The New York State Senate

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

                                 3171--A

                       2019-2020 Regular Sessions

                            I N  S E N A T E

                            February 4, 2019
                               ___________

Introduced  by Sens. KRUEGER, SEWARD, THOMAS, AMEDORE, BOYLE, GOUNARDES,
  HARCKHAM, LIU, MARTINEZ, SALAZAR, SEPULVEDA, SKOUFIS -- read twice and
  ordered printed, and when printed to be committed to the Committee  on
  Insurance  -- committee discharged, bill amended, ordered reprinted as
  amended and recommitted to said committee

AN ACT to amend the financial services law, in relation to  establishing
  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.
                                                           LBD03101-04-9

S. 3171--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   OR

S. 3171--A                          3

HOSPITAL,  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
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.