The New York State Senate

                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                   264

                       2019-2020 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 9, 2019
                               ___________

Introduced  by  M.  of  A.  CAHILL, COLTON, ARROYO, JEAN-PIERRE, TAYLOR,
  McDONOUGH -- Multi-Sponsored by -- M. of A. EPSTEIN -- 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 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.

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

                                                           LBD03101-01-9

A. 264                              2

  (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:
  §  604.  Criteria for determining a reasonable fee. In determining the
appropriate amount to pay for a  health  care  service,  an  independent

A. 264                              3

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, WITH REGARD TO  PHYSICIAN
SERVICES,
  (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
________________________________________________________________________

                                 264--A

                       2019-2020 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 9, 2019
                               ___________

Introduced  by  M.  of  A.  CAHILL, COLTON, ARROYO, JEAN-PIERRE, TAYLOR,
  McDONOUGH -- Multi-Sponsored by -- M. of A. EPSTEIN -- read  once  and
  referred  to  the Committee on Insurance -- committee discharged, bill
  amended, ordered reprinted as amended and recommitted to said  commit-
  tee

AN  ACT  to  amend  the  financial  services law, in relation to patient
  protections from excess hospital 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,
INCLUDING  A  BILL FOR INPATIENT SERVICES WHICH FOLLOW AN EMERGENCY ROOM
VISIT, 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  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 OR HOSPITAL pursuant to subsection (c) of section three  thou-
sand 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  SERVICES, THE HEALTH CARE PLAN

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets

                      [ ] is old law to be omitted.
                                                           LBD03101-02-9

A. 264--A                           2

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.
  (D)  THE  PROVISIONS OF THIS SECTION SHALL NOT APPLY TO HOSPITALS THAT
HAD AT LEAST  SIXTY  PERCENT  OF  INPATIENT  DISCHARGES  ANNUALLY  WHICH
CONSISTED  OF  MEDICAID,  UNINSURED,  AND  DUAL  ELIGIBLE INDIVIDUALS AS
DETERMINED BY THE DEPARTMENT OF HEALTH IN ITS  DETERMINATION  OF  SAFETY
NET HOSPITALS.
  §  2.  Subsection (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

A. 264--A                           3

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:
  § 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, WITH REGARD TO  PHYSICIAN
SERVICES,
  (f) the usual and customary cost of the service.
  § 4. This act shall take effect immediately.