Senate Bill S6363A

2017-2018 Legislative Session

Includes hospitals and ambulance services in dispute resolution process for charges for emergency services

download bill text pdf

Archive: Last Bill Status - In Senate Committee Health Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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Actions

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Date of Action	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 03, 2018	referred to health
Dec 20, 2017	print number 6363a
Dec 20, 2017	amend (t) and recommit to health
May 11, 2017	referred to health

Bill Amendments

Original

A (Active)

2017-S6363 - Details

Current Committee:: Senate Health
Law Section:: Public Health Law
Laws Affected:: Amd §2803, Pub Health L; amd §122-b, Gen Muni, amd §§603, 605, 606 & 608, Fin Serv L; amd §3241, Ins L
Versions Introduced in 2019-2020 Legislative Session:: S1793

2017-S6363 - Summary

Includes hospitals and ambulance services in dispute resolution process for charges for emergency services.

2017-S6363 - Sponsor Memo

                                 BILL NUMBER:  S6363

 TITLE OF BILL :  An act to amend the public health law, in relation
to hospital statements of rights and responsibilities of patients; to
amend the financial services law, in relation to dispute resolution
for emergency services; and to amend the financial services law and
the insurance law, in relation to assignment of health insurance
benefits

 PURPOSE :

Ensure consumers are held harmless from charges for emergency
services.

 SUMMARY OF PROVISIONS :

Section one amends Public Health Law § 2803(1) to update the patient
rights and responsibilities to advise patients of their right to be
held harmless in certain situations.

Section two amends the Financial Services Law §§ 605, 607 and 608 to
include hospital charges in the emergency charges that are subject to
the independent dispute resolution process and to ensure that when a
patient assigns benefits to a non-participating hospital or physician
for emergency charges the patient is held harmless and the insurer
acknowledges the assignment of benefits and issues payment to the

assignee.

Section three amends Insurance Law § 3241(c) to provide when an
insured or enrollee has authorized payment to the health care
provider, such payment shall be made to the provider.

Section four provides that this act shall take effect 90 days after
enactment.

 JUSTIFICATION :

As part of the SFY 2014-15 budget, the Legislature enacted monumental
consumer protections to end surprise medical bills which have been
looked upon as a national model. Included among these protections were
provisions holding consumers harmless from emergency and surprise
medical bills and provisions establishing an independent dispute
resolution process to resolve billing disputes for emergency care and
surprise medical bills. The underlying intent of these changes was to
establish a process by which consumers were not dragged into disputes
between providers and insurers. This legislation makes changes to
ensure the original intent is achieved.

While the law does provide hold harmless protections for both
emergency and surprise bills, the provisions are drafted differently
and in a manner that has had real world implications. For a surprise
medical bill, if the patient assigns his or her benefit, the health
plan must pay the provider and the provider is prohibited from balance
billing the patient for anything beyond an applicable copayment,
coinsurance or deductible. For emergency services, the insurer is
prohibited from balance billing the patient, but nothing prohibits the
provider from balance billing an insured unless there has been a
determination made by the independent dispute resolution entity.
Further, there is no protection in law requiring the health plan to
pay a provider directly when the consumer has assigned his or her
benefit. The end result of this discrepancy has been many consumers
receiving bills from providers for emergency services, and if these
consumers are not aware of the protections afforded to them, or do not
contact their health plan after receiving such bills, they end up
paying bills that they may not be obligated to pay. Following the
original intent of the law, this legislation makes changes to align
the provisions and ensure consumers are truly left out of disputes
involving emergency care.

As part of the 2014-15 budget, a workgroup was established to study
and report on certain issues involving out-of-network billing and
coverage. One of the recommendations of the workgroup was to include
hospital charges for emergency services, in addition to physician
charges, within the independent dispute resolution process. Bringing
hospital charges within the process as amended herein will further
protect consumers from being balance billed by out-of-network
hospitals for emergency services. The workgroup also suggested that
extending this process to hospital charges may improve coverage,
ensure hospitals are paid directly and discourage excessive billing.

 LEGISLATIVE HISTORY :

New bill.

 FISCAL IMPLICATIONS :

None.

 EFFECTIVE DATE :
90 days after enactment.

2017-S6363 - Bill Text download pdf

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   6363
 
                        2017-2018 Regular Sessions
 
                             I N  S E N A T E
 
                               May 11, 2017
                                ___________
 
 Introduced  by  Sen.  HANNON -- read twice and ordered printed, and when
   printed to be committed to the Committee on Health
 
 AN ACT to amend the public health law, in relation  to  hospital  state-
   ments  of rights and responsibilities of patients; to amend the finan-
   cial services law, in relation to  dispute  resolution  for  emergency
   services;  and  to  amend the financial services law and the insurance
   law, in relation to assignment of health insurance benefits
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.  Paragraph  (k)  of  subdivision  1 of section 2803 of the
 public health law, as added by chapter 241  of  the  laws  of  2016,  is
 amended to read as follows:
   (k)  The  statement  regarding  patient  rights  and responsibilities,
 required pursuant to paragraph (g) of this  subdivision,  shall  include
 provisions informing the patient of his or her right to [choose] BE HELD
 HARMLESS  FROM  CERTAIN BILLS FOR EMERGENCY SERVICES AND SURPRISE BILLS,
 AND to submit surprise bills or bills  for  emergency  services  to  the
 independent  dispute process established in article six of the financial
 services law, and informing the patient of his or her right  to  view  a
 list  of the hospital's standard charges and the health plans the hospi-
 tal participates with consistent with section twenty-four of this  chap-
 ter.
   § 2. Sections 605, 606 and 608 of the financial services law, as added
 by  section  26 of part H of chapter 60 of the laws of 2014, are 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-
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.

                                                            LBD11735-01-7

 S. 6363                             2
 
 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
 pursuant to subsection (c) of section three thousand two hundred  forty-
 one of the insurance law. IF AN INSURED ASSIGNS BENEFITS TO A NON-PARTI-
 CIPATING  PHYSICIAN  OR HOSPITAL, SUCH PAYMENT SHALL BE MADE DIRECTLY TO
 THE ASSIGNEE.
   (2) A non-participating physician, 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.
   (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 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.
   § 606. Hold harmless and assignment of benefits for EMERGENCY SERVICES
 AND surprise bills for insureds. When an insured assigns benefits for AN
 EMERGENCY SERVICE OR a surprise bill in writing to  a  non-participating
 physician  OR  HOSPITAL that knows the insured is insured under a health
 care plan, the non-participating physician OR HOSPITAL  shall  not  bill
 the  insured except for any applicable copayment, coinsurance or deduct-
 ible that would be owed if the insured utilized a  participating  physi-
 cian.
   §  608.  Payment  for  independent  dispute resolution entity. (a) For
 disputes involving an insured, when the independent  dispute  resolution
 entity  determines the health care plan's payment is reasonable, payment

 S. 6363                             3
 
 for the dispute resolution process shall be the  responsibility  of  the
 non-participating  physician  OR  HOSPITAL. When the independent dispute
 resolution entity determines the non-participating physician's OR HOSPI-
 TAL'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 resolution entity pursu-
 ant  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 OR HOSPITAL, the health  care  plan
 and  the non-participating physician OR HOSPITAL shall evenly divide and
 share the prorated cost for dispute resolution.
   (b) For disputes involving a patient that is not an insured, when  the
 independent  dispute resolution entity determines the physician's fee is
 reasonable, payment for the dispute  resolution  process  shall  be  the
 responsibility  of the patient unless payment for the dispute resolution
 process would pose a hardship to the patient. The  superintendent  shall
 promulgate  a regulation to determine payment for the dispute resolution
 process in cases of hardship. When the  independent  dispute  resolution
 entity  determines  the physician's fee is unreasonable, payment for the
 dispute resolution process shall be the responsibility of the physician.
   § 3.  Subsection (c) of section 3241 of the insurance law, as added by
 section 6 of part H of chapter 60 of the laws of  2014,  is  amended  to
 read as follows:
   (c)  (1)  When  an insured or enrollee under a contract or policy that
 provides coverage for emergency services receives the  services  from  a
 health  care  provider that does not participate in the provider network
 of 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,  a  health  maintenance
 organization  certified  pursuant  to  article  forty-four of the public
 health law, or a student health plan established or maintained  pursuant
 to section one thousand one hundred twenty-four of this chapter ("health
 care  plan"),  the  health  care  plan  shall ensure that the insured or
 enrollee shall (A) incur no greater out-of-pocket costs for the emergen-
 cy services than the insured or enrollee  would  have  incurred  with  a
 health care provider that participates in the health care plan's provid-
 er network AND (B) PROVIDE THE INSURED OR ENROLLEE THE OPTION OF ASSIGN-
 ING  THE  PAYMENT  OF  ANY  BENEFITS  DUE  UNDER SUCH CONTRACT OR POLICY
 DIRECTLY TO THE HEALTH CARE PROVIDER. WHENEVER, IN ANY HEALTH  INSURANCE
 CLAIM  FORM,  AN INSURED OR ENROLLEE SPECIFICALLY AUTHORIZES THE PAYMENT
 OF BENEFITS DIRECTLY TO A HEALTH CARE PROVIDER,  THE  HEALTH  CARE  PLAN
 SHALL  MAKE  SUCH  PAYMENT  TO  THE  HEALTH CARE PROVIDER.   (2) For the
 purpose of this section, "emergency services" shall have the meaning set
 forth in subparagraph (D) of paragraph nine of subsection (i) of section
 three thousand two hundred sixteen of this article, subparagraph (D)  of
 paragraph  four  of subsection (k) of section three thousand two hundred
 twenty-one of this article, and subparagraph (D)  of  paragraph  two  of
 subsection  (a)  of  section  four  thousand three hundred three of this
 chapter.
   § 4. This act shall take effect on the ninetieth day  after  it  shall
 have become a law.

2017-S6363A (ACTIVE) - Details

Current Committee:: Senate Health
Law Section:: Public Health Law
Laws Affected:: Amd §2803, Pub Health L; amd §122-b, Gen Muni, amd §§603, 605, 606 & 608, Fin Serv L; amd §3241, Ins L
Versions Introduced in 2019-2020 Legislative Session:: S1793

2017-S6363A (ACTIVE) - Summary

Includes hospitals and ambulance services in dispute resolution process for charges for emergency services.

2017-S6363A (ACTIVE) - Sponsor Memo

                                
 
BILL NUMBER: S6363A

SPONSOR: HANNON
 
TITLE OF BILL:  An act to amend the public health law, in relation to
hospital statements of rights and responsibilities of patients; to amend
the general municipal law, in relation to insurance coverage of ambu-
lance and emergency medical services; to amend the financial services
law, in relation to dispute resolution for emergency services; and to
amend the financial services law and the insurance law, in relation to
assignment of health insurance benefits

 
PURPOSE:

Ensure consumers are held harmless from charges for emergency services,
including ambulance and hospital charges.

 
SUMMARY OF PROVISIONS:

Section one amends Public Health Law § 2803(1) to update the patient
rights and responsibilities to advise patients of their right to be held
harmless in certain situations.

Section two amends § 122-b of the General Municipal Law to require any
municipality that contracts out ambulance services to ensure the
contracted ambulance provider does not balance bill individuals for
services provided.

Section three amends Financial Services Law § 603 to include ambulance
services under the definition of emergency services

Section four amends the Financial Services Law §§ 605, 606 and 608 to
include ambulance and hospital charges within the emergency charges that
are subject to the independent dispute resolution process. This section
also provides that when a patient assigns benefits to a nonparticipating
ambulance provider, hospital or physician for emergency services the
patient is held harmless and the insurer must acknowledge the assignment
of benefits and issue payment to the assignee.

Section five amends Insurance Law § 3241(c) to provide when an insured
or enrollee has authorized payment to the health care provider, such
payment shall be made to the provider.

Section six provides that this act shall take effect 90 days after
enactment.

 
JUSTIFICATION:

As part of the SFY 2014-15 budget, the Legislature enacted monumental
consumer protections to end surprise medical bills which have been
looked upon as a national model. Included among these protections were
provisions holding consumers harmless from emergency and surprise
medical bills and provisions establishing an independent dispute resol-
ution process to resolve billing disputes for emergency services and
surprise medical bills. The underlying intent of these changes was to
establish a process by which consumers held harmless and were not
dragged into disputes between providers and insurers.  This legislation
makes changes to ensure the original intent is fully achieved.


While current law does provide hold harmless protections for both emer-
gency and surprise bills, the provisions are drafted differently, in a
manner that has had real world implications. For a surprise medical
bill, if the patient assigns his or her benefit, the health plan must
pay the provider and the provider is prohibited from balance billing the
patient for anything beyond an applicable copayment, coinsurance or
deductible. For emergency services, the insurer is prohibited from
balance billing the patient, but nothing prohibits the provider from
balance billing an insured unless there has been a determination made by
the independent dispute resolution entity. Further, there is no
protection in law requiring the health plan to pay a provider directly
when the consumer has assigned his or her benefit. The end result of
this discrepancy has been many consumers receiving bills from providers
for emergency services, and if these consumers are not aware of the
protections afforded to them, or do not contact their health plan after
receiving such bills, they end up paying bills they may not be obligated
to pay. Following the original intent of the law, this legislation makes
changes to align the provisions and ensure consumers are truly left out
of disputes involving emergency care.

As part of the 2014-15 budget, a workgroup was established to study and
report on certain issues involving out-of-network billing and coverage.
One of the recommendations of the workgroup was to include hospital
charges for emergency services, in addition to physician charges, within
the independent dispute resolution process. Bringing hospital charges
within the process as amended herein will further protect consumers from
being balance billed by out-of-network hospitals for emergency services.
The workgroup also suggested that extending this process to hospital
charges may improve coverage, ensure hospitals are paid directly and
discourage excessive billing

Lastly, recent reports have brought to light the growing issue of ambu-
lances sticking patients with surprise bills. While years ago most ambu-
lance services were provided by volunteers or fire departments using tax
dollars, making them free to patients, today ambulances are increasingly
run by private companies. When the private ambulance company is not in
the insurance network, which is often the case because the health plan
and company are unable to agree upon a price, the patient is billed.
There are typically two scenarios in which patients use ambulance
services, they call 911 and one is sent to them, or an ambulance is
transferring them to another facility. In either scenario, the patient
has little choice or ability to ensure they are utilizing an in-network
provider, nonetheless they are saddled with the bill. Burdening consum-
ers with medical debt based on circumstances completely outside of their
control is unconscionable.  Consumers should be protected from these
charges as they are for other emergency services.

 
LEGISLATIVE HISTORY:

New bill.

 
FISCAL IMPLICATIONS:

None.

 
EFFECTIVE DATE:
90 days after enactment.

2017-S6363A (ACTIVE) - Bill Text download pdf

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  6363--A
 
                        2017-2018 Regular Sessions
 
                             I N  S E N A T E
 
                               May 11, 2017
                                ___________
 
 Introduced  by  Sen.  HANNON -- read twice and ordered printed, and when
   printed to be committed  to  the  Committee  on  Health  --  committee
   discharged, bill amended, ordered reprinted as amended and recommitted
   to said committee
 
 AN  ACT  to  amend the public health law, in relation to hospital state-
   ments of rights and responsibilities of patients; to amend the general
   municipal law, in relation to  insurance  coverage  of  ambulance  and
   emergency  medical  services;  to amend the financial services law, in
   relation to dispute resolution for emergency services;  and  to  amend
   the  financial  services  law  and  the  insurance law, in relation to
   assignment of health insurance benefits
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.  Paragraph  (k)  of  subdivision  1 of section 2803 of the
 public health law, as added by chapter 241  of  the  laws  of  2016,  is
 amended to read as follows:
   (k)  The  statement  regarding  patient  rights  and responsibilities,
 required pursuant to paragraph (g) of this  subdivision,  shall  include
 provisions informing the patient of his or her right to [choose] BE HELD
 HARMLESS  FROM  CERTAIN BILLS FOR EMERGENCY SERVICES AND SURPRISE BILLS,
 AND to submit surprise bills or bills  for  emergency  services  to  the
 independent  dispute process established in article six of the financial
 services law, and informing the patient of his or her right  to  view  a
 list  of the hospital's standard charges and the health plans the hospi-
 tal participates with consistent with section twenty-four of this  chap-
 ter.
   §  2.  Subdivision 2 of section 122-b of the general municipal law, as
 amended by chapter 303 of the laws  of  1980,  is  amended  to  read  as
 follows:
   2. Such municipality shall formulate rules and regulations relating to
 the  use  of  such apparatus and equipment in the provision of emergency

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

                                                            LBD11735-02-7

 S. 6363--A                          2
 
 medical services or ambulance service and may fix a schedule of fees  or
 charges  to  be  paid  by persons requesting the use of such facilities.
 SUCH RULES AND REGULATIONS SHALL ENSURE THAT INSURED  INDIVIDUALS  INCUR
 NO  OUT-OF-POCKET  COSTS  FOR  USE  OF  SUCH SERVICES AND/OR FACILITIES,
 EXCEPT ANY APPLICABLE CO-PAYMENT, COINSURANCE OR DEDUCTIBLE. Such  muni-
 cipalities  may  provide  for the collection of such fees and charges or
 may formulate rules and regulations for the collection  thereof  by  the
 individuals,  municipal  corporations,  associations, or other organiza-
 tions furnishing service under contract as provided in paragraph (c)  of
 subdivision one of this section.
   §  3.  Subsection (b) of section 603 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:
   (b) "Emergency services" means AMBULANCE SERVICES AS DEFINED IN SUBDI-
 VISION  ONE  OF SECTION THREE THOUSAND ONE OF THE PUBLIC HEALTH LAW AND,
 with respect to an emergency condition:  (1) a medical  screening  exam-
 ination  as  required  under section 1867 of the social security act, 42
 U.S.C. § 1395dd, which is within the capability of the emergency depart-
 ment of a hospital, including ancillary services routinely available  to
 the  emergency  department to evaluate 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. §
 1395dd, to stabilize the patient.
   § 4.  Sections 605, 606 and 608 of  the  financial  services  law,  as
 added  by  section  26  of part H of chapter 60 of the laws of 2014, are
 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, HOSPITAL OR AMBU-
 LANCE  PROVIDER, the health care plan shall pay an amount that it deter-
 mines is reasonable for the emergency services rendered by the  non-par-
 ticipating physician, HOSPITAL OR AMBULANCE PROVIDER, in accordance with
 section  three  thousand two hundred twenty-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  pursuant to subsection (c) of section
 three thousand two hundred forty-one of the insurance law. IF AN INSURED
 ASSIGNS BENEFITS TO A NON-PARTICIPATING PHYSICIAN, HOSPITAL OR AMBULANCE
 PROVIDER, SUCH PAYMENT SHALL BE MADE DIRECTLY TO THE ASSIGNEE.
   (2) A non-participating physician, HOSPITAL OR AMBULANCE PROVIDER,  or
 a  health  care plan may submit a dispute regarding a fee or payment for
 emergency services for review to an independent dispute resolution enti-
 ty.
   (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, HOSPITAL'S OR
 AMBULANCE PROVIDER'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, HOSPITAL'S OR
 AMBULANCE PROVIDER'S fee, that a settlement between the health care plan

 S. 6363--A                          3
 
 and non-participating  physician,  HOSPITAL  OR  AMBULANCE  PROVIDER  is
 reasonably  likely,  or that both the health care plan's payment and the
 non-participating physician's, HOSPITAL'S OR  AMBULANCE  PROVIDER'S  fee
 represent 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, HOSPI-
 TAL OR AMBULANCE PROVIDER may be granted up to  ten  business  days  for
 this negotiation, which shall run concurrently with the thirty day peri-
 od 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,  HOSPITAL'S  OR  AMBULANCE  PROVIDER'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  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.
   § 606. Hold harmless and assignment of benefits for EMERGENCY SERVICES
 AND surprise bills for insureds. When an insured assigns benefits for AN
 EMERGENCY  SERVICE  OR a surprise bill in writing to a non-participating
 physician, HOSPITAL OR AMBULANCE PROVIDER  that  knows  the  insured  is
 insured  under  a  health  care  plan,  the non-participating physician,
 HOSPITAL OR AMBULANCE PROVIDER shall not bill the insured except for any
 applicable copayment, coinsurance or deductible that would  be  owed  if
 the insured utilized a participating physician.
   §  608.  Payment  for  independent  dispute resolution entity. (a) For
 disputes involving an insured, when the independent  dispute  resolution
 entity  determines the health care plan's payment is reasonable, payment
 for the dispute resolution process shall be the  responsibility  of  the
 non-participating  physician,  HOSPITAL  OR AMBULANCE PROVIDER. When the
 independent dispute resolution entity determines  the  non-participating
 physician's,  HOSPITAL'S  OR  AMBULANCE  PROVIDER'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 resolution 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-participat-
 ing physician, HOSPITAL OR AMBULANCE PROVIDER, the health care plan  and
 the  non-participating  physician,  HOSPITAL OR AMBULANCE PROVIDER shall
 evenly divide and share the prorated cost for dispute resolution.
   (b) For disputes involving a patient that is not an insured, when  the
 independent  dispute resolution entity determines the physician's fee is
 reasonable, payment for the dispute  resolution  process  shall  be  the
 responsibility  of the patient unless payment for the dispute resolution
 process would pose a hardship to the patient. The  superintendent  shall
 promulgate  a regulation to determine payment for the dispute resolution
 process in cases of hardship. When the  independent  dispute  resolution

 S. 6363--A                          4
 
 entity  determines  the physician's fee is unreasonable, payment for the
 dispute resolution process shall be the responsibility of the physician.
   § 5.  Subsection (c) of section 3241 of the insurance law, as added by
 section  6  of  part  H of chapter 60 of the laws of 2014, is amended to
 read as follows:
   (c) (1) When an insured or enrollee under a contract  or  policy  that
 provides  coverage  for  emergency services receives the services from a
 health care provider that does not participate in the  provider  network
 of  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, a health maintenance
 organization certified pursuant to  article  forty-four  of  the  public
 health  law, or a student health plan established or maintained pursuant
 to section one thousand one hundred twenty-four of this chapter ("health
 care plan"), the health care plan  shall  ensure  that  the  insured  or
 enrollee shall (A) incur no greater out-of-pocket costs for the emergen-
 cy  services  than  the  insured  or enrollee would have incurred with a
 health care provider that participates in the health care plan's provid-
 er network AND (B) PROVIDE THE INSURED OR ENROLLEE THE OPTION OF ASSIGN-
 ING THE PAYMENT OF ANY  BENEFITS  DUE  UNDER  SUCH  CONTRACT  OR  POLICY
 DIRECTLY  TO THE HEALTH CARE PROVIDER. WHENEVER, IN ANY HEALTH INSURANCE
 CLAIM FORM, AN INSURED OR ENROLLEE SPECIFICALLY AUTHORIZES  THE  PAYMENT
 OF  BENEFITS  DIRECTLY  TO  A HEALTH CARE PROVIDER, THE HEALTH CARE PLAN
 SHALL MAKE SUCH PAYMENT TO THE  HEALTH  CARE  PROVIDER.    (2)  For  the
 purpose of this section, "emergency services" shall have the meaning set
 forth  in  [subparagraph  (D)  of  paragraph  nine  of subsection (i) of
 section three thousand two hundred sixteen of this article, subparagraph
 (D) of paragraph four of subsection (k) of section  three  thousand  two
 hundred  twenty-one  of  this article, and subparagraph (D) of paragraph
 two of subsection (a) of section four thousand three  hundred  three  of
 this  chapter] SUBSECTION (B) OF SECTION SIX HUNDRED THREE OF THE FINAN-
 CIAL SERVICES LAW.
   § 6. This act shall take effect on the ninetieth day  after  it  shall
 have become a law.

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Kemp Hannon

Archive: Last Bill Status - In Senate Committee Health Committee

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