S T A T E O F N E W Y O R K
________________________________________________________________________
4437
2015-2016 Regular Sessions
I N A S S E M B L Y
January 30, 2015
___________
Introduced by M. of A. SILVER, GOTTFRIED -- Multi-Sponsored by -- M. of
A. BRAUNSTEIN, BRINDISI, DINOWITZ, HEVESI -- read once and referred to
the Committee on Health
AN ACT to amend the public health law, in relation to prohibiting Medi-
care charges by healthcare providers in excess of statutory limita-
tions
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Section 19 of the public health law, as added by chapter
572 of the laws of 1990, is amended to read as follows:
S 19. Reasonable charges for medicare beneficiaries. 1. No [physician
licensed under article one hundred thirty-one of the education law]
HEALTHCARE PROVIDER shall charge from a beneficiary of health insurance
under title XVIII of the federal social security act (medicare) any
amount in excess of ONE HUNDRED AND FIVE PERCENT OF the [following limi-
tations:
(a) Effective January first, nineteen hundred ninety-one, a physi-
cian's charge shall not exceed one hundred fifteen percent of the
reasonable charge for that service as determined by the United States
secretary for health and human services.
(b) Beginning January first, nineteen hundred ninety-three, a physi-
cian's charge shall not exceed one hundred ten percent of the reasonable
charge] ESTABLISHED MEDICARE PAYMENT RATE, INCLUDING ANY DEDUCTIBLES,
COINSURANCE OR COPAYMENTS for that service as determined by the United
States secretary for health and human services[, provided however, that
if the statewide percentage of medicare part B claims billed at or below
the reasonable charge as determined by the United States secretary for
health and human services for federal fiscal year nineteen hundred
eighty-nine fails to increase by five percentage points for federal
fiscal year nineteen hundred ninety-two, such physician's charge shall,
thereafter, not exceed one hundred five percent of the reasonable charge
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD06783-01-5
A. 4437 2
as determined by the United States secretary for health and human
services. If, in any subsequent federal fiscal year, such statewide
percentage of medicare part B claims billed at or below such reasonable
charge fails to maintain such five percentage point increase, physi-
cian's charge shall thereafter not exceed one hundred five percent of
the reasonable charge as determined by the United States secretary for
health and human services].
1-A. IN THE EVENT A BENEFICIARY OF MEDICARE EXHAUSTS ANY CAPPED BENE-
FIT FOR HEALTH CARE SERVICES, INCLUDING, BUT NOT LIMITED TO, REHABILI-
TATION SERVICES, THE CHARGE LIMITATION SET FORTH IN SUBDIVISION ONE OF
THIS SECTION SHALL CONTINUE TO APPLY, PROVIDED THAT SUCH SERVICES ARE
DETERMINED TO BE MEDICALLY NECESSARY.
2. The charge limitation set forth in subdivision one of this section
shall not apply if the service which such beneficiary is to be billed is
either an office or home visit as set forth in procedure codes 90000
through 90170 in the Physician Current Procedural Terminology 4th
Edition 1989.
3. [The state office for the aging shall, through agreement with
carriers and/or intermediaries contracted with by the federal government
in this state pursuant to title XVIII of the federal social security act
(medicare), obtain the percentages of physician's bills submitted at or
below the reasonable charge as established by the United States secre-
tary for health and human services, and shall issue a report by December
first, nineteen hundred ninety-two and every December first, thereafter,
stating whether the percentage of bills submitted at or below such
reasonable charge for federal fiscal year nineteen hundred ninety-two
increased by five percentage points over the statewide percentage of
bills submitted at or below such reasonable charge for federal fiscal
year nineteen hundred eighty-nine and whether such percentage has been
maintained for each successive federal fiscal year after nineteen
hundred ninety-two.
4.] Notwithstanding any inconsistent provision of this chapter, a
[physician] HEALTHCARE PROVIDER who is determined, after opportunity for
a hearing, to have violated the provisions of this section shall be
subject for the first violation to a fine of not more than one thousand
dollars nor less than the greater of three times the amount collected,
or, if not collected, three times the amount charged, in excess of the
limitations set forth in subdivision one of this section, and, for each
additional violation committed within five years of the date of an imme-
diately preceding violation of this section, to a fine of not more than
five thousand dollars nor less than the greater of one thousand dollars
or three times the amount collected, or, if not collected, three times
the amount charged, in excess of the limitations set forth in subdivi-
sion one of this section; provided, however, that in no event shall the
fine for an individual violation of this section be greater than five
thousand dollars. In addition, where the provisions of this section have
been violated, the [physician] HEALTHCARE PROVIDER shall refund to the
beneficiary the amount collected in excess of the limitations set forth
in subdivision one of this section.
4. FOR PURPOSES OF THIS SECTION, A "HEALTHCARE PROVIDER" SHALL MEAN A
HEALTHCARE PRACTITIONER LICENSED OR CERTIFIED UNDER TITLE EIGHT OF THE
EDUCATION LAW OR A LAWFUL COMBINATION OF SUCH HEALTHCARE PRACTITIONERS;
AND AN ENTITY LICENSED OR CERTIFIED UNDER ARTICLE TWENTY-EIGHT OR THIR-
TY-SIX OF THIS CHAPTER.
S 2. This act shall take effect immediately and shall apply to all
charges incurred on and after January 1, 2014.