S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  1793--A
 
                        2019-2020 Regular Sessions
 
                             I N  S E N A T E
 
                             January 16, 2019
                                ___________
 
 Introduced  by  Sen.  RIVERA -- 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  financial services law, in relation to services
   rendered by a non-participating provider; 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 insur-
   ance  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.  Subsection  (h)  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:
   (h) "Surprise bill" means a bill for health care services, other  than
 emergency services, received by:
   (1)  an insured for services rendered by a non-participating physician
 at a participating hospital  or  ambulatory  surgical  center,  where  a
 participating  physician is unavailable or a non-participating physician
 renders services without the insured's knowledge, or unforeseen  medical
 services  arise  at  the  time  the  health  care services are rendered;
 provided, however, that a surprise bill shall not mean a  bill  received
 for health care services when a participating physician is available and
 the  insured  has  elected  to  obtain services from a non-participating
 physician;
   (2) an insured for services rendered by a non-participating  provider,
 where  the services were referred by a participating physician to a non-
 participating provider without explicit written consent of  the  insured

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

                                                            LBD07755-02-9

 S. 1793--A                          2
 
 acknowledging  that the participating physician is referring the insured
 to a non-participating provider and that  the  referral  may  result  in
 costs not covered by the health care plan; [or]
   (3)  AN  INSURED FOR SERVICES RENDERED BY A NON-PARTICIPATING PROVIDER
 WHEN THE INSURED REASONABLY RELIED UPON AN  ORAL  OR  WRITTEN  STATEMENT
 THAT THE NON-PARTICIPATING PROVIDER WAS A PARTICIPATING PROVIDER MADE BY
 A HEALTH CARE PLAN, OR AGENT OR REPRESENTATIVE OF A HEALTH CARE PLAN, OR
 AS  SPECIFIED  IN THE HEALTH CARE PLAN PROVIDER LISTING OR DIRECTORY, OR
 PROVIDER INFORMATION ON THE HEALTH PLAN'S WEBSITE;
   (4) AN INSURED FOR SERVICES RENDERED BY A  NON-PARTICIPATING  PROVIDER
 WHEN  THE INSURED REASONABLY RELIED UPON A STATEMENT THAT THE NON-PARTI-
 CIPATING PROVIDER WAS A PARTICIPATING PROVIDER MADE BY THE  NON-PARTICI-
 PATING  PROVIDER,  OR  AGENT  OR REPRESENTATIVE OF THE NON-PARTICIPATING
 PROVIDER, OR AS SPECIFIED ON THE NON-PARTICIPATING  PROVIDER'S  WEBSITE;
 OR
   (5)  a patient who is not an insured for services rendered by a physi-
 cian at a hospital or ambulatory surgical center, where the patient  has
 not  timely received all of the disclosures required pursuant to section
 twenty-four of the public health law.
   § 2. 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.
   § 3. 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
 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.
   § 4. 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 TWO 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

 S. 1793--A                          3
 
 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.
   § 5. 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  AMBULANCE
 PROVIDER, the health care plan shall pay an amount that it determines is
 reasonable  for the emergency services rendered by the non-participating
 physician OR AMBULANCE PROVIDER, in accordance with section three  thou-
 sand  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 OR AMBULANCE PROVIDER,
 SUCH PAYMENT SHALL BE MADE DIRECTLY TO THE ASSIGNEE.
   (2)  A  non-participating physician 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 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  AMBULANCE
 PROVIDER'S  fee.  The independent dispute resolution entity shall deter-
 mine 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 AMBULANCE PROVIDER'S
 fee, that a settlement between the health care plan and  non-participat-
 ing  physician  OR AMBULANCE PROVIDER is reasonably likely, or that both
 the health care plan's payment and the non-participating physician's  OR
 AMBULANCE PROVIDER'S fee represent unreasonable extremes, then the inde-
 pendent  dispute  resolution entity may direct both parties to attempt a
 good faith negotiation for settlement. The health care plan and non-par-
 ticipating physician OR AMBULANCE PROVIDER 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 OR AMBULANCE
 PROVIDER may submit a dispute regarding a fee for emergency services for
 review to an independent 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 AMBULANCE PROVIDER'S fee  in  order  to  be  eligible  to
 submit the dispute for review to an independent dispute resolution enti-
 ty.

 S. 1793--A                          4
 
   (c)  The  determination  of  an  independent dispute resolution entity
 shall be binding on the health care plan, physician OR AMBULANCE PROVID-
 ER and patient, and shall be admissible in any court proceeding  between
 the  health  care  plan, physician, AMBULANCE PROVIDER or patient, or in
 any  administrative  proceeding  between this state and the physician OR
 AMBULANCE PROVIDER.
   § 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 AMBULANCE PROVIDER that knows the insured is insured under
 a health care plan, the non-participating physician OR AMBULANCE PROVID-
 ER shall not bill the insured except for any applicable copayment, coin-
 surance 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 OR AMBULANCE PROVIDER.  When the independent
 dispute  resolution  entity determines the non-participating physician'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 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  OR  AMBU-
 LANCE PROVIDER, the health care plan and the non-participating physician
 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 OR
 AMBULANCE PROVIDER'S fee is reasonable, payment for the  dispute  resol-
 ution  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 inde-
 pendent dispute resolution entity determines the  physician's  OR  AMBU-
 LANCE PROVIDER'S fee is unreasonable, payment for the dispute resolution
 process shall be the responsibility of the physician.
   §  6. 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: (A) ensure that the insured or
 enrollee shall incur no greater out-of-pocket costs  for  the  emergency
 services  than the insured or enrollee would have incurred with a health
 care provider that participates  in  the  health  care  plan's  provider

 S. 1793--A                          5
 
 network; AND (B) PROVIDE THE INSURED OR ENROLLEE THE OPTION OF ASSIGNING
 THE  PAYMENT  OF ANY BENEFITS DUE UNDER SUCH CONTRACT OR POLICY DIRECTLY
 TO THE HEALTH CARE PROVIDER. WHENEVER, IN ANY  HEALTH  INSURANCE  CLAIMS
 FORM,  AN  INSURED  OR  ENROLLEE  SPECIFICALLY AUTHORIZES THE PAYMENT OF
 BENEFITS DIRECTLY TO A HEALTH CARE PROVIDER, THE  HEALTH  CARE  PROVIDER
 SHALL  SUBMIT CLAIMS FOR BENEFITS TO THE HEALTH CARE PLAN AND THE HEALTH
 CARE PLAN SHALL MAKE PAYMENT FOR ANY BENEFITS TO THE HEALTH CARE PROVID-
 ER.
   (2) WHENEVER  AN  INSURED  OR  ENROLLEE  SPECIFICALLY  AUTHORIZES  THE
 PAYMENT  OF BENEFITS DIRECTLY TO A HEALTH CARE PROVIDER, THE HEALTH CARE
 PROVIDER SHALL NOT BILL THE INSURED  OR  ENROLLEE  FOR  PAYMENT  OF  ANY
 AMOUNT  OTHER  THAN ANY APPLICABLE COPAYMENT, COINSURANCE AND/OR DEDUCT-
 IBLE UNLESS THE HEALTH PLAN FAILS TO HONOR AN ASSIGNMENT OF BENEFITS.
   (3) THE HEALTH CARE PROVIDER SHALL NOT FURTHER  BILL  THE  INSURED  OR
 ENROLLEE  FOR  ANY  REMAINING BALANCE ONCE THE HEALTH CARE PLAN HAS MADE
 ITS INITIAL PAYMENT FOR WHICH THE INSURED OR ENROLLEE MUST BE HELD HARM-
 LESS BY THE HEALTH PLAN, BUT SHALL, WITH NOTICE TO THE INSURED OR ENROL-
 LEE OF THE EXISTING BALANCE, RESUBMIT THE BALANCE TO THE HEALTH PLAN. IN
 THE EVENT AN INSURED OR ENROLLEE MISTAKENLY  REIMBURSES  A  HEALTH  CARE
 PROVIDER  FOR  EMERGENCY  SERVICES FOR WHICH THE INSURED OR ENROLLEE HAS
 ASSIGNED  PAYMENT  OF  BENEFITS  PURSUANT  TO  PARAGRAPH  ONE  OF   THIS
 SUBSECTION, THE HEALTH CARE PROVIDER SHALL PROMPTLY REFUND SUCH PAYMENT,
 LESS  ANY  APPLICABLE  COPAYMENT,  COINSURANCE AND/OR DEDUCTIBLE, TO THE
 INSURED OR ENROLLEE.
   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 FINANCIAL SERVICES LAW.
   § 7. This act shall take effect immediately.