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.