S T A T E O F N E W Y O R K
________________________________________________________________________
7120
2023-2024 Regular Sessions
I N A S S E M B L Y
May 11, 2023
___________
Introduced by M. of A. WEPRIN -- read once and referred to the Committee
on Insurance
AN ACT to amend the financial services law, in relation to preserving
the ability of health care providers to access the independent dispute
resolution process
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Subsection (c) 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:
(c) "Health care plan" means an insurer licensed to write accident and
health insurance pursuant to article thirty-two of the insurance law; a
corporation organized pursuant to article forty-three of the insurance
law; a municipal cooperative health benefit plan certified pursuant to
article forty-seven of the insurance law; a health maintenance organiza-
tion 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 the insurance law; OR ANY
PROVISION OF HEALTH BENEFITS UNDER SECTION ONE HUNDRED SIXTY-TWO OF THE
CIVIL SERVICE LAW.
§ 2. Section 604 of the financial services law, as amended by section
4 of subpart A of part AA of chapter 57 of the laws of 2022, 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
provider for services rendered as compared to:
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD09745-01-3
A. 7120 2
(1) fees paid to the involved provider for the same services rendered
by the provider to other patients in health care plans in which the
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 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 health care
professional, and in the case of a hospital, the teaching staff, scope
of services and case mix;
(c) the provider's usual charge for comparable services with regard to
patients in health care plans in which the provider is not participat-
ing;
(d) the circumstances and complexity of the particular case, including
time and place of the service;
(e) individual patient characteristics; AND
(f) [the median of the rate recognized by the health care plan to
reimburse similarly qualified providers for the same or similar services
in the same region that are participating with the health care plan; and
(g)] with regard to physician services, the usual and customary cost
of the service.
§ 3. This act shall take effect immediately.