senate Bill S2551

2013-2014 Legislative Session

Establishes protections to prevent surprise medical bills

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Archive: Last Bill Status - In Committee


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed/Vetoed by Governor

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Assembly Actions - Lowercase
Senate Actions - UPPERCASE
Jan 08, 2014 referred to insurance
returned to senate
died in assembly
Jun 20, 2013 referred to insurance
delivered to assembly
passed senate
ordered to third reading cal.1478
committee discharged and committed to rules
Jan 18, 2013 referred to insurance

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S2551 - Bill Details

See Assembly Version of this Bill:
A7253
Current Committee:
Senate Insurance
Law Section:
Insurance Law
Laws Affected:
Amd Ins L, generally; add §§23 & 24, amd §§4408, 4900, 4903, 4904, 4910 & 4914, Pub Health L; add Art 7 §§701 - 704, Fin Serv L
Versions Introduced in 2011-2012 Legislative Session:
S7745

S2551 - Bill Texts

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Establishes protections to prevent surprise medical bills including network adequacy requirements, claim submission requirements, adequacy of and access to out-of-network care and prohibition of excessive emergency charges.

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BILL NUMBER:S2551

TITLE OF BILL:
An act
to amend the insurance
law, the public health law and the financial
services law, in relation to establishing
protections to prevent surprise medical bills
including network adequacy requirements,
claim submission requirements, adequacy of
and access to out-of-network care and
prohibition of excessive emergency charges; and providing for the
repeal of certain provisions upon expiration thereof

PURPOSE:
This bill establishes consumer protections from surprise medical bills
by: requiring certain disclosures from insurers, health care
providers and hospitals; requiring adequate access to care;
establishing a minimum reimbursement for out-of-network services; and
prohibiting excessive emergency room charges.

SUMMARY OF PROVISIONS:

Section one amends Insurance Law § 3217-a(a) to make several conforming
changes and require insurers to provide several additional
disclosures. For all policies offering out-of-network coverage
pursuant to § 3420(b)&(c) of this article, the insurer must provide a
clear description of the methodology used to determine reimbursement
for out-of-network health care services, including a description of
the amount set forth as a percentage of the usual and customary cost
for out-of-network health care services and examples of anticipated
out-of-pocket costs.

Section two amends Insurance Law § 3217-a(b) to require the insurer
disclose, upon request, whether a health care provider scheduled to
perform services is in-network and where applicable, 1) the dollar
amount the insurer will pay for specific out-of-network services, and
2) information permitting an insured or prospective insured to
determine anticipated out-of-pocket costs for out-of-network services
in a geographical area, based upon the difference the insurer will
reimburse and the usual and customary cost.

Section three amends Insurance Law § 3217-a(f) to define the usual and
customary cost as the eightieth percentile of all charges for a
particular health care service performed in the same or similar
specialty and provided in the same geographical area as reported by
FAIR Health, Inc.

Section four amends Insurance Law § 3217-d(d) to provide that
comprehensive policies under this article must provide access to
out-of-network services if there is no in-network provider.

Section five amends Insurance Law § 3224-a to require an insurer, a
corporation or organization under Article 43 or Article 47 of this
chapter and HMOs under Article 44 of the Public Health Law to accept
claims submitted through the internet, e-mail or fax.


Section six adds a new § 3240 to the Insurance Law. Section 3240(a)
requires that an insurer, a corporation organized pursuant to Article
43 and a municipal cooperative health benefit plan under Article 47
of this chapter maintain an adequate network. Sections 3240(b) & (c)
requires an insurer, a corporation organized pursuant to Article 43,
a municipal cooperative health benefit plan certified under Article
47 of this Chapter and an HMO under article 44 of the Public Health
Law to provide: 1) significant coverage of the usual and customary
cost of out-of-network services; and 2) to offer at least one policy
or contract option in each geographical region covered that provides
coverage for at least 80% of the usual and customary cost of
out-of-network health care services, after imposition of a deductible.

Section seven amends Insurance Law § 4306-c to require Article 43
corporations and municipal cooperative health benefit plans certified
pursuant to Article 47 that utilize a network of providers to provide
access to out-of-network services.

Section eight amends Insurance Law § 4324 to make the changes outlined
in section one of this bill to Article 43 corporations.

Section nine amends Insurance Law § 4324 to make the changes outlined
in section two of this bill applicable to Article 43 corporations.

Section ten amends Insurance Law § 4324 to define the usual and
customary cost for purposes of this section.

Sections 11, 12, 13, 14 and 15 amend Article 49 of the Insurance Law
to establish a procedure for the review and appeal of denials of
out-of-network referrals.

Section 16 adds Public Health Law § 23-§ 24 requiring physicians to
submit a claim form with a patient bill and requiring care
professionals and hospitals to provide certain disclosures.

Section 17 amends Public Health Law § 4408 to make the same disclosures
detailed in sections one and eight of this bill applicable to HMOs.

Section 18 amends Public Health Law § 4408 make the same changes
provided in sections two and nine of this bill applicable to HMOs.

Section 19 amends Public Health Law § 4408 to define the usual and
customary cost of out-of-network services.

Sections 20, 21, 22, 23 and 24 amend Article 49 of the Public Health
Law to establish a procedure for the review and appeal of denials of
out-of-network referrals.

Section 25 amends the Financial Services Law to establish a new
Article 7 to prohibit excessive charges for emergency services. This
article establishes a binding dispute resolution process and criteria
for determining what constitutes excessive charges.

Section 26 provides that this act shall take effect on January 1,
2014, provided, however, that: 1) policies renewed on and after such
date this act shall take effect on the renewal date; 2) sections 12,
16, 21 and 25 shall apply to health care services provided on and


after such date and section 26 shall be deemed repealed on January 1,
2016; and 3) sections 11, 13, 14, 15, 20, 22, 23 and 24 of this act
shall apply to denials issued on and after such date.

JUSTIFICATION:
Some consumers choose health insurance policies that permit them to
receive care from a nonparticipating provider because it allows them
to see the health care provider of their choice. However, this
out-of-network system has been fraught with problems.

In February 2008, then Attorney General Andrew M. Cuomo announced an
investigation into a scheme by health insurers to defraud consumers
by manipulating the reasonable and customary rates. As part of this
investigation, the Attorney General announced his intent to file suit
against Ingenix, Inc. (a health care pricing database), subsidiary of
United Health Group, asserting that the rates found in the database
were lower than the actual cost of medical expenses. According to the
Attorney General, this allowed health insurance companies to deny a
portion of provider claims inappropriately, thereby pushing costs
down to members. In January 2009, United Health Group reached a
settlement with the Attorney General whereby they agreed to pay S50
million to fund a not-for-profit entity to develop a new, independent
product to replace its database. As a result, FAIR Health, Inc. was
established with the mission of ensuring transparency in health care
costs.

The FAIR Health database is now operational for reporting medical
charge data. However, since the fall of Ingenix, a number of insurers
have begun using Medicare rates as the benchmark for determining
reimbursement of out-of-network costs. This often results in what
some deem to be inadequate reimbursement. This legislation is
intended to ensure that the FAIR Health database is appropriately
utilized.

The New York Times recently reported an instance in which a patient
was billed 52,800 for half an hour of anesthesia provided by an
out-of-net-work anesthesiologist during a routine colonoscopy
provided by a participating provider. The Department of Financial
Services recently released a report detailing the challenges
consumers face with unexpected medical billings. This legislation
would address these concerns by requiring certain disclosures by
health care providers, hospitals and insurers to prevent surprise
medical bills. This bill also protects
consumers by ensuring they have adequate access to in-network
services, with the capability to go out-of-network in the event there
is no in-network provider. Furthermore, this legislation protects
consumers from excessive charges for emergency services.

LEGISLATIVE HISTORY: 2012 S.7745 Passed Senate

FISCAL IMPLICATIONS: None.

EFFECTIVE DATE:
January 1, 2013 with certain provisions.


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

                                  2551

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                            January 18, 2013
                               ___________

Introduced  by  Sens. HANNON, LAVALLE -- read twice and ordered printed,
  and when printed to be committed to the Committee on Insurance

AN ACT to amend the insurance law, the public health law and the  finan-
  cial  services law, in relation to establishing protections to prevent
  surprise medical bills including network adequacy requirements,  claim
  submission requirements, adequacy of and access to out-of-network care
  and  prohibition of excessive emergency charges; and providing for the
  repeal of certain provisions upon expiration thereof

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

  Section  1.  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,

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD02652-01-3

S. 2551                             2

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;
  (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  THREE  THOUSAND  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 2. 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;

S. 2551                             3

  (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.
  S 3. 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  4.  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
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  5.  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 6. 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

S. 2551                             4

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
FORTY-SEVEN OF THIS CHAPTER, OR A HEALTH MAINTENANCE ORGANIZATION CERTI-
FIED PURSUANT TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW.
  S  7.  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 8. 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

S. 2551                             5

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
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
LISTING 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

S. 2551                             6

  (C)  EXAMPLES OF ANTICIPATED OUT-OF-POCKET COSTS FOR FREQUENTLY BILLED
OUT-OF-NETWORK HEALTH CARE SERVICES.
  S  9.  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.
  S  10.  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
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 11. 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  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. 2551                             7

  S 12. 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 13. 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  PHYSICIAN,  WHO  MUST  BE  A
LICENSED, BOARD CERTIFIED OR BOARD ELIGIBLE PHYSICIAN QUALIFIED TO PRAC-
TICE IN THE SPECIALTY AREA OF PRACTICE APPROPRIATE TO TREAT THE  INSURED
FOR  THE  HEALTH  SERVICE  SOUGHT  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 14. 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
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 PHYSICIAN, WHO SHALL BE A LICENSED,  BOARD
CERTIFIED  OR  BOARD  ELIGIBLE  PHYSICIAN  QUALIFIED  TO PRACTICE IN THE
SPECIALTY AREA OF PRACTICE APPROPRIATE TO  TREAT  THE  INSURED  FOR  THE
HEALTH SERVICE SOUGHT, CERTIFIES THAT THE IN-NETWORK HEALTH CARE PROVID-
ER  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 WITH THE
APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR  HEALTH  CARE
NEEDS  OF  AN  INSURED,  AND WHO IS ABLE TO PROVIDE THE REQUESTED HEALTH
SERVICE.
  S 15. 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 REVIEW-
ERS DETERMINES, UPON REVIEW  OF  THE  TRAINING  AND  EXPERIENCE  OF  THE
IN-NETWORK  HEALTH  CARE PROVIDER OR PROVIDERS PROPOSED BY THE PLAN, THE

S. 2551                             8

TRAINING AND EXPERIENCE OF THE REQUESTED  OUT-OF-NETWORK  PROVIDER,  THE
CLINICAL  STANDARDS OF THE PLAN, 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 MORE 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 16. The public health law is amended by adding two new  sections  23
and 24 to read as follows:
  S  23.  CLAIM  FORMS.    A  PHYSICIAN SHALL INCLUDE A CLAIM FORM FOR A
THIRD-PARTY PAYOR WITH A PATIENT BILL FOR HEALTH  CARE  SERVICES,  OTHER
THAN A BILL FOR THE PATIENT'S CO-PAYMENT, COINSURANCE OR DEDUCTIBLE.
  S  24.  DISCLOSURE.    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
PARTICIPATING  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 WHO  IS  A  PHYSICIAN  SHALL  PROVIDE  A
PATIENT  OR  PROSPECTIVE  PATIENT  WITH THE NAME, PRACTICE NAME, MAILING
ADDRESS, AND TELEPHONE NUMBER OF ANY HEALTH CARE  PROVIDER  OF  ANESTHE-
SIOLOGY,  LABORATORY, PATHOLOGY, RADIOLOGY OR ASSISTANT SURGEON SERVICES
PERFORMED IN THE PHYSICIAN'S OFFICE OR COORDINATED OR  REFERRED  BY  THE
PHYSICIAN.
  4.    A  HEALTH  CARE  PROFESSIONAL  WHO  IS  A PHYSICIAN SHALL, FOR A
PATIENT'S SCHEDULED HOSPITAL 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 PHYSICIAN  WHOSE
SERVICES WILL BE ARRANGED BY THE PHYSICIAN 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 WHO IS A PHYSICIAN AND WHOSE SERVICES  WILL  BE

S. 2551                             9

PROVIDED AT THE HOSPITAL, 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 WHO
IS A PHYSICIAN AND WHOSE SERVICES ARE REASONABLY ANTICIPATED AT THE TIME
OF THE PRE-ADMISSION TESTING, REGISTRATION  OR  ADMISSION  AND  WILL  BE
PROVIDED AT THE HOSPITAL, BUT WILL NOT BE BILLED AS PART OF THE HOSPITAL
CHARGES, AS REPORTED BY THE PATIENT'S PHYSICIAN; AND (B) DISCLOSE WHETH-
ER  THE  SERVICES  OF  HEALTH  CARE PROFESSIONALS WHO ARE PHYSICIANS AND
TYPICALLY PROVIDE HOSPITAL SERVICES SUCH AS, BUT NOT LIMITED TO, ANESTH-
ESIOLOGY, PATHOLOGY OR RADIOLOGY ARE BILLED  AS  PART  OF  THE  HOSPITAL
CHARGES.
  8. FOR PURPOSES OF THIS SECTION:
  (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 A SELF-FUNDED EMPLOYEE WELFARE BENEFIT PLAN.
  (B) "HEALTH CARE PROFESSIONAL" MEANS AN APPROPRIATELY LICENSED, REGIS-
TERED  OR  CERTIFIED HEALTH CARE PROFESSIONAL PURSUANT TO TITLE EIGHT OF
THE EDUCATION LAW.
  S 17. Paragraphs (p-1), (q) and (r) of subdivision 1 of  section  4408
of the public health law, paragraph (p-1) as added by chapter 554 of the
laws  of 2002, and paragraphs (q) and (r) as added by chapter 705 of the
laws of 1996, 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

S. 2551                            10

  (T) WHERE APPLICABLE, WHEN A CONTRACT OFFERS  OUT-OF-NETWORK  COVERAGE
PURSUANT  TO  SUBSECTIONS  (B)  AND  (C)  OF  SECTION THREE THOUSAND TWO
HUNDRED FORTY OF THE INSURANCE LAW:
  (I)  A CLEAR DESCRIPTION OF THE METHODOLOGY USED BY THE HEALTH MAINTE-
NANCE ORGANIZATION TO DETERMINE REIMBURSEMENT FOR OUT-OF-NETWORK  HEALTH
CARE SERVICES;
  (II) A DESCRIPTION OF THE AMOUNT THAT THE HEALTH MAINTENANCE ORGANIZA-
TION 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  18.  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]
  (1) 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.
  S 19. 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  20.  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-

S. 2551                            11

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 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 21. 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 22. Section 4904 of the public health law is amended by adding a new
subdivision 1-b to read as follows:
  1-B. AN ENROLLEE OR THE ENROLLEE'S DESIGNEE MAY APPEAL A DENIAL OF  AN
OUT-OF-NETWORK  REFERRAL  BY  A HEALTH CARE PLAN BY SUBMITTING A WRITTEN
STATEMENT FROM  THE  ENROLLEE'S  ATTENDING  PHYSICIAN,  WHO  MUST  BE  A
LICENSED, BOARD CERTIFIED OR BOARD ELIGIBLE PHYSICIAN QUALIFIED TO PRAC-
TICE IN THE SPECIALTY AREA OF PRACTICE APPROPRIATE TO TREAT THE ENROLLEE
FOR  THE  HEALTH  SERVICE  SOUGHT  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 ENROLLEE FOR THE HEALTH SERVICE; AND (B) RECOMMENDS AN
OUT-OF-NETWORK PROVIDER WITH THE APPROPRIATE TRAINING AND EXPERIENCE  TO
MEET  THE  PARTICULAR HEALTH CARE NEEDS OF THE ENROLLEE, AND WHO IS ABLE
TO PROVIDE THE REQUESTED HEALTH SERVICE.
  S 23. 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 ENROLLEE 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 ENROLLEE, AND
WHO IS ABLE TO PROVIDE THE REQUESTED HEALTH SERVICE.
  (II) THE ENROLLEE'S ATTENDING PHYSICIAN,  WHO  SHALL  BE  A  LICENSED,
BOARD CERTIFIED OR BOARD ELIGIBLE PHYSICIAN QUALIFIED TO PRACTICE IN THE
SPECIALTY  AREA  OF  PRACTICE  APPROPRIATE TO TREAT THE ENROLLEE FOR THE
HEALTH SERVICE SOUGHT, CERTIFIES THAT THE IN-NETWORK HEALTH CARE PROVID-
ER 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 ENROLLEE, AND RECOMMENDS AN OUT-OF-NETWORK PROVIDER WITH THE
APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR  HEALTH  CARE
NEEDS  OF  AN  ENROLLEE, AND WHO IS ABLE TO PROVIDE THE REQUESTED HEALTH
SERVICE.
  S 24. 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-

S. 2551                            12

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 REVIEW-
ERS  DETERMINES,  UPON  REVIEW  OF  THE  TRAINING  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
CLINICAL STANDARDS OF THE PLAN, 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 EXPERI-
ENCE 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 PARTIC-
ULAR  HEALTH CARE NEEDS OF AN ENROLLEE, IS ABLE TO PROVIDE THE REQUESTED
HEALTH SERVICE, AND IS LIKELY TO PRODUCE A  MORE  CLINICALLY  BENEFICIAL
OUTCOME; OR
  (2) 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 ENROLLEE; AND
  (V) BE ADMISSIBLE IN ANY COURT PROCEEDING.
  S 25. The financial services law is amended by adding a new article  7
to read as follows:
                                 ARTICLE 7
                       EMERGENCY MEDICAL SERVICES
SECTION 701. DEFINITIONS.
        702. PROHIBITION OF EXCESSIVE CHARGES FOR EMERGENCY SERVICES.
        703. DISPUTE RESOLUTION.
        704. CRITERIA FOR DETERMINING EXCESSIVE CHARGES.
  S 701. DEFINITIONS. FOR THE PURPOSES OF THIS ARTICLE:
  (A) "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 (1) 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;  (2) SERIOUS IMPAIRMENT TO SUCH PERSON'S BODILY FUNC-
TIONS; (3) SERIOUS DYSFUNCTION OF ANY  BODILY  ORGAN  OR  PART  OF  SUCH
PERSON;  (4)  SERIOUS  DISFIGUREMENT  OF SUCH PERSON; OR (5) A CONDITION
DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A)  OF  THE
SOCIAL SECURITY ACT.
  (B)  "EMERGENCY  SERVICES"  MEANS, WITH RESPECT TO AN EMERGENCY CONDI-
TION: (1) A MEDICAL SCREENING EXAMINATION AS REQUIRED UNDER SECTION 1867
OF THE SOCIAL SECURITY ACT, 42 U.S.C. S  1395DD,  WHICH  IS  WITHIN  THE
CAPABILITY  OF  THE EMERGENCY DEPARTMENT OF A HOSPITAL, INCLUDING ANCIL-
LARY SERVICES ROUTINELY AVAILABLE TO THE EMERGENCY DEPARTMENT TO  EVALU-
ATE SUCH EMERGENCY MEDICAL CONDITION; AND (2) WITHIN THE CAPABILITIES OF
THE STAFF AND FACILITIES AVAILABLE AT THE HOSPITAL, 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.

S. 2551                            13

  (C) "EXCESSIVE FEE" MEANS A FEE THAT IS IN EXCESS OF AN AMOUNT  DETER-
MINED IN ACCORDANCE WITH SECTION SEVEN HUNDRED FOUR OF THIS ARTICLE.
  (D)  "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  THE  PUBLIC  HEALTH  LAW;  OR A SELF-FUNDED EMPLOYEE WELFARE BENEFIT
PLAN.
  (E) "INSURED" MEANS A PATIENT COVERED UNDER A POLICY OR CONTRACT  WITH
A HEALTH CARE PLAN.
  (F)  "PATIENT"  MEANS A PERSON WHO RECEIVES EMERGENCY SERVICES IN THIS
STATE.
  (G) "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 SUPERINTENDENT. THE NONPROFIT ORGANIZATION
SHALL NOT BE AFFILIATED WITH AN INSURER, A CORPORATION SUBJECT TO  ARTI-
CLE  FORTY-THREE  OF  THE  INSURANCE LAW, A MUNICIPAL COOPERATIVE HEALTH
BENEFIT PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THE  INSURANCE
LAW,  OR A HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE
FORTY-FOUR OF THE PUBLIC HEALTH LAW.
  S 702. PROHIBITION OF EXCESSIVE CHARGES FOR EMERGENCY SERVICES.  (A) A
PHYSICIAN WHO PROVIDES HEALTH CARE SERVICES  IN  THIS  STATE  SHALL  NOT
CHARGE  AN  EXCESSIVE  FEE BASED ON THE CRITERIA FOR PROVIDING EMERGENCY
SERVICES IN SECTION SEVEN HUNDRED THREE OF THIS ARTICLE.
  (B) THIS ARTICLE SHALL NOT APPLY TO EMERGENCY SERVICES WHERE  PROVIDER
FEES  ARE  SUBJECT  TO SCHEDULES OR OTHER MONETARY LIMITATIONS UNDER ANY
OTHER LAW, INCLUDING THE WORKERS' COMPENSATION LAW AND ARTICLE FIFTY-ONE
OF THE INSURANCE LAW, AND SHALL NOT PREEMPT ANY SUCH LAW.
  S 703. DISPUTE RESOLUTION.  (A) A HEALTH CARE PLAN OR A PATIENT ALLEG-
ING THAT A PHYSICIAN HAS CHARGED AN EXCESSIVE FEE FOR PROVIDING EMERGEN-
CY SERVICES MAY SUBMIT THE DISPUTE FOR REVIEW TO AN INDEPENDENT  DISPUTE
RESOLUTION  ENTITY,  IN  ACCORDANCE  WITH REGULATIONS PROMULGATED BY THE
SUPERINTENDENT, IF THE PHYSICIAN'S CHARGE EXCEEDS THE USUAL AND  CUSTOM-
ARY COST OF THE HEALTH CARE SERVICES.
  (B)  A  PATIENT  SHALL  NOT  BE REQUIRED TO PAY THE PHYSICIAN'S FEE IN
ORDER TO BE ELIGIBLE TO SUBMIT THE DISPUTE FOR REVIEW TO THE INDEPENDENT
DISPUTE RESOLUTION ENTITY.
  S 704. CRITERIA FOR DETERMINING EXCESSIVE CHARGES.  (A) (1) THE  INDE-
PENDENT  DISPUTE  RESOLUTION ENTITY SHALL DECIDE WHETHER THE FEE CHARGED
BY THE PHYSICIAN FOR THE SERVICES RENDERED IS EXCESSIVE. IN MAKING  SUCH
A DETERMINATION THE INDEPENDENT DISPUTE RESOLUTION ENTITY SHALL CONSIDER
ALL RELEVANT FACTORS INCLUDING:
  (I)  WHETHER THERE IS A GROSS DISPARITY BETWEEN THE FEE CHARGED BY THE
PHYSICIAN FOR SERVICES RENDERED AS COMPARED TO: (A)  FEES  PAID  BY  THE
HEALTH  CARE  PLAN  TO  REIMBURSE SIMILARLY QUALIFIED PHYSICIANS FOR THE
SAME SERVICES IN THE SAME REGION WHO DO NOT PARTICIPATE WITH THE  HEALTH
CARE  PLAN;  AND  (B)  FEES  PAID TO THE INVOLVED PHYSICIAN FOR THE SAME
SERVICES RENDERED BY THE PHYSICIAN TO PATIENTS IN HEALTH CARE  PLANS  IN
WHICH THE PHYSICIAN DOES NOT PARTICIPATE;
  (II) THE LEVEL OF TRAINING, EDUCATION AND EXPERIENCE OF THE PHYSICIAN;

S. 2551                            14

  (III) THE PHYSICIAN'S USUAL CHARGE FOR COMPARABLE SERVICES WITH REGARD
TO PATIENTS IN HEALTH CARE PLANS IN WHICH THE PHYSICIAN DOES NOT PARTIC-
IPATE;
  (IV)  THE CIRCUMSTANCES AND COMPLEXITY OF THE PARTICULAR CASE, INCLUD-
ING TIME AND PLACE OF THE SERVICE;
  (V) INDIVIDUAL PATIENT CHARACTERISTICS; AND
  (VI) THE USUAL AND CUSTOMARY COST OF THE SERVICE.
  (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
PHYSICIAN 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.
  (B) THE DETERMINATION OF  AN  INDEPENDENT  DISPUTE  RESOLUTION  ENTITY
SHALL  BE  BINDING  ON  THE HEALTH CARE PLAN, PHYSICIAN AND PATIENT, AND
SHALL BE ADMISSIBLE IN ANY COURT  PROCEEDING  BETWEEN  THE  HEALTH  CARE
PLAN,  PHYSICIAN OR PATIENT, OR IN ANY ADMINISTRATIVE PROCEEDING BETWEEN
THIS STATE AND THE PHYSICIAN.
  (C) THE SUPERINTENDENT SHALL PROMULGATE REGULATIONS TO ESTABLISH STAN-
DARDS FOR THE DISPUTE RESOLUTION PROCESS INCLUDING STANDARDS FOR  ESTAB-
LISHING  WHICH  PARTY  SHALL  BE  RESPONSIBLE FOR PAYMENT OF THE DISPUTE
RESOLUTION PROCESS.
  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 twelve, sixteen, twenty-one and twenty-five  of  this  act
shall  apply to health care services provided on and after such date and
section twenty-five of this act shall  expire  and  be  deemed  repealed
January 1, 2016; and
  3.  sections  eleven, thirteen, fourteen, fifteen, twenty, twenty-two,
twenty-three and twenty-four of this act shall apply to  denials  issued
on and after such date.

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