand-
ing referral;
  (13)    where applicable, notice that an insured enrolled in a managed
care product OR A  COMPREHENSIVE  POLICY  THAT  UTILIZES  A  NETWORK  OF
PROVIDERS  offered  by the insurer with (i) a life-threatening condition
or disease, or (ii) a degenerative and disabling condition  or  disease,
either of which requires specialized medical care over a prolonged peri-
od of time may request a specialist responsible for providing or coordi-
nating  the  insured's medical care and the procedure for requesting and
obtaining such a specialist;
  (14) where applicable, notice that an insured enrolled  in  a  managed
care  product  OR  A  COMPREHENSIVE  POLICY  THAT  UTILIZES A NETWORK OF
PROVIDERS offered by the insurer with (i) a  life-threatening  condition
or  disease,  or (ii) a degenerative and disabling condition or disease,
either of which requires specialized medical care over a prolonged peri-
od of time, may request access to a specialty care center and the proce-
dure by which such access may be obtained;
  (16) notice of all appropriate mailing addresses and telephone numbers
to be utilized by insureds seeking information or authorization; [and]
  (16-A) WHERE APPLICABLE, NOTICE THAT  AN  INSURED  SHALL  HAVE  DIRECT
ACCESS  TO  PRIMARY  AND  PREVENTIVE  OBSTETRIC AND GYNECOLOGIC SERVICES
INCLUDING ANNUAL EXAMINATIONS, CARE RESULTING FROM SUCH ANNUAL  EXAMINA-
TIONS,  AND  TREATMENT OF ACUTE GYNECOLOGIC CONDITIONS, FROM A QUALIFIED
PROVIDER OF SUCH SERVICES OF HER CHOICE FROM WITHIN THE PLAN OR FOR  ANY
CARE RELATED TO A PREGNANCY;
  (17) where applicable, a listing by specialty, which may be in a sepa-
rate  document that is updated annually, of the name, address, and tele-
phone number of all participating providers, including  facilities,  and
in   addition,  in  the  case  of  physicians,  board  certification[.],
LANGUAGES SPOKEN AND AFFILIATION WITH PARTICIPATING HOSPITALS. THE LIST-
ING SHALL ALSO BE POSTED ON THE INSURER'S WEBSITE AND THE INSURER  SHALL
UPDATE THE WEBSITE WITHIN FIFTEEN DAYS OF THE ADDITION OR TERMINATION OF
A  PROVIDER  FROM  THE  INSURER'S  NETWORK  OR A CHANGE IN A PHYSICIAN'S
HOSPITAL AFFILIATION;

A. 7813                             9

  (18) A DESCRIPTION OF THE METHOD BY WHICH  AN  INSURED  MAY  SUBMIT  A
CLAIM  FOR  HEALTH  CARE SERVICES, INCLUDING THROUGH THE INTERNET, ELEC-
TRONIC MAIL OR BY FACSIMILE; AND
  (19)  WHERE  APPLICABLE,  WHEN A POLICY OFFERS OUT-OF-NETWORK COVERAGE
PURSUANT TO SUBSECTIONS (B) AND (C) OF SECTION THIRTY-TWO HUNDRED  FORTY
OF THIS ARTICLE:
  (A)  A  CLEAR  DESCRIPTION  OF  THE METHODOLOGY USED BY THE INSURER TO
DETERMINE REIMBURSEMENT FOR OUT-OF-NETWORK HEALTH CARE SERVICES;
  (B) A DESCRIPTION OF THE AMOUNT THAT THE INSURER WILL REIMBURSE  UNDER
THE  METHODOLOGY  FOR OUT-OF-NETWORK HEALTH CARE SERVICES SET FORTH AS A
PERCENTAGE OF THE USUAL AND CUSTOMARY  COST  FOR  OUT-OF-NETWORK  HEALTH
CARE SERVICES; AND
  (C)  EXAMPLES OF ANTICIPATED OUT-OF-POCKET COSTS FOR FREQUENTLY BILLED
OUT-OF-NETWORK HEALTH CARE SERVICES.
  S 12. Paragraphs 11 and 12 of subsection (b) of section 3217-a of  the
insurance  law, as added by chapter 705 of the laws of 1996, are amended
and three new paragraphs 13, 14 and 15 are added to read as follows:
  (11) where applicable, provide the written application procedures  and
minimum  qualification  requirements  for  health  care  providers to be
considered by the insurer for participation in the insurer's network for
a managed care product; [and]
  (12) disclose such other information as required  by  the  superinten-
dent,  provided  that  such requirements are promulgated pursuant to the
state administrative procedure act[.];
  (13) DISCLOSE WHETHER A HEALTH CARE PROVIDER SCHEDULED  TO  PROVIDE  A
HEALTH CARE SERVICE IS AN IN-NETWORK PROVIDER;
  (14)  WHERE  APPLICABLE,  WITH  RESPECT  TO  OUT-OF-NETWORK  COVERAGE,
DISCLOSE THE DOLLAR AMOUNT THAT THE INSURER  WILL  PAY  FOR  A  SPECIFIC
OUT-OF-NETWORK HEALTH CARE SERVICE; AND
  (15)  PROVIDE  INFORMATION  IN WRITING AND THROUGH AN INTERNET WEBSITE
THAT REASONABLY PERMITS AN INSURED OR PROSPECTIVE INSURED  TO  DETERMINE
THE  ANTICIPATED  OUT-OF-POCKET  COST  FOR  OUT-OF-NETWORK  HEALTH  CARE
SERVICES IN A GEOGRAPHICAL AREA OR ZIP CODE BASED  UPON  THE  DIFFERENCE
BETWEEN  WHAT  THE INSURER WILL REIMBURSE FOR OUT-OF-NETWORK HEALTH CARE
SERVICES AND THE USUAL AND CUSTOMARY COST FOR OUT-OF-NETWORK HEALTH CARE
SERVICES EXPRESSED IN DOLLAR AMOUNTS.
  S 13. Section 3217-a of the insurance law is amended by adding  a  new
subsection (f) to read as follows:
  (F)  FOR  PURPOSES  OF  THIS SECTION, "USUAL AND CUSTOMARY COST" SHALL
MEAN THE EIGHTIETH PERCENTILE OF ALL CHARGES FOR THE  PARTICULAR  HEALTH
CARE  SERVICE  PERFORMED  BY A PROVIDER IN THE SAME OR SIMILAR SPECIALTY
AND PROVIDED IN THE SAME GEOGRAPHICAL AREA AS REPORTED IN A BENCHMARKING
DATABASE MAINTAINED BY A NONPROFIT ORGANIZATION SPECIFIED BY THE  SUPER-
INTENDENT.  THE  NONPROFIT  ORGANIZATION SHALL NOT BE AFFILIATED WITH AN
INSURER, A CORPORATION SUBJECT TO ARTICLE FORTY-THREE OF THIS CHAPTER, A
MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN CERTIFIED PURSUANT TO  ARTICLE
FORTY-SEVEN OF THIS CHAPTER, OR A HEALTH MAINTENANCE ORGANIZATION CERTI-
FIED PURSUANT TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW.
  S  14.  Section 3217-d of the insurance law is amended by adding a new
subsection (d) to read as follows:
  (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  OUT-OF-NETWORK  SERVICES
CONSISTENT WITH THE REQUIREMENTS OF SUBSECTION (A) OF SECTION FOUR THOU-
SAND  EIGHT HUNDRED FOUR OF THIS CHAPTER, SUBSECTIONS (G-6) AND (G-7) OF

A. 7813                            10

SECTION FOUR THOUSAND NINE HUNDRED OF THIS  CHAPTER,  SUBSECTIONS  (A-1)
AND  (A-2)  OF  SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS CHAPTER,
PARAGRAPHS THREE AND FOUR OF SUBSECTION (B)  OF  SECTION  FOUR  THOUSAND
NINE HUNDRED TEN OF THIS CHAPTER, AND SUBPARAGRAPHS (C) AND (D) OF PARA-
GRAPH FOUR OF SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED FOUR-
TEEN OF THIS CHAPTER.
  S  15.  Section 3224-a of the insurance law is amended by adding a new
subsection (j) to read as follows:
  (J) AN INSURER OR AN ORGANIZATION OR CORPORATION LICENSED OR CERTIFIED
PURSUANT TO ARTICLE FORTY-THREE OR FORTY-SEVEN OF THIS CHAPTER OR  ARTI-
CLE FORTY-FOUR OF THE PUBLIC HEALTH LAW SHALL ACCEPT CLAIMS SUBMITTED BY
A  POLICYHOLDER  OR COVERED PERSON THROUGH THE INTERNET, ELECTRONIC MAIL
OR BY FACSIMILE.
  S 16. The insurance law is amended by adding a  new  section  3240  to
read as follows:
  S  3240.  NETWORK  COVERAGE.  (A)  AN INSURER, A CORPORATION ORGANIZED
PURSUANT TO ARTICLE FORTY-THREE OF THIS CHAPTER, OR A MUNICIPAL  COOPER-
ATIVE  HEALTH  BENEFIT PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF
THIS CHAPTER THAT ISSUES A HEALTH INSURANCE POLICY OR  CONTRACT  WITH  A
NETWORK  OF  HEALTH  CARE  PROVIDERS  SHALL  ENSURE  THAT THE NETWORK IS
ADEQUATE TO MEET THE HEALTH NEEDS OF INSUREDS AND PROVIDE AN APPROPRIATE
CHOICE OF PROVIDERS SUFFICIENT TO RENDER THE SERVICES COVERED UNDER  THE
POLICY  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 POLICY OR CONTRACT; AT LEAST
EVERY THREE YEARS THEREAFTER; AND UPON APPLICATION FOR EXPANSION OF  ANY
SERVICE  AREA ASSOCIATED WITH THE POLICY OR CONTRACT. TO THE EXTENT THAT
THE NETWORK HAS BEEN DETERMINED BY THE COMMISSIONER OF  HEALTH  TO  MEET
THE  STANDARDS  SET  FORTH  IN SUBDIVISION FIVE OF SECTION FOUR THOUSAND
FOUR HUNDRED THREE OF THE PUBLIC  HEALTH  LAW,  SUCH  NETWORK  SHALL  BE
DEEMED ADEQUATE BY THE SUPERINTENDENT.
  (B)   AN   INSURER,   A  CORPORATION  ORGANIZED  PURSUANT  TO  ARTICLE
FORTY-THREE OF THIS CHAPTER, A MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN
CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THIS CHAPTER, OR  A  HEALTH
MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR OF THE
PUBLIC  HEALTH  LAW,  THAT PROVIDES COVERAGE FOR OUT-OF-NETWORK SERVICES
SHALL PROVIDE SIGNIFICANT COVERAGE OF THE USUAL AND CUSTOMARY  COSTS  OF
OUT-OF-NETWORK HEALTH CARE SERVICES.
  (C)   AN   INSURER,   A  CORPORATION  ORGANIZED  PURSUANT  TO  ARTICLE
FORTY-THREE OF THIS CHAPTER, A MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN
CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THIS CHAPTER, OR  A  HEALTH
MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR OF THE
PUBLIC  HEALTH  LAW,  THAT PROVIDES COVERAGE FOR OUT-OF-NETWORK SERVICES
SHALL OFFER AT LEAST ONE POLICY OR CONTRACT OPTION IN EACH  GEOGRAPHICAL
REGION COVERED THAT PROVIDES COVERAGE FOR AT LEAST EIGHTY PERCENT OF THE
USUAL  AND  CUSTOMARY  COST OF OUT-OF-NETWORK HEALTH CARE SERVICES AFTER
IMPOSITION OF A DEDUCTIBLE.
  (D) FOR THE PURPOSES OF THIS SECTION "USUAL AND CUSTOMARY COST"  SHALL
MEAN  THE  EIGHTIETH PERCENTILE OF ALL CHARGES FOR THE PARTICULAR HEALTH
CARE SERVICE PERFORMED BY A PROVIDER IN THE SAME  OR  SIMILAR  SPECIALTY
AND PROVIDED IN THE SAME GEOGRAPHICAL AREA AS REPORTED IN A BENCHMARKING
DATABASE  MAINTAINED BY A NONPROFIT ORGANIZATION SPECIFIED BY THE SUPER-
INTENDENT. THE NONPROFIT ORGANIZATION SHALL NOT BE  AFFILIATED  WITH  AN
INSURER, A CORPORATION SUBJECT TO ARTICLE FORTY-THREE OF THIS ARTICLE, A
MUNICIPAL  COOPERATIVE HEALTH BENEFIT PLAN CERTIFIED PURSUANT TO ARTICLE

A. 7813                            11

FORTY-SEVEN OF THIS CHAPTER, OR A HEALTH MAINTENANCE ORGANIZATION CERTI-
FIED PURSUANT TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW.
  S  17.  Section 4306-c of the insurance law is amended by adding a new
subsection (d) to read as follows:
  (D) A CORPORATION, INCLUDING A MUNICIPAL  COOPERATIVE  HEALTH  BENEFIT
PLAN  CERTIFIED  PURSUANT  TO  ARTICLE FORTY-SEVEN OF THIS CHAPTER, 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 OUT-OF-NETWORK SERVICES CONSISTENT WITH  THE  REQUIRE-
MENTS  OF  SUBSECTION (A) OF SECTION FOUR THOUSAND EIGHT HUNDRED FOUR OF
THIS CHAPTER, SUBSECTIONS (G-6) AND (G-7) OF SECTION FOUR THOUSAND  NINE
HUNDRED  OF  THIS  CHAPTER,  SUBSECTIONS (A-1) AND (A-2) OF SECTION FOUR
THOUSAND NINE HUNDRED FOUR OF THIS CHAPTER, PARAGRAPHS THREE AND FOUR OF
SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED TEN OF  THIS  CHAP-
TER,  AND  SUBPARAGRAPHS (C) AND (D) OF PARAGRAPH FOUR OF SUBSECTION (B)
OF SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN OF THIS CHAPTER.
  S 18. Paragraphs 11, 12, 13, 14, 16-a, 17, and 18 of subsection (a) of
section 4324 of the insurance law, as added by chapter 705 of  the  laws
of 1996, paragraph 16-a as added by chapter 554 of the laws of 2002, are
amended and two new paragraphs 19 and 20 are added to read as follows:
  (11)  where applicable, notice that a subscriber enrolled in a managed
care  product  OR  A  COMPREHENSIVE  CONTRACT THAT UTILIZES A NETWORK OF
PROVIDERS offered by the corporation may obtain a referral to  a  health
care  provider  outside  of  the corporation's network or panel when the
corporation does not have a health care provider with appropriate train-
ing and experience in the network or panel to meet the particular health
care needs of the subscriber and the procedure by which  the  subscriber
can obtain such referral;
  (12)  where applicable, notice that a subscriber enrolled in a managed
care product OR A COMPREHENSIVE CONTRACT  THAT  UTILIZES  A  NETWORK  OF
PROVIDERS  offered  by  the  corporation with a condition which requires
ongoing care from a specialist may request a standing referral to such a
specialist and the procedure for requesting and obtaining such a  stand-
ing referral;
  (13)  where applicable, notice that a subscriber enrolled in a managed
care product OR A COMPREHENSIVE CONTRACT  THAT  UTILIZES  A  NETWORK  OF
PROVIDERS  offered by the corporation with (i) a life-threatening condi-
tion or disease, or (ii)  a  degenerative  and  disabling  condition  or
disease,  either  of  which  requires  specialized  medical  care over a
prolonged period of  time  may  request  a  specialist  responsible  for
providing  or  coordinating the subscriber's medical care and the proce-
dure for requesting and obtaining such a specialist;
  (14) where applicable, notice that a subscriber enrolled in a  managed
care  product  OR  A  COMPREHENSIVE  CONTRACT THAT UTILIZES A NETWORK OF
PROVIDERS offered by the corporation with (i) a life-threatening  condi-
tion  or  disease,  or  (ii)  a  degenerative and disabling condition or
disease, either of  which  requires  specialized  medical  care  over  a
prolonged  period  of time may request access to a specialty care center
and the procedure by which such access may be obtained;
  (16-a) where applicable, notice that an  enrollee  shall  have  direct
access  to  primary  and  preventive  obstetric and gynecologic services
INCLUDING ANNUAL EXAMINATIONS, CARE RESULTING FROM SUCH ANNUAL  EXAMINA-
TIONS,  AND  TREATMENT OF ACUTE GYNECOLOGIC CONDITIONS, from a qualified
provider of such services of her choice from within  the  plan  [for  no
fewer  than two examinations annually for such services] or [to] FOR any

A. 7813                            12

care related to A pregnancy [and that additionally, the  enrollee  shall
have  direct  access to primary and preventive obstetric and gynecologic
services required as a result of such annual examinations or as a result
of an acute gynecologic condition];
  (17) where applicable, a listing by specialty, which may be in a sepa-
rate  document that is updated annually, of the name, address, and tele-
phone number of all participating providers, including  facilities,  and
in  addition,  in  the  case  of physicians, board certification[; and],
LANGUAGES SPOKEN AND AFFILIATION WITH PARTICIPATING HOSPITALS. THE LIST-
ING SHALL ALSO BE POSTED ON THE CORPORATION'S  WEBSITE  AND  THE  CORPO-
RATION  SHALL  UPDATE THE WEBSITE WITHIN FIFTEEN DAYS OF THE ADDITION OR
TERMINATION OF A PROVIDER FROM THE CORPORATION'S NETWORK OR A CHANGE  IN
A PHYSICIAN'S HOSPITAL AFFILIATION;
  (18)  a description of the mechanisms by which subscribers may partic-
ipate in the development of the policies of the corporation[.];
  (19) A DESCRIPTION OF THE METHOD BY WHICH A SUBSCRIBER  MAY  SUBMIT  A
CLAIM  FOR  HEALTH  CARE SERVICES, INCLUDING THROUGH THE INTERNET, ELEC-
TRONIC MAIL OR BY FACSIMILE; AND
  (20) WHERE APPLICABLE, WHEN A CONTRACT OFFERS OUT-OF-NETWORK  COVERAGE
PURSUANT  TO  SUBSECTIONS  (B)  AND  (C)  OF  SECTION THREE THOUSAND TWO
HUNDRED FORTY OF THIS CHAPTER:
  (A) A CLEAR DESCRIPTION OF THE METHODOLOGY USED BY THE CORPORATION  TO
DETERMINE REIMBURSEMENT FOR OUT-OF-NETWORK HEALTH CARE SERVICES;
  (B)  A  DESCRIPTION  OF THE AMOUNT THAT THE CORPORATION WILL REIMBURSE
UNDER THE METHODOLOGY FOR OUT-OF-NETWORK HEALTH CARE SERVICES SET  FORTH
AS  A  PERCENTAGE  OF  THE  USUAL  AND CUSTOMARY COST FOR OUT-OF-NETWORK
HEALTH CARE SERVICES; AND
  (C) EXAMPLES OF ANTICIPATED OUT-OF-POCKET COSTS FOR FREQUENTLY  BILLED
OUT-OF-NETWORK HEALTH CARE SERVICES.
  S  19.  Paragraphs  11 and 12 of subsection (b) of section 4324 of the
insurance law, as added by chapter 705 of the laws of 1996, are  amended
and three new paragraphs 13, 14 and 15 are added to read as follows:
  (11)  where applicable, provide the written application procedures and
minimum qualification requirements  for  health  care  providers  to  be
considered  by  the  corporation  for participation in the corporation's
network for a managed care product; [and]
  (12) disclose such other information as required  by  the  superinten-
dent,  provided  that  such requirements are promulgated pursuant to the
state administrative procedure act[.];
  (13) DISCLOSE WHETHER A HEALTH CARE PROVIDER SCHEDULED  TO  PROVIDE  A
HEALTH CARE SERVICE IS AN IN-NETWORK PROVIDER;
  (14)  WHERE  APPLICABLE,  WITH  RESPECT  TO  OUT-OF-NETWORK  COVERAGE,
DISCLOSE THE DOLLAR AMOUNT THAT THE CORPORATION WILL PAY FOR A  SPECIFIC
OUT-OF-NETWORK HEALTH CARE SERVICE; AND
  (15)  PROVIDE  INFORMATION  IN WRITING AND THROUGH AN INTERNET WEBSITE
THAT REASONABLY PERMITS A SUBSCRIBER OR PROSPECTIVE SUBSCRIBER TO DETER-
MINE THE ANTICIPATED OUT-OF-POCKET COST FOR OUT-OF-NETWORK  HEALTH  CARE
SERVICES  IN  A  GEOGRAPHICAL AREA OR ZIP CODE BASED UPON THE DIFFERENCE
BETWEEN WHAT THE CORPORATION WILL REIMBURSE  FOR  OUT-OF-NETWORK  HEALTH
CARE SERVICES AND THE USUAL AND CUSTOMARY COST FOR OUT-OF-NETWORK HEALTH
CARE SERVICES EXPRESSED IN DOLLAR AMOUNTS.
  S  20.  Section  4324  of the insurance law is amended by adding a new
subsection (f) to read as follows:
  (F) FOR PURPOSES OF THIS SECTION, "USUAL  AND  CUSTOMARY  COST"  SHALL
MEAN  THE  EIGHTIETH PERCENTILE OF ALL CHARGES FOR THE PARTICULAR HEALTH
CARE SERVICE PERFORMED BY A PROVIDER IN THE SAME  OR  SIMILAR  SPECIALTY

A. 7813                            13

AND PROVIDED IN THE SAME GEOGRAPHICAL AREA AS REPORTED IN A BENCHMARKING
DATABASE  MAINTAINED BY A NONPROFIT ORGANIZATION SPECIFIED BY THE SUPER-
INTENDENT.  THE NONPROFIT ORGANIZATION SHALL NOT BE AFFILIATED  WITH  AN
INSURER,  A CORPORATION SUBJECT TO THIS ARTICLE, A MUNICIPAL COOPERATIVE
HEALTH BENEFIT PLAN CERTIFIED PURSUANT TO ARTICLE  FORTY-SEVEN  OF  THIS
CHAPTER,  OR  A  HEALTH  MAINTENANCE  ORGANIZATION CERTIFIED PURSUANT TO
ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW.
  S 21. Subsection (g-7) of section 4900 of the insurance law is  redes-
ignated  subsection (g-8) and a new subsection (g-7) is added to read as
follows:
  (G-7) "OUT-OF-NETWORK REFERRAL DENIAL" MEANS A DENIAL UNDER A  MANAGED
CARE PRODUCT AS DEFINED IN SUBSECTION (C) OF SECTION FOUR THOUSAND EIGHT
HUNDRED  ONE OF THIS CHAPTER OF A REQUEST FOR AN AUTHORIZATION OR REFER-
RAL TO AN OUT-OF-NETWORK PROVIDER ON THE BASIS THAT THE HEALTH CARE PLAN
HAS A HEALTH CARE PROVIDER IN THE IN-NETWORK  BENEFITS  PORTION  OF  ITS
NETWORK  WITH APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR
HEALTH CARE NEEDS OF  AN  INSURED,  AND  WHO  IS  ABLE  TO  PROVIDE  THE
REQUESTED  HEALTH  SERVICE.  THE NOTICE OF A DENIAL OF AN OUT-OF-NETWORK
REFERRAL PROVIDED TO AN INSURED  SHALL  INCLUDE  INFORMATION  EXPLAINING
WHAT  INFORMATION  THE INSURED MUST SUBMIT IN ORDER TO APPEAL THE DENIAL
OF AN OUT-OF-NETWORK REFERRAL PURSUANT TO SUBSECTION  (A-2)  OF  SECTION
FOUR  THOUSAND NINE HUNDRED FOUR OF THIS ARTICLE. A DENIAL OF AN OUT-OF-
NETWORK REFERRAL UNDER THIS SUBSECTION DOES NOT  CONSTITUTE  AN  ADVERSE
DETERMINATION  BASED  ON MEDICAL NECESSITY AS DEFINED IN THIS ARTICLE. A
DENIAL OF AN OUT-OF-NETWORK REFERRAL SHALL NOT BE CONSTRUED  TO  INCLUDE
AN OUT-OF-NETWORK DENIAL AS DEFINED IN SUBSECTION (G-6) OF THIS SECTION.
  S 22. Subsection (b) of section 4903 of the insurance law, as added by
chapter 705 of the laws of 1996, is amended to read as follows:
  (b)  A utilization review agent shall make a utilization review deter-
mination involving health care services which require  pre-authorization
and provide notice of a determination to the insured or insured's desig-
nee  and  the insured's health care provider by telephone and in writing
within three business days of receipt of the necessary information.  THE
NOTIFICATION SHALL IDENTIFY WHETHER THE SERVICES ARE CONSIDERED  IN-NET-
WORK OR OUT-OF-NETWORK.
  S  23.  Section  4904  of the insurance law is amended by adding a new
subsection (a-2) to read as follows:
  (A-2) AN INSURED OR THE INSURED'S DESIGNEE MAY APPEAL A DENIAL  OF  AN
OUT-OF-NETWORK  REFERRAL  BY  A HEALTH CARE PLAN BY SUBMITTING A WRITTEN
STATEMENT FROM THE INSURED'S ATTENDING  HEALTH  CARE  PROFESSIONAL,  WHO
SHALL BE THE INSURED'S IN-NETWORK PRIMARY CARE PROVIDER OR A HEALTH CARE
PROFESSIONAL  QUALIFIED  TO  PRACTICE  IN THE SPECIALTY AREA OF PRACTICE
APPROPRIATE TO TREAT THE INSURED FOR THE HEALTH SERVICE SOUGHT (WHO  MAY
BE  THE  PROPOSED  OUT-OF-NETWORK  HEALTH  CARE  PROVIDER) THAT: (1) THE
IN-NETWORK HEALTH CARE PROVIDER OR PROVIDERS RECOMMENDED BY  THE  HEALTH
CARE  PLAN  DO  NOT HAVE THE APPROPRIATE TRAINING AND EXPERIENCE TO MEET
THE PARTICULAR HEALTH CARE NEEDS OF THE INSURED FOR THE HEALTH  SERVICE;
AND  (2)  RECOMMENDS  AN  OUT-OF-NETWORK  PROVIDER  WITH THE APPROPRIATE
TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH CARE NEEDS OF  THE
INSURED, AND WHO IS ABLE TO PROVIDE THE REQUESTED HEALTH SERVICE.
  S  24.  Subsection (b) of section 4910 of the insurance law is amended
by adding a new paragraph 4 to read as follows:
  (4)(A) THE INSURED HAS HAD AN OUT-OF-NETWORK REFERRAL  DENIED  ON  THE
GROUNDS  THAT  THE  HEALTH  CARE  PLAN HAS A HEALTH CARE PROVIDER IN THE
IN-NETWORK BENEFITS PORTION OF ITS NETWORK WITH APPROPRIATE TRAINING AND

A. 7813                            14

EXPERIENCE TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN  INSURED,  AND
WHO IS ABLE TO PROVIDE THE REQUESTED HEALTH SERVICE.
  (B) THE INSURED'S ATTENDING HEALTH CARE PROFESSIONAL, WHO SHALL BE THE
INSURED'S IN-NETWORK PRIMARY CARE PROVIDER OR A HEALTH CARE PROFESSIONAL
QUALIFIED  TO  PRACTICE IN THE SPECIALTY AREA OF PRACTICE APPROPRIATE TO
TREAT THE INSURED FOR THE HEALTH SERVICE SOUGHT (WHO MAY BE THE PROPOSED
OUT-OF-NETWORK HEALTH CARE  PROVIDER),  CERTIFIES  THAT  THE  IN-NETWORK
HEALTH CARE PROVIDER OR PROVIDERS RECOMMENDED BY THE HEALTH CARE PLAN DO
NOT  HAVE THE APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR
HEALTH CARE NEEDS  OF  AN  INSURED,  AND  RECOMMENDS  AN  OUT-OF-NETWORK
PROVIDER  WHOSE  APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTIC-
ULAR HEALTH CARE NEEDS OF AN INSURED, AND WHO IS  ABLE  TO  PROVIDE  THE
REQUESTED HEALTH SERVICE.
  S  25.  Paragraph 4 of subsection (b) of section 4914 of the insurance
law is amended by adding a new subparagraph (D) to read as follows:
  (D) FOR EXTERNAL APPEALS  REQUESTED  PURSUANT  TO  PARAGRAPH  FOUR  OF
SUBSECTION  (B)  OF SECTION FOUR THOUSAND NINE HUNDRED TEN OF THIS TITLE
RELATING TO AN OUT-OF-NETWORK REFERRAL, THE EXTERNAL APPEAL AGENT  SHALL
REVIEW  THE  UTILIZATION REVIEW AGENT'S FINAL ADVERSE DETERMINATION AND,
IN ACCORDANCE WITH THE PROVISIONS OF THIS TITLE, SHALL MAKE  A  DETERMI-
NATION AS TO WHETHER THE OUT-OF-NETWORK REFERRAL SHALL BE COVERED BY THE
HEALTH  PLAN;  PROVIDED  THAT SUCH DETERMINATION SHALL: (I) BE CONDUCTED
ONLY BY ONE OR A GREATER ODD NUMBER OF CLINICAL PEER REVIEWERS; (II)  BE
ACCOMPANIED BY A WRITTEN STATEMENT: (I) THAT THE OUT-OF-NETWORK REFERRAL
SHALL  BE  COVERED BY THE HEALTH CARE PLAN EITHER WHEN THE REVIEWER OR A
MAJORITY OF THE PANEL OF REVIEWERS DETERMINES, UPON REVIEW OF THE TRAIN-
ING AND EXPERIENCE OF THE IN-NETWORK HEALTH CARE PROVIDER  OR  PROVIDERS
PROPOSED  BY THE PLAN, THE TRAINING AND EXPERIENCE OF THE REQUESTED OUT-
OF-NETWORK PROVIDER, THE INFORMATION PROVIDED  CONCERNING  THE  INSURED,
THE  ATTENDING PHYSICIAN'S RECOMMENDATION, THE INSURED'S MEDICAL RECORD,
AND ANY OTHER PERTINENT INFORMATION, THAT THE HEALTH PLAN DOES NOT  HAVE
A  PROVIDER  WITH  THE  APPROPRIATE  TRAINING AND EXPERIENCE TO MEET THE
PARTICULAR HEALTH CARE NEEDS OF AN INSURED WHO IS ABLE  TO  PROVIDE  THE
REQUESTED  HEALTH  SERVICE, AND THAT THE OUT-OF-NETWORK PROVIDER HAS THE
APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR  HEALTH  CARE
NEEDS  OF  AN  INSURED, IS ABLE TO PROVIDE THE REQUESTED HEALTH SERVICE,
AND IS LIKELY TO  PRODUCE  A  CLINICALLY  BENEFICIAL  OUTCOME;  OR  (II)
UPHOLDING  THE HEALTH PLAN'S DENIAL OF COVERAGE; (III) BE SUBJECT TO THE
TERMS AND CONDITIONS GENERALLY APPLICABLE TO BENEFITS UNDER THE EVIDENCE
OF COVERAGE UNDER THE HEALTH CARE PLAN; (IV) BE BINDING ON THE PLAN  AND
THE INSURED; AND (V) BE ADMISSIBLE IN ANY COURT PROCEEDING.
  S  26.  This act shall take effect January 1, 2014, provided, however,
that:
  1. for policies renewed on and after such date  this  act  shall  take
effect on the renewal date;
  2. sections one, two, seven, and twenty-two of this act shall apply to
health care services provided on and after such date;
  3.  section twenty-six of this act shall expire and be deemed repealed
January 1, 2016; and
  4. sections six, eight, nine, ten, twenty-one,  twenty-three,  twenty-
four  and  twenty-five  of this act shall apply to denials issued on and
after such date.