S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   1529
 
                        2017-2018 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 12, 2017
                                ___________
 
 Introduced  by M. of A. JENNE, DiPIETRO, STECK, WOERNER -- read once and
   referred to the Committee on Insurance
 
 AN ACT to amend the insurance law and the public health law, in relation
   to provider credentialing
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:

   Section  1.    Subsection (a) of section 4803 of the insurance law, as
 amended by chapter 237 of the laws of 2009, is amended by adding  a  new
 paragraph 3 to read as follows:
   (3) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED
 TO  THIS  STATE  FROM  ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED IN
 THIS STATE, OR  A  PHYSICIAN  WHO  HAS  CHANGED  HIS  OR  HER  CORPORATE
 RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI-
 CATION  NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR, WHO
 IS EMPLOYED BY A GENERAL HOSPITAL LICENSED PURSUANT TO  ARTICLE  TWENTY-
 EIGHT  OF  THE  PUBLIC  HEALTH  LAW, AND WHOSE OTHER EMPLOYED PHYSICIANS
 PARTICIPATE IN THE IN-NETWORK  PORTION OF AN INSURER'S NETWORK, SHALL BE
 DEEMED "PROVISIONALLY CREDENTIALED"  AND MAY PARTICIPATE IN THE  IN-NET-
 WORK  PORTION OF AN INSURER'S NETWORK UPON: (I) THE INSURER'S RECEIPT OF
 THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTIONS OF THE INSURER'S CREDEN-
 TIALING APPLICATION; AND (II) THE INSURER BEING NOTIFIED IN WRITING THAT
 THE HEALTH CARE PROFESSIONAL HAS BEEN GRANTED HOSPITAL PRIVILEGES PURSU-
 ANT TO THEIR REQUIREMENTS OF SECTION TWENTY-EIGHT HUNDRED FIVE-K OF  THE
 PUBLIC HEALTH LAW. HOWEVER, A PROVISIONALLY CREDENTIALED PHYSICIAN SHALL
 NOT BE DESIGNATED AS AN INSURED'S PRIMARY CARE PHYSICIAN UNTIL SUCH TIME
 AS  THE PHYSICIAN HAS BEEN FULLY CREDENTIALED BY THE INSURER. AN INSURER
 SHALL NOT BE REQUIRED TO MAKE  ANY  PAYMENTS  TO  THE  LICENSED  GENERAL
 HOSPITAL  FOR  SERVICES  PROVIDED BY A PROVISIONALLY CREDENTIALED PHYSI-
 CIAN, UNTIL AND UNLESS THE PHYSICIAN IS FULLY CREDENTIALED BY THE INSUR-
 ER, PROVIDED, HOWEVER, THAT UPON BEING FULLY CREDENTIALED, THE  LICENSED
 GENERAL  HOSPITAL  SHALL  BE PAID FOR ALL SERVICES THAT THE CREDENTIALED
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD02441-01-7

 A. 1529                             2
 
 PHYSICIAN PROVIDED TO THE INSURER'S INSUREDS FROM THE DATE THE PHYSICIAN
 FULLY MET THE REQUIREMENTS TO BE PROVISIONALLY CREDENTIALED PURSUANT  TO
 THIS  PARAGRAPH.  SHOULD  THE  APPLICATION  ULTIMATELY  BE DENIED BY THE
 INSURER, THE INSURER SHALL NOT BE LIABLE FOR ANY PAYMENT TO THE LICENSED
 GENERAL  HOSPITAL FOR THE SERVICES PROVIDED BY THE PROVISIONALLY CREDEN-
 TIALED HEALTH CARE PROFESSIONAL THAT EXCEED ANY OUT-OF-NETWORK  BENEFITS
 PAYABLE  UNDER THE INSURED'S CONTRACT WITH THE INSURER; AND THE LICENSED
 GENERAL HOSPITAL SHALL NOT PURSUE REIMBURSEMENT FROM THE INSURED, EXCEPT
 TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD  HAVE  BEEN
 PAYABLE  HAD  THE  INSURED  RECEIVED SERVICES FROM A HEALTH CARE PROFES-
 SIONAL PARTICIPATING IN THE IN-NETWORK PORTION OF AN INSURER'S NETWORK.
   § 2. Subsection (a) of section 4803 of the insurance law,  as  amended
 by chapter 425 of the laws of 2016, is amended by adding a new paragraph
 3 to read as follows:
   (3) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED
 TO  THIS  STATE  FROM  ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED IN
 THIS STATE, OR  A  PHYSICIAN  WHO  HAS  CHANGED  HIS  OR  HER  CORPORATE
 RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI-
 CATION  NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR, WHO
 IS EMPLOYED BY A GENERAL HOSPITAL LICENSED PURSUANT TO  ARTICLE  TWENTY-
 EIGHT  OF  THE  PUBLIC  HEALTH  LAW, AND WHOSE OTHER EMPLOYED PHYSICIANS
 PARTICIPATE IN THE IN-NETWORK  PORTION OF AN INSURER'S NETWORK, SHALL BE
 DEEMED "PROVISIONALLY CREDENTIALED"  AND MAY PARTICIPATE IN THE  IN-NET-
 WORK  PORTION OF AN INSURER'S NETWORK UPON: (I) THE INSURER'S RECEIPT OF
 THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTIONS OF THE INSURER'S CREDEN-
 TIALING APPLICATION; AND (II) THE INSURER BEING NOTIFIED IN WRITING THAT
 THE HEALTH CARE PROFESSIONAL HAS BEEN GRANTED HOSPITAL PRIVILEGES PURSU-
 ANT TO THEIR REQUIREMENTS OF SECTION TWENTY-EIGHT HUNDRED FIVE-K OF  THE
 PUBLIC HEALTH LAW. HOWEVER, A PROVISIONALLY CREDENTIALED PHYSICIAN SHALL
 NOT BE DESIGNATED AS AN INSURED'S PRIMARY CARE PHYSICIAN UNTIL SUCH TIME
 AS  THE PHYSICIAN HAS BEEN FULLY CREDENTIALED BY THE INSURER. AN INSURER
 SHALL NOT BE REQUIRED TO MAKE  ANY  PAYMENTS  TO  THE  LICENSED  GENERAL
 HOSPITAL  FOR  SERVICES  PROVIDED BY A PROVISIONALLY CREDENTIALED PHYSI-
 CIAN, UNTIL AND UNLESS THE PHYSICIAN IS FULLY CREDENTIALED BY THE INSUR-
 ER, PROVIDED, HOWEVER, THAT UPON BEING FULLY CREDENTIALED, THE  LICENSED
 GENERAL  HOSPITAL  SHALL  BE PAID FOR ALL SERVICES THAT THE CREDENTIALED
 PHYSICIAN PROVIDED TO THE INSURER'S INSUREDS FROM THE DATE THE PHYSICIAN
 FULLY MET THE REQUIREMENTS TO BE PROVISIONALLY CREDENTIALED PURSUANT  TO
 THIS  PARAGRAPH.  SHOULD  THE  APPLICATION  ULTIMATELY  BE DENIED BY THE
 INSURER, THE INSURER SHALL NOT BE LIABLE FOR ANY PAYMENT TO THE LICENSED
 GENERAL HOSPITAL FOR THE SERVICES PROVIDED BY THE PROVISIONALLY  CREDEN-
 TIALED  HEALTH CARE PROFESSIONAL THAT EXCEED ANY OUT-OF-NETWORK BENEFITS
 PAYABLE UNDER THE INSURED'S CONTRACT WITH THE INSURER; AND THE  LICENSED
 GENERAL HOSPITAL SHALL NOT PURSUE REIMBURSEMENT FROM THE INSURED, EXCEPT
 TO  COLLECT  THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE BEEN
 PAYABLE HAD THE INSURED RECEIVED SERVICES FROM  A  HEALTH  CARE  PROFES-
 SIONAL PARTICIPATING IN THE IN-NETWORK PORTION OF AN INSURER'S NETWORK.
   §  3.  Subdivision  1  of  section 4406-d of the public health law, as
 amended by chapter 237 of the laws of 2009, is amended by adding  a  new
 paragraph (c) to read as follows:
   (C) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED
 TO  THIS  STATE  FROM  ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED IN
 THIS STATE, OR  A  PHYSICIAN  WHO  HAS  CHANGED  HIS  OR  HER  CORPORATE
 RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI-
 CATION  NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR, WHO
 IS EMPLOYED BY A GENERAL HOSPITAL LICENSED PURSUANT TO  ARTICLE  TWENTY-

 A. 1529                             3
 
 EIGHT  OF  THIS CHAPTER, AND WHOSE OTHER EMPLOYED PHYSICIANS PARTICIPATE
 IN THE IN-NETWORK PORTION OF A HEALTH  CARE  PLAN'S  NETWORK,  SHALL  BE
 DEEMED  "PROVISIONALLY  CREDENTIALED" AND MAY PARTICIPATE IN THE IN-NET-
 WORK  PORTION  OF  A  HEALTH  CARE  PLAN'S  NETWORK UPON: (I) THE PLAN'S
 RECEIPT OF THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTION OF THE  PLAN'S
 CREDENTIALING  APPLICATION; AND (II) THE HEALTH CARE PLAN BEING NOTIFIED
 IN WRITING THAT THE HEALTH CARE PROFESSIONAL HAS BEEN  GRANTED  HOSPITAL
 PRIVILEGE  PURSUANT  TO THE REQUIREMENTS OF SECTION TWENTY-EIGHT HUNDRED
 FIVE-K OF THIS CHAPTER. HOWEVER, A PROVISIONALLY CREDENTIALED  PHYSICIAN
 SHALL  NOT  BE  DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL
 SUCH TIME AS THE PHYSICIAN HAS BEEN FULLY  CREDENTIALED  BY  THE  HEALTH
 CARE PLAN. A HEALTH CARE PLAN SHALL NOT BE REQUIRED TO MAKE ANY PAYMENTS
 TO  THE  LICENSED  GENERAL  HOSPITAL  FOR  SERVICES PROVIDED BY A PROVI-
 SIONALLY CREDENTIALED PHYSICIAN, UNTIL AND UNLESS THE PHYSICIAN IS FULLY
 CREDENTIALED BY THE HEALTH CARE PLAN, PROVIDED HOWEVER THAT  UPON  BEING
 FULLY  CREDENTIALED, THE LICENSED GENERAL HOSPITAL SHALL BE PAID FOR ALL
 SERVICES THAT THE CREDENTIALED PHYSICIAN PROVIDED TO THE  HEALTH  PLAN'S
 ENROLLEES  FROM  THE DATE THE PHYSICIAN FULLY MET THE REQUIREMENTS TO BE
 PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH. SHOULD THE APPLI-
 CATION ULTIMATELY BE DENIED BY THE HEALTH CARE  PLAN,  THE  HEALTH  CARE
 PLAN  SHALL NOT BE LIABLE FOR ANY PAYMENT TO THE LICENSED GENERAL HOSPI-
 TAL FOR THE SERVICES PROVIDED BY THE PROVISIONALLY  CREDENTIALED  HEALTH
 CARE  PROFESSIONAL THAT EXCEED ANY OUT-OF-NETWORK BENEFITS PAYABLE UNDER
 THE ENROLLEE'S CONTRACT WITH THE  HEALTH  CARE  PLAN  AND  THE  LICENSED
 GENERAL  HOSPITAL  SHALL  NOT  PURSUE  REIMBURSEMENT  FROM THE ENROLLEE,
 EXCEPT TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE
 BEEN PAYABLE HAD THE ENROLLEE  RECEIVED  SERVICES  FROM  A  HEALTH  CARE
 PROFESSIONAL  PARTICIPATING  IN  THE  IN-NETWORK PORTION OF AN INSURER'S
 NETWORK.
   § 4. Subdivision 1 of section 4406-d of  the  public  health  law,  as
 amended  by  chapter 425 of the laws of 2016, is amended by adding a new
 paragraph (c) to read as follows:
   (C) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED
 TO THIS STATE FROM ANOTHER STATE AND HAS  NOT  PREVIOUSLY  PRACTICED  IN
 THIS  STATE,  OR  A  PHYSICIAN  WHO  HAS  CHANGED  HIS  OR HER CORPORATE
 RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI-
 CATION NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR,  WHO
 IS  EMPLOYED  BY A GENERAL HOSPITAL LICENSED PURSUANT TO ARTICLE TWENTY-
 EIGHT OF THIS CHAPTER, AND WHOSE OTHER EMPLOYED  PHYSICIANS  PARTICIPATE
 IN  THE  IN-NETWORK  PORTION  OF  A HEALTH CARE PLAN'S NETWORK, SHALL BE
 DEEMED "PROVISIONALLY CREDENTIALED" AND MAY PARTICIPATE IN  THE  IN-NET-
 WORK  PORTION  OF  A  HEALTH  CARE  PLAN'S  NETWORK UPON: (I) THE PLAN'S
 RECEIPT OF THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTION OF THE  PLAN'S
 CREDENTIALING  APPLICATION; AND (II) THE HEALTH CARE PLAN BEING NOTIFIED
 IN WRITING THAT THE HEALTH CARE PROFESSIONAL HAS BEEN  GRANTED  HOSPITAL
 PRIVILEGE  PURSUANT  TO THE REQUIREMENTS OF SECTION TWENTY-EIGHT HUNDRED
 FIVE-K OF THIS CHAPTER. HOWEVER, A PROVISIONALLY CREDENTIALED  PHYSICIAN
 SHALL  NOT  BE  DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL
 SUCH TIME AS THE PHYSICIAN HAS BEEN FULLY  CREDENTIALED  BY  THE  HEALTH
 CARE PLAN. A HEALTH CARE PLAN SHALL NOT BE REQUIRED TO MAKE ANY PAYMENTS
 TO  THE  LICENSED  GENERAL  HOSPITAL  FOR  SERVICES PROVIDED BY A PROVI-
 SIONALLY CREDENTIALED PHYSICIAN, UNTIL AND UNLESS THE PHYSICIAN IS FULLY
 CREDENTIALED BY THE HEALTH CARE PLAN, PROVIDED HOWEVER THAT  UPON  BEING
 FULLY  CREDENTIALED, THE LICENSED GENERAL HOSPITAL SHALL BE PAID FOR ALL
 SERVICES THAT THE CREDENTIALED PHYSICIAN PROVIDED TO THE  HEALTH  PLAN'S
 ENROLLEES  FROM  THE DATE THE PHYSICIAN FULLY MET THE REQUIREMENTS TO BE

 A. 1529                             4
 
 PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH. SHOULD THE APPLI-
 CATION ULTIMATELY BE DENIED BY THE HEALTH CARE  PLAN,  THE  HEALTH  CARE
 PLAN  SHALL NOT BE LIABLE FOR ANY PAYMENT TO THE LICENSED GENERAL HOSPI-
 TAL  FOR  THE SERVICES PROVIDED BY THE PROVISIONALLY CREDENTIALED HEALTH
 CARE PROFESSIONAL THAT EXCEED ANY OUT-OF-NETWORK BENEFITS PAYABLE  UNDER
 THE  ENROLLEE'S  CONTRACT  WITH  THE  HEALTH  CARE PLAN AND THE LICENSED
 GENERAL HOSPITAL SHALL  NOT  PURSUE  REIMBURSEMENT  FROM  THE  ENROLLEE,
 EXCEPT TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE
 BEEN  PAYABLE  HAD  THE  ENROLLEE  RECEIVED  SERVICES FROM A HEALTH CARE
 PROFESSIONAL PARTICIPATING IN THE IN-NETWORK  PORTION  OF  AN  INSURER'S
 NETWORK.
   §  5.  This  act shall take effect on the ninetieth day after it shall
 have become a law; provided, however, that if chapter 425 of the laws of
 2016 shall not have taken effect on or before such  date  then  sections
 two  and  four of this act shall take effect on the same date and in the
 same manner as such chapter of the laws of 2016 takes effect;  provided,
 further, that this act shall apply to applications submitted on or after
 such  date  and  shall not apply to applications submitted prior to such
 date if such application is resubmitted in substantially similar form on
 or after the effective date of this act.