Assembly Bill A7611C

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   7611
 
                        2017-2018 Regular Sessions
 
                           I N  A S S E M B L Y
 
                                May 3, 2017
                                ___________
 
 Introduced by M. of A. CAHILL -- read once and referred to the Committee
   on Insurance
 
 AN  ACT to amend the financial services law, in relation to establishing
   protections from excessive hospital emergency charges
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:

   Section  1.  Section  605  of  the financial services law, as added by
 section 26 of part H of chapter 60 of the laws of 2014,  is  amended  to
 read as follows:
   §  605.  Dispute  resolution  for  emergency  services.  (a) Emergency
 services for an insured. (1) When a health care plan receives a bill for
 emergency services from a non-participating physician OR  HOSPITAL,  the
 health  care  plan  shall pay an amount that it determines is reasonable
 for the emergency services rendered by the  non-participating  physician
 OR HOSPITAL, in accordance with section three thousand two hundred twen-
 ty-four-a  of  the  insurance  law, except for the insured's co-payment,
 coinsurance or deductible, if any, and shall  ensure  that  the  insured
 shall  incur  no  greater out-of-pocket costs for the emergency services
 than the insured would have incurred with a participating  physician  OR
 HOSPITAL  pursuant  to  subsection  (c)  of  section  three thousand two
 hundred forty-one of the insurance law.
   (2) A non-participating physician OR HOSPITAL or a  health  care  plan
 may  submit  a dispute regarding a fee or payment for emergency services
 for review to an independent dispute resolution entity. IN CASES WHERE A
 HEALTH CARE PLAN SUBMITS A DISPUTE REGARDING A  FEE  FOR  PAYMENT  OF  A
 NON-PARTICIPATING  HOSPITAL'S  EMERGENCY  ROOM SERVICES, THE HEALTH CARE
 PLAN SHALL PAY THE AMOUNT IT DETERMINES IS REASONABLY  DIRECTLY  TO  THE
 NON-PARTICIPATING HOSPITAL.
   (3)  The  independent  dispute resolution entity shall make a determi-
 nation within thirty days of receipt of the dispute for review.

  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD09770-01-7
              

 A. 7611                             2
 
   (4) In determining a reasonable fee  for  the  services  rendered,  an
 independent  dispute  resolution  entity  shall select either the health
 care plan's payment or the non-participating physician's  OR  HOSPITAL'S
 fee.  The  independent  dispute  resolution entity shall determine which
 amount  to  select  based  upon  the conditions and factors set forth in
 section six hundred four of this  article.  If  an  independent  dispute
 resolution  entity  determines,  based on the health care plan's payment
 and the non-participating physician's OR HOSPITAL'S fee, that a  settle-
 ment  between  the  health  care plan and non-participating physician OR
 HOSPITAL is reasonably likely, or  that  both  the  health  care  plan's
 payment  and  the non-participating physician's OR HOSPITAL'S fee repre-
 sent unreasonable extremes,  then  the  independent  dispute  resolution
 entity  may  direct both parties to attempt a good faith negotiation for
 settlement. The health care  plan  and  non-participating  physician  OR
 HOSPITAL  may  be  granted up to ten business days for this negotiation,
 which shall run concurrently with the  thirty  day  period  for  dispute
 resolution.
   (b)  Emergency  services  for  a patient that is not an insured. (1) A
 patient that is not an insured or the patient's physician may  submit  a
 dispute  regarding  a  fee for emergency services for review to an inde-
 pendent dispute resolution entity upon approval of the superintendent.
   (2) An independent dispute resolution entity shall determine a reason-
 able fee for the services based upon the same conditions and factors set
 forth in section six hundred four of this article.
   (3) A patient that is not an insured shall not be required to pay  the
 physician's  OR  HOSPITAL'S  fee  in  order to be eligible to submit the
 dispute for review to an independent dispute resolution entity.
   (c) The determination of  an  independent  dispute  resolution  entity
 shall  be  binding  on  the  health care plan, physician OR HOSPITAL and
 patient, and shall be admissible in any  court  proceeding  between  the
 health  care  plan, physician OR HOSPITAL or patient, or in any adminis-
 trative proceeding between this state and the physician OR HOSPITAL.
   § 2. Paragraph (a) of section 608 of the financial  services  law,  as
 added  by  section  26  of  part H of chapter 60 of the laws of 2014, is
 amended to read as follows:
   (a) For disputes involving an insured, when  the  independent  dispute
 resolution  entity  determines the health care plan's payment is reason-
 able, payment for the dispute resolution process shall be the  responsi-
 bility  of  the non-participating physician OR HOSPITAL.  When the inde-
 pendent  dispute  resolution  entity  determines  the  non-participating
 physician's  OR  HOSPITAL'S  fee  is reasonable, payment for the dispute
 resolution process shall be the responsibility of the health care  plan.
 When a good faith negotiation directed by the independent dispute resol-
 ution entity pursuant to paragraph four of subsection (a) of section six
 hundred  five  of  this  article,  or paragraph six of subsection (a) of
 section six hundred seven  of  this  article  results  in  a  settlement
 between the health care plan and non-participating physician, the health
 care  plan  and the non-participating physician OR HOSPITAL shall evenly
 divide and share the prorated cost for dispute resolution.
   § 3. This act shall take effect immediately.

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  7611--A
                                                         Cal. No. 561
 
                        2017-2018 Regular Sessions
 
                           I N  A S S E M B L Y
 
                                May 3, 2017
                                ___________
 
 Introduced  by  M.  of A. CAHILL, SEPULVEDA -- read once and referred to
   the Committee on Insurance -- reported and referred to  the  Committee
   on Codes -- advanced to a third reading, passed by Assembly and deliv-
   ered  to the Senate, recalled from the Senate, vote reconsidered, bill
   amended, ordered reprinted, retaining its place on the order of  third
   reading
 
 AN  ACT to amend the financial services law, in relation to establishing
   protections from excessive hospital emergency charges
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.  Section  605  of  the financial services law, as added by
 section 26 of part H of chapter 60 of the laws of 2014,  is  amended  to
 read as follows:
   §  605.  Dispute  resolution  for  emergency  services.  (a) Emergency
 services for an insured. (1) When a health care plan receives a bill for
 emergency services from a non-participating physician OR  HOSPITAL,  the
 health  care  plan  shall pay an amount that it determines is reasonable
 for the emergency services rendered by the  non-participating  physician
 OR HOSPITAL, in accordance with section three thousand two hundred twen-
 ty-four-a  of  the  insurance  law, except for the insured's co-payment,
 coinsurance or deductible, if any, and shall  ensure  that  the  insured
 shall  incur  no  greater out-of-pocket costs for the emergency services
 than the insured would have incurred with a participating  physician  OR
 HOSPITAL  pursuant  to  subsection  (c)  of  section  three thousand two
 hundred forty-one of the insurance law.
   (2) A non-participating physician OR HOSPITAL or a  health  care  plan
 may  submit  a dispute regarding a fee or payment for emergency services
 for review to an independent dispute resolution entity.  IN CASES  WHERE
 A  HEALTH  CARE  PLAN SUBMITS A DISPUTE REGARDING A FEE FOR PAYMENT OF A
 NON-PARTICIPATING PHYSICIAN OR HOSPITAL'S EMERGENCY SERVICES, THE HEALTH
 CARE PLAN SHALL, AFTER THE INITIAL PAYMENT, PAY ANY  ADDITIONAL  AMOUNTS
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                       [ ] is old law to be omitted.
                                                            LBD09770-05-7

 A. 7611--A                          2
 
 IT  DETERMINES IS REASONABLE DIRECTLY TO THE NON-PARTICIPATING PHYSICIAN
 OR HOSPITAL, RESPECTIVELY.
   (3)  The  independent  dispute resolution entity shall make a determi-
 nation within thirty days of receipt of the dispute for review.
   (4) In determining a reasonable fee  for  the  services  rendered,  an
 independent  dispute  resolution  entity  shall select either the health
 care plan's payment or the non-participating physician's  OR  HOSPITAL'S
 fee.  The  independent  dispute  resolution entity shall determine which
 amount to select based upon the conditions  and  factors  set  forth  in
 section  six  hundred  four  of  this article. If an independent dispute
 resolution entity determines, based on the health  care  plan's  payment
 and  the non-participating physician's OR HOSPITAL'S fee, that a settle-
 ment between the health care plan  and  non-participating  physician  OR
 HOSPITAL  is  reasonably  likely,  or  that  both the health care plan's
 payment and the non-participating physician's OR HOSPITAL'S  fee  repre-
 sent  unreasonable  extremes,  then  the  independent dispute resolution
 entity may direct both parties to attempt a good faith  negotiation  for
 settlement.  The  health  care  plan  and non-participating physician OR
 HOSPITAL may be granted up to ten business days  for  this  negotiation,
 which  shall  run  concurrently  with  the thirty day period for dispute
 resolution.
   (b) Emergency services for a patient that is not  an  insured.  (1)  A
 patient  that  is not an insured or the patient's physician may submit a
 dispute regarding a fee for emergency services for review  to  an  inde-
 pendent dispute resolution entity upon approval of the superintendent.
   (2) An independent dispute resolution entity shall determine a reason-
 able fee for the services based upon the same conditions and factors set
 forth in section six hundred four of this article.
   (3)  A patient that is not an insured shall not be required to pay the
 physician's OR HOSPITAL'S fee in order to  be  eligible  to  submit  the
 dispute for review to an independent dispute resolution entity.
   (c)  The  determination  of  an  independent dispute resolution entity
 shall be binding on the health care  plan,  physician  OR  HOSPITAL  and
 patient,  and  shall  be  admissible in any court proceeding between the
 health care plan, physician OR HOSPITAL or patient, or in  any  adminis-
 trative proceeding between this state and the physician OR HOSPITAL.
   §  2. Subdivision (a) of section 608 of the financial services law, as
 added by section 26 of part H of chapter 60 of  the  laws  of  2014,  is
 amended to read as follows:
   (a)  For  disputes  involving an insured, when the independent dispute
 resolution entity determines the health care plan's payment  is  reason-
 able,  payment for the dispute resolution process shall be the responsi-
 bility of the non-participating physician OR HOSPITAL.   When the  inde-
 pendent  dispute  resolution  entity  determines  the  non-participating
 physician's OR HOSPITAL'S fee is reasonable,  payment  for  the  dispute
 resolution  process shall be the responsibility of the health care plan.
 When a good faith negotiation directed by the independent dispute resol-
 ution entity pursuant to paragraph four of subsection (a) of section six
 hundred five of this article, or paragraph  six  of  subsection  (a)  of
 section  six  hundred  seven  of  this  article  results in a settlement
 between the health care plan and non-participating physician, the health
 care plan and the non-participating physician OR HOSPITAL  shall  evenly
 divide and share the prorated cost for dispute resolution.
   § 3. Section 604 of the financial services law, as added by section 26
 of  part  H  of  chapter  60  of the laws of 2014, is amended to read as
 follows:

 A. 7611--A                          3
 
   § 604. Criteria for determining a reasonable fee. In  determining  the
 appropriate  amount  to  pay  for  a health care service, an independent
 dispute resolution entity shall consider all relevant  factors,  includ-
 ing:
   (a)  whether there is a gross disparity between the fee charged by the
 [physician] HEALTH CARE PROVIDER for services rendered as compared to:
   (1) fees paid to the involved [physician] HEALTH CARE PROVIDER for the
 same services rendered by the [physician] HEALTH CARE PROVIDER to  other
 patients  in  health  care  plans  in  which the [physician] HEALTH CARE
 PROVIDER is not participating, and
   (2) in the case of a dispute involving a health care plan,  fees  paid
 by  the  health  care plan to reimburse similarly qualified [physicians]
 HEALTH CARE PROVIDERS for the same services in the same region  who  are
 not participating with the health care plan;
   (b) the level of training, education and experience of the [physician]
 HEALTH CARE PROVIDER;
   (c) the [physician's] HEALTH CARE PROVIDER'S usual charge for compara-
 ble  services  with regard to patients in health care plans in which the
 [physician] HEALTH CARE PROVIDER is not participating;
   (d) the circumstances and complexity of the particular case, including
 time and place of the service;
   (e) individual patient characteristics; and, WHERE APPLICABLE,
   (f) the usual and customary cost of the service.
   § 4. This act shall take effect immediately.

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  7611--B
                                                         Cal. No. 534
 
                        2017-2018 Regular Sessions
 
                           I N  A S S E M B L Y
 
                                May 3, 2017
                                ___________
 
 Introduced  by  M.  of  A.  CAHILL, COLTON, ARROYO, JEAN-PIERRE, TAYLOR,
   McDONOUGH -- read once and referred to the Committee on  Insurance  --
   reported and referred to the Committee on Codes -- advanced to a third
   reading, passed by Assembly and delivered to the Senate, recalled from
   the  Senate,  vote  reconsidered,  bill  amended,  ordered  reprinted,
   retaining its place on the order of third reading -- passed by  Assem-
   bly and delivered to the Senate, recalled from the Senate, vote recon-
   sidered,  bill  amended, ordered reprinted, retaining its place on the
   order of third reading
 
 AN ACT to amend the financial services law, in relation to  establishing
   protections from excessive hospital emergency charges
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Section 605 of the financial  services  law,  as  added  by
 section  26  of  part H of chapter 60 of the laws of 2014, is amended to
 read as follows:
   § 605.  Dispute  resolution  for  emergency  services.  (a)  Emergency
 services for an insured. (1) When a health care plan receives a bill for
 emergency  services  from a non-participating physician OR HOSPITAL, the
 health care plan shall pay an amount that it  determines  is  reasonable
 for  the  emergency services rendered by the non-participating physician
 OR HOSPITAL, in accordance with section three thousand two hundred twen-
 ty-four-a of the insurance law, except  for  the  insured's  co-payment,
 coinsurance  or  deductible,  if  any, and shall ensure that the insured
 shall incur no greater out-of-pocket costs for  the  emergency  services
 than  the  insured would have incurred with a participating physician OR
 HOSPITAL pursuant to  subsection  (c)  of  section  three  thousand  two
 hundred forty-one of the insurance law.
   (2)  A  non-participating  physician OR HOSPITAL or a health care plan
 may submit a dispute regarding a fee or payment for  emergency  services
 for  review to an independent dispute resolution entity.  IN CASES WHERE
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                       [ ] is old law to be omitted.
                                                            LBD09770-07-8

 A. 7611--B                          2
 
 A HEALTH CARE PLAN SUBMITS A DISPUTE REGARDING A FEE FOR  PAYMENT  OF  A
 NON-PARTICIPATING  HOSPITAL'S  EMERGENCY  SERVICES, THE HEALTH CARE PLAN
 SHALL, AFTER THE INITIAL PAYMENT, PAY ANY ADDITIONAL AMOUNTS  IT  DETER-
 MINES IS REASONABLE DIRECTLY TO THE NON-PARTICIPATING HOSPITAL.
   (3)  The  independent  dispute resolution entity shall make a determi-
 nation within thirty days of receipt of the dispute for review.
   (4) In determining a reasonable fee  for  the  services  rendered,  an
 independent  dispute  resolution  entity  shall select either the health
 care plan's payment or the non-participating physician's  OR  HOSPITAL'S
 fee.  The  independent  dispute  resolution entity shall determine which
 amount to select based upon the conditions  and  factors  set  forth  in
 section  six  hundred  four  of  this article. If an independent dispute
 resolution entity determines, based on the health  care  plan's  payment
 and  the non-participating physician's OR HOSPITAL'S fee, that a settle-
 ment between the health care plan  and  non-participating  physician  OR
 HOSPITAL  is  reasonably  likely,  or  that  both the health care plan's
 payment and the non-participating physician's OR HOSPITAL'S  fee  repre-
 sent  unreasonable  extremes,  then  the  independent dispute resolution
 entity may direct both parties to attempt a good faith  negotiation  for
 settlement.  The  health  care  plan  and non-participating physician OR
 HOSPITAL may be granted up to ten business days  for  this  negotiation,
 which  shall  run  concurrently  with  the thirty day period for dispute
 resolution.
   (b) Emergency services for a patient that is not  an  insured.  (1)  A
 patient  that  is not an insured or the patient's physician may submit a
 dispute regarding a fee for emergency services for review  to  an  inde-
 pendent dispute resolution entity upon approval of the superintendent.
   (2) An independent dispute resolution entity shall determine a reason-
 able fee for the services based upon the same conditions and factors set
 forth in section six hundred four of this article.
   (3)  A patient that is not an insured shall not be required to pay the
 physician's OR HOSPITAL'S fee in order to  be  eligible  to  submit  the
 dispute for review to an independent dispute resolution entity.
   (c)  The  determination  of  an  independent dispute resolution entity
 shall be binding on the health care  plan,  physician  OR  HOSPITAL  and
 patient,  and  shall  be  admissible in any court proceeding between the
 health care plan, physician OR HOSPITAL or patient, or in  any  adminis-
 trative proceeding between this state and the physician OR HOSPITAL.
   §  2. Subdivision (a) of section 608 of the financial services law, as
 added by section 26 of part H of chapter 60 of  the  laws  of  2014,  is
 amended to read as follows:
   (a)  For  disputes  involving an insured, when the independent dispute
 resolution entity determines the health care plan's payment  is  reason-
 able,  payment for the dispute resolution process shall be the responsi-
 bility of the non-participating physician OR HOSPITAL.   When the  inde-
 pendent  dispute  resolution  entity  determines  the  non-participating
 physician's OR HOSPITAL'S fee is reasonable,  payment  for  the  dispute
 resolution  process shall be the responsibility of the health care plan.
 When a good faith negotiation directed by the independent dispute resol-
 ution entity pursuant to paragraph four of subsection (a) of section six
 hundred five of this article, or paragraph  six  of  subsection  (a)  of
 section  six  hundred  seven  of  this  article  results in a settlement
 between the health care plan and non-participating physician, the health
 care plan and the non-participating physician OR HOSPITAL  shall  evenly
 divide and share the prorated cost for dispute resolution.

 A. 7611--B                          3
 
   § 3. Section 604 of the financial services law, as added by section 26
 of  part  H  of  chapter  60  of the laws of 2014, is amended to read as
 follows:
   §  604.  Criteria for determining a reasonable fee. In determining the
 appropriate amount to pay for a  health  care  service,  an  independent
 dispute  resolution  entity shall consider all relevant factors, includ-
 ing:
   (a) whether there is a gross disparity between the fee charged by  the
 [physician] HEALTH CARE PROVIDER for services rendered as compared to:
   (1) fees paid to the involved [physician] HEALTH CARE PROVIDER for the
 same  services rendered by the [physician] HEALTH CARE PROVIDER to other
 patients in health care plans  in  which  the  [physician]  HEALTH  CARE
 PROVIDER is not participating, and
   (2)  in  the case of a dispute involving a health care plan, fees paid
 by the health care plan to reimburse  similarly  qualified  [physicians]
 HEALTH  CARE  PROVIDERS for the same services in the same region who are
 not participating with the health care plan;
   (b) the level of training, education and experience of the [physician]
 HEALTH CARE PROVIDER;
   (c) the [physician's] HEALTH CARE PROVIDER'S usual charge for compara-
 ble services with regard to patients in health care plans in  which  the
 [physician] HEALTH CARE PROVIDER is not participating;
   (d) the circumstances and complexity of the particular case, including
 time and place of the service;
   (e) individual patient characteristics; and, WHERE APPLICABLE,
   (f) the usual and customary cost of the service.
   § 4. This act shall take effect immediately.