S T A T E O F N E W Y O R K
________________________________________________________________________
2140--A
2025-2026 Regular Sessions
I N A S S E M B L Y
January 15, 2025
___________
Introduced by M. of A. JACKSON, LASHER, GONZALEZ-ROJAS, SIMON, SIMONE,
MEEKS, DINOWITZ, CRUZ, BORES, ROSENTHAL, KELLES, STECK, FORREST,
BURROUGHS, GLICK, TAPIA, PHEFFER AMATO, BICHOTTE HERMELYN, TORRES,
KASSAY, LAVINE, GALLAGHER, YEGER, R. CARROLL, RAGA, TAYLOR, WIEDER,
VALDEZ, LEVENBERG, SHIMSKY, ZINERMAN, DE LOS SANTOS, BURDICK, WRIGHT
-- read once and referred to the Committee on Health -- recommitted to
the Committee on Health in accordance with Assembly Rule 3, sec. 2 --
committee discharged, bill amended, ordered reprinted as amended and
recommitted to said committee
AN ACT to amend the public health law, in relation to fair pricing for
low-complexity, routine medical care; and to amend the insurance law,
in relation to billing and reimbursement
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Section 2830 of the public health law, as added by chapter
764 of the laws of 2022, is renumbered section 2833 and a new section
2834 is added to read as follows:
§ 2834. FAIR PRICING FOR CERTAIN SERVICES. 1. AS USED IN THIS SECTION:
(A) "SITE-NEUTRAL PAYMENT POLICY" MEANS THE POLICY OF REIMBURSING
HEALTH CARE PROVIDERS THE SAME AMOUNT FOR A SIMILAR SERVICE, REGARDLESS
OF THE SITE OR SETTING OF THE SERVICE.
(B) "APPLICABLE SERVICES" MEANS OUTPATIENT OR AMBULATORY ITEMS OR
SERVICES THAT CAN SAFELY BE PROVIDED ACROSS AMBULATORY CARE SETTINGS;
INCLUDING:
(I) ANY OUTPATIENT OR AMBULATORY ITEM OR SERVICE PAID BY MEDICARE ON A
SITE-NEUTRAL BASIS, SUCH AS SERVICES PAID EXCLUSIVELY THROUGH NON-HOSPI-
TAL FEE SCHEDULES OR PAID AT A RATE SET TO MATCH WITH A NON-HOSPITAL FEE
SCHEDULE RATE;
(II) THE SERVICES, IDENTIFIED BY HEALTHCARE COMMON PROCEDURE CODING
SYSTEM (HCPCS) CODES, CONTAINED WITHIN THE SIXTY-SIX AMBULATORY PAYMENT
CLASSIFICATIONS (APCS) IDENTIFIED BY THE MEDICARE PAYMENT ADVISORY
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD02527-11-6
A. 2140--A 2
COMMISSION (MEDPAC) IN ITS JUNE TWO THOUSAND TWENTY-THREE REPORT TO
CONGRESS AND ANY SUBSEQUENT SERVICES MEDPAC RECOMMENDS FOR SITE-NEUTRAL
PAYMENT POLICY; OR
(III) ADDITIONAL OUTPATIENT OR AMBULATORY ITEMS OR SERVICES AS DESIG-
NATED BY THE COMMISSIONER AS SAFE AND APPROPRIATE TO BE PROVIDED IN
LOWER-COST SETTINGS, AS EVALUATED EVERY FIVE YEARS, AS NEEDED TO KEEP
THE APPLICABLE SERVICES LIST CONSISTENT WITH CHANGES IN CODES AND TECH-
NOLOGICAL UPDATES THAT MAY OCCUR OVER TIME.
(C) (I) "HEALTH CARE PROVIDER" MEANS AN INDIVIDUAL, ENTITY, CORPO-
RATION, PERSON, OR ORGANIZATION, WHETHER FOR PROFIT OR NONPROFIT,
AUTHORIZED TO PRACTICE OR HOLDING AN OPERATING CERTIFICATE, REGISTRA-
TION, OR CERTIFICATION UNDER TITLE VIII OF THE EDUCATION LAW, ARTICLE
TWENTY-EIGHT, THIRTY-ONE, OR FORTY-SEVEN OF THIS CHAPTER, OR ARTICLE
THIRTY-ONE OR THIRTY-TWO OF THE MENTAL HYGIENE LAW THAT FURNISHES, BILLS
OR IS PAID FOR HEALTH CARE SERVICE DELIVERY IN THE NORMAL COURSE OF
BUSINESS, AND INCLUDES, BUT IS NOT LIMITED TO, HOSPITALS, HOSPITAL
EXTENSION CLINICS, DIAGNOSTIC AND TREATMENT CENTERS, PHYSICIAN OFFICES,
AND CLINICAL LABORATORIES. IT SHALL ALSO INCLUDE ANY AFFILIATED PROVIDER
OR ENTITY ACTING ON THE HEALTH CARE PROVIDER'S OR AFFILIATED PROVIDER'S
BEHALF.
(II) "HEALTH CARE PROVIDER" SHALL NOT INCLUDE ANY OF THE FOLLOWING:
(A) ANY FACILITY THAT IS ELIGIBLE TO BE DESIGNATED OR HAS RECEIVED A
DESIGNATION AS A FEDERALLY QUALIFIED HEALTH CENTER IN ACCORDANCE WITH 42
U.S.C. § 1396A(AA), AS AMENDED, OR ANY SUCCESSOR LAW THERETO, INCLUDING
THOSE FACILITIES THAT ARE ALSO LICENSED UNDER ARTICLE THIRTY-ONE OR
THIRTY-TWO OF THE MENTAL HYGIENE LAW;
(B) AN ENHANCED SAFETY NET HOSPITAL, AS DEFINED IN SUBDIVISION THIR-
TY-FOUR OF SECTION TWENTY-EIGHT HUNDRED SEVEN-C OF THIS ARTICLE;
(C) A GENERAL HOSPITAL THAT IS A DISTRESSED SAFETY NET HOSPITAL, WHICH
FOR PURPOSES OF THIS SUBDIVISION SHALL MEAN A PRIVATE, FINANCIALLY
DISTRESSED HOSPITAL THAT SERVES AT LEAST FORTY-FIVE PERCENT MEDICAID AND
UNINSURED PAYOR MIX AND HAS AN AVERAGE OPERATING MARGIN THAT IS LESS
THAN OR EQUAL TO ZERO PERCENT OVER THE PAST FOUR CALENDAR YEARS OF
AVAILABLE DATA BASED ON AUDITED HOSPITAL INSTITUTIONAL COST REPORTS; OR
(D) A PPS-EXEMPT CANCER HOSPITAL UNDER MEDICARE. A PUBLIC HOSPITAL,
WHICH FOR PURPOSES OF THIS SUBDIVISION, SHALL MEAN A GENERAL HOSPITAL
OPERATED BY A COUNTY, MUNICIPALITY OR A PUBLIC BENEFIT CORPORATION.
(D) "AFFILIATED PROVIDER" MEANS A PROVIDER THAT IS BILLING FOR MEDICAL
GOODS OR SERVICES THAT WERE DELIVERED AT A FACILITY THAT IS:
(I) EMPLOYED BY THE HEALTH CARE PROVIDER;
(II) UNDER A PROFESSIONAL SERVICES AGREEMENT WITH THE HEALTH CARE
PROVIDER; OR
(III) A CLINICAL FACULTY MEMBER OF A MEDICAL SCHOOL OR OTHER SCHOOL
THAT TRAINS INDIVIDUALS TO BE PROVIDERS AND THAT IS AFFILIATED WITH THE
HEALTH CARE PROVIDER.
(E) "HEALTH BENEFIT PLAN" MEANS A PLAN, POLICY, CONTRACT, CERTIFICATE,
OR AGREEMENT ENTERED INTO, OFFERED, OR ISSUED BY A HEALTH INSURANCE
CARRIER, PLAN SPONSOR, OR THIRD-PARTY ADMINISTRATOR ACTING ON BEHALF OF
A PLAN SPONSOR TO PROVIDE, DELIVER, ARRANGE FOR, PAY FOR, OR REIMBURSE
ANY OF THE COSTS OF HEALTH CARE SERVICES AND INCLUDES ALL PLANS ADMINIS-
TERED BY AN INSURER, HEALTH MAINTENANCE ORGANIZATION, CORPORATION OR
PLAN AUTHORIZED, LICENSED OR CERTIFIED UNDER ARTICLE THIRTY-TWO, FORTY-
TWO, FORTY-THREE, FORTY-FOUR, OR FORTY-SEVEN OF THE INSURANCE LAW, OR
ARTICLE FORTY-FOUR OR SECTION TWENTY-FIVE HUNDRED ELEVEN OF THIS CHAP-
TER. HEALTH BENEFIT PLAN DOES NOT INCLUDE ANY PLANS, PROGRAMS OF COVER-
AGE, OR BENEFITS ADMINISTERED UNDER 42 U.S.C. § 1395 ET SEQ. (MEDICARE).
A. 2140--A 3
(F) "PLAN SPONSOR" MEANS:
(I) THE EMPLOYER IN THE CASE OF A BENEFIT PLAN ESTABLISHED OR MAIN-
TAINED BY A SINGLE EMPLOYER;
(II) THE EMPLOYEE ORGANIZATION IN THE CASE OF A BENEFIT PLAN ESTAB-
LISHED OR MAINTAINED BY AN EMPLOYEE ORGANIZATION, PROVIDED THAT "EMPLOY-
EE ORGANIZATION" SHALL MEAN ANY LABOR UNION OR ANY ORGANIZATION OF ANY
KIND, OR ANY AGENCY OR EMPLOYEE REPRESENTATION COMMITTEE, ASSOCIATION,
GROUP, OR PLAN, IN WHICH EMPLOYEES PARTICIPATE AND THAT EXISTS FOR THE
PURPOSE, IN WHOLE OR IN PART, OF DEALING WITH EMPLOYERS CONCERNING AN
EMPLOYEE BENEFIT PLAN, OR OTHER MATTERS INCIDENTAL TO EMPLOYMENT
RELATIONSHIPS, OR ANY EMPLOYEES' BENEFICIARY ASSOCIATION ORGANIZED FOR
THE PURPOSE IN WHOLE OR IN PART, OF ESTABLISHING SUCH A PLAN; OR
(III) IN THE CASE OF A BENEFIT PLAN ESTABLISHED OR MAINTAINED BY TWO
OR MORE EMPLOYERS OR JOINTLY BY ONE OR MORE EMPLOYERS AND ONE OR MORE
EMPLOYEE ORGANIZATIONS, THE ASSOCIATION, COMMITTEE, JOINT BOARD OF TRUS-
TEES, OR OTHER SIMILAR GROUP OF REPRESENTATIVES OF THE PARTIES WHO
ESTABLISH OR MAINTAIN THE BENEFIT PLAN.
(G) "HEALTH CARE CONTRACT" MEANS A CONTRACT, AGREEMENT, OR UNDERSTAND-
ING, EITHER ORALLY OR IN WRITING, ENTERED INTO, AMENDED, RESTATED, OR
RENEWED BETWEEN A HEALTH CARE PROVIDER AND A HEALTH INSURANCE CARRIER,
ONE OR MORE THIRD-PARTY ADMINISTRATORS, A PLAN SPONSOR OR ITS CONTRAC-
TORS OR AGENTS FOR THE DELIVERY OF HEALTH CARE SERVICES TO AN ENROLLEE
OF A HEALTH BENEFIT PLAN.
(H) "MEDICARE NON-HOSPITAL RATE" MEANS THE AMOUNT PAID BY MEDICARE FOR
THOSE SAME SERVICES PURSUANT TO THE MEDICARE PHYSICIAN FEE SCHEDULE, SET
FORTH UNDER 42 U.S.C. § 1395W-4, OR THE AMBULATORY SURGICAL CENTER (ASC)
PAYMENT SYSTEM, SET FORTH UNDER 42 U.S.C. § 1395L(I)(2)(D), ACCORDING TO
THE SITE OF SERVICE RECOMMENDED BY MEDPAC AS THE REFERENCE RATE WHERE
APPLICABLE.
2. (A) NO HEALTH CARE PROVIDER SHALL CHARGE, BILL, OR ACCEPT PAYMENT
FOR ANY APPLICABLE SERVICES THAT EXCEEDS THE LESSER OF: (I) ONE HUNDRED
FIFTY PERCENT OF THE MEDICARE NON-HOSPITAL RATE; OR (II) THE NEGOTIATED
RATE AGREED UPON BY THE HEALTH CARE PROVIDER AND THE HEALTH BENEFIT
PLAN. THIS PROVISION APPLIES REGARDLESS OF WHETHER THE HEALTH CARE
PROVIDER HAS AN EXISTING CONTRACT WITH THE PAYOR, INCLUDING SELF-PAY
INDIVIDUALS.
(B) NO HEALTH CARE PROVIDER SHALL CHARGE, BILL, OR COLLECT, OR OTHER-
WISE DEMAND PAYMENT FOR ANY APPLICABLE SERVICE ON AN INSTITUTIONAL CLAIM
FORM SUCH AS A UB-04 OR CMS-1450 FORM, OR SUCCESSOR FORMS, WHEN A
PROFESSIONAL CLAIM, SUCH AS CMS-1500 FORM, OR SUCCESSOR FORMS, MAY BE
FILED FOR THE SAME SERVICE. IN NO CIRCUMSTANCE SHOULD BOTH A PROFES-
SIONAL CLAIM AND AN INSTITUTIONAL CLAIM BE CHARGED OR BILLED FOR THE
SAME SERVICE.
(C) ALL HEALTH CARE PROVIDERS THAT ENTER INTO A HEALTH CARE CONTRACT
TO BE A PARTICIPATING PROVIDER WITH A HEALTH BENEFIT PLAN, MUST OFFER TO
ACCEPT AS PAYMENT IN FULL FOR ALL APPLICABLE SERVICES, RATES THAT SHALL
NOT EXCEED ONE HUNDRED FIFTY PERCENT OF THE MEDICARE NON-HOSPITAL RATE.
(D) NO BENEFICIARY OR SELF-PAY INDIVIDUAL SHALL BE LIABLE TO ANY
HEALTH CARE PROVIDER FOR ANY AMOUNTS IN EXCESS OF THE RATES SET FORTH IN
THIS SUBDIVISION OR FOR CLAIMS, CHARGES, OR BILLS PROHIBITED BY PARA-
GRAPH (B) OF THIS SUBDIVISION, INCLUDING ANY COPAYMENTS, DEDUCTIBLES
AND/OR COINSURANCE FOR ANY PORTION OF SUCH PROHIBITED RATES.
3. (A) COMMENCING ONE YEAR AFTER THE EFFECTIVE DATE OF THIS SECTION,
THE DEPARTMENT, IN CONSULTATION WITH THE SUPERINTENDENT, SHALL PUBLISH
ON A PUBLICLY ACCESSIBLE WEBSITE AN ANNUAL REPORT ON MULTI-YEAR SPENDING
TRENDS AND COST DRIVERS FOR AMBULATORY SERVICES, INCLUDING THE APPLICA-
A. 2140--A 4
BLE SERVICES, STRATIFIED BY SITE OF SERVICE. THE REPORT SHALL INCLUDE,
BUT IS NOT LIMITED TO, THE FOLLOWING:
(I) ANALYSIS OF IMPACT FROM THIS SECTION ON UTILIZATION OF, AND SPEND-
ING ON, THE APPLICABLE SERVICES, INCLUDING AVERAGE PRICES CHARGED AND
ALLOWED RELATIVE TO MEDICARE NON-HOSPITAL RATES, PATIENT COST-SHARING,
SERVICE VOLUMES, TOTAL SPENDING, AND AN ESTIMATE OF SAVINGS TO PAYERS
AND CONSUMERS;
(II) SERVICE-SPECIFIC RATES FOR THE MOST COMMON SERVICES, FORMATTED TO
ALLOW PRICE COMPARISONS STRATIFIED BY SITE AND ACROSS EACH OF THE LARG-
EST HOSPITALS AND NON-HOSPITAL PROVIDER GROUPS;
(III) A LIST OF GENERAL HOSPITALS WHICH CHARGE FOR SERVICES IN
VIOLATION OF PARAGRAPH (A) OF SUBDIVISION TWO OF THIS SECTION AND
ACTIONS TAKEN BY THE STATE FOR NON-COMPLIANCE; AND
(IV) RECOMMENDATIONS TO THE GOVERNOR AND LEGISLATURE REGARDING AMBULA-
TORY SERVICES PRICING, INCLUDING OTHER ITEMS OR SERVICES THAT SHOULD BE
CONSIDERED FOR SITE-NEUTRAL PAYMENT POLICY.
(B) IF THE ALL PAYER DATABASE DATA IS NOT IN A FORMAT SUFFICIENT FOR
THE REPORTING DESCRIBED IN THIS SUBDIVISION, THE DEPARTMENT SHALL
COLLECT ANY ADDITIONAL DATA SUBMISSIONS NEEDED FOR THE PURPOSES OF ACCU-
RATE AND COMPREHENSIVE REPORTING.
(C) THE DEPARTMENT SHALL ANNUALLY POST ON A PUBLICLY AVAILABLE WEBSITE
AN OFFICIAL LIST OF HEALTH CARE FACILITIES EXEMPT FROM THIS SECTION AS
DESCRIBED IN SUBPARAGRAPH (II) OF PARAGRAPH (C) OF SUBDIVISION ONE OF
THIS SECTION.
4. A HEALTH CARE PROVIDER THAT VIOLATES ANY PROVISION OF THIS SECTION
OR ANY OF THE RULES AND REGULATIONS ADOPTED PURSUANT HERETO SHALL BE
SUBJECT TO AN ADMINISTRATIVE PENALTY IN AN AMOUNT WHICH IS THE GREATER
OF:
(A) A STATUTORY PENALTY OF ONE HUNDRED THOUSAND DOLLARS PER CONTRACT
OCCURRENCE; OR
(B) ONE THOUSAND DOLLARS PER CLAIM IMPROPERLY BILLED.
5. ANY VIOLATION OF THIS SECTION, SUBSECTION (Q) OF SECTION THREE
THOUSAND TWO HUNDRED SEVENTEEN-B, SUBSECTION (W) OF SECTION THREE THOU-
SAND TWO HUNDRED TWENTY-ONE, SECTION FOUR THOUSAND TWO HUNDRED FORTY-
TWO, SUBSECTION (Q) OF SECTION FOUR THOUSAND THREE HUNDRED TWENTY-FIVE,
SUBSECTION (H) OF SECTION FOUR THOUSAND FOUR HUNDRED THIRTEEN, OR
SECTION FOUR THOUSAND SEVEN HUNDRED FIFTEEN OF THE INSURANCE LAW, OR OF
SUBDIVISION FIFTEEN OF SECTION FORTY-FOUR HUNDRED SIX-C OF THIS CHAPTER
SHALL CONSTITUTE AN UNLAWFUL DECEPTIVE ACT OR PRACTICE UNDER SECTION
THREE HUNDRED FORTY-NINE OF THE GENERAL BUSINESS LAW. ANY PERSON OR
ENTITY WHO SUFFERS A LOSS AS A RESULT OF A VIOLATION OF THIS SECTION
SHALL BE ENTITLED TO INITIATE AN ACTION AND SEEK ALL REMEDIES, DAMAGES,
COSTS, AND FEES AVAILABLE UNDER SUBDIVISION (H) OF SECTION THREE HUNDRED
FORTY-NINE OF THE GENERAL BUSINESS LAW.
§ 2. Section 3217-b of the insurance law is amended by adding a new
subsection (q) to read as follows:
(Q) NO INSURER THAT PROVIDES COVERAGE FOR APPLICABLE SERVICES AS
DEFINED IN SUBDIVISION ONE OF SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR
OF THE PUBLIC HEALTH LAW SHALL REIMBURSE OR ENTER INTO CONTRACTS THAT
INCLUDE PROVISIONS TO REIMBURSE A HEALTH CARE PROVIDER FOR ANY APPLICA-
BLE SERVICES IN AMOUNTS IN EXCESS OF THE RATES SET FORTH IN SUBDIVISION
TWO OF SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR OF THE PUBLIC HEALTH LAW
OR FOR SERVICES BILLED IN VIOLATION OF PARAGRAPH (A) OF SUBDIVISION TWO
OF SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR OF THE PUBLIC HEALTH LAW.
THE SUPERINTENDENT, AFTER NOTICE AND HEARING, MAY IMPOSE A PENALTY OF UP
A. 2140--A 5
TO FIFTY THOUSAND DOLLARS PER DAY FOR EACH DAY THAT A CONTRACT IS IN
VIOLATION OF THIS SUBSECTION.
§ 3. Section 3221 of the insurance law is amended by adding a new
subsection (w) to read as follows:
(W) NO POLICY THAT PROVIDES COVERAGE FOR APPLICABLE SERVICES AS
DEFINED IN SUBDIVISION ONE OF SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR
OF THE PUBLIC HEALTH LAW SHALL REIMBURSE OR ENTER INTO CONTRACTS THAT
INCLUDE PROVISIONS TO REIMBURSE A HEALTH CARE PROVIDER FOR ANY APPLICA-
BLE SERVICES IN AMOUNTS IN EXCESS OF THE RATES SET FORTH IN SUBDIVISION
TWO OF SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR OF THE PUBLIC HEALTH LAW
OR FOR SERVICES BILLED IN VIOLATION OF PARAGRAPH (A) OF SUBDIVISION TWO
OF SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR OF THE PUBLIC HEALTH LAW.
THE SUPERINTENDENT, AFTER NOTICE AND HEARING, MAY IMPOSE A PENALTY OF UP
TO FIFTY THOUSAND DOLLARS PER DAY FOR EACH DAY THAT A CONTRACT IS IN
VIOLATION OF THIS SUBSECTION.
§ 4. The insurance law is amended by adding a new section 4242 to read
as follows:
§ 4242. PENALTY FOR VIOLATION OF FAIR PRICING LAW. ANY AUTHORIZED
INSURER THAT OFFERS GROUP OR BLANKET INSURANCE AND PROVIDES COVERAGE FOR
APPLICABLE SERVICES AS DEFINED IN SUBDIVISION ONE OF SECTION TWENTY-
EIGHT HUNDRED THIRTY-FOUR OF THE PUBLIC HEALTH LAW SHALL NOT REIMBURSE
OR ENTER INTO CONTRACTS THAT INCLUDE PROVISIONS TO REIMBURSE A HEALTH
CARE PROVIDER FOR ANY APPLICABLE SERVICES IN AMOUNTS IN EXCESS OF THE
RATES SET FORTH IN SUBDIVISION TWO OF SECTION TWENTY-EIGHT HUNDRED THIR-
TY-FOUR OF THE PUBLIC HEALTH LAW OR FOR SERVICES BILLED IN VIOLATION OF
PARAGRAPH (A) OF SUBDIVISION TWO OF SECTION TWENTY-EIGHT HUNDRED THIR-
TY-FOUR OF THE PUBLIC HEALTH LAW. THE SUPERINTENDENT, AFTER NOTICE AND
HEARING, MAY IMPOSE A PENALTY OF UP TO FIFTY THOUSAND DOLLARS PER DAY
FOR EACH DAY THAT A CONTRACT IS IN VIOLATION OF THIS SECTION.
§ 5. Section 4325 of the insurance law is amended by adding a new
subsection (q) to read as follows:
(Q) NO CORPORATION ORGANIZED UNDER THIS ARTICLE THAT PROVIDES COVERAGE
FOR APPLICABLE SERVICES AS DEFINED IN SUBDIVISION ONE OF SECTION TWEN-
TY-EIGHT HUNDRED THIRTY-FOUR OF THE PUBLIC HEALTH LAW SHALL REIMBURSE OR
ENTER INTO CONTRACTS THAT INCLUDE PROVISIONS TO REIMBURSE A HEALTH CARE
PROVIDER FOR ANY APPLICABLE SERVICES IN AMOUNTS IN EXCESS OF THE RATES
SET FORTH IN SUBDIVISION TWO OF SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR
OF THE PUBLIC HEALTH LAW OR FOR SERVICES BILLED IN VIOLATION OF PARA-
GRAPH (A) OF SUBDIVISION TWO OF SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR
OF THE PUBLIC HEALTH LAW. THE SUPERINTENDENT, AFTER NOTICE AND HEARING,
MAY IMPOSE A PENALTY OF UP TO FIFTY THOUSAND DOLLARS PER DAY FOR EACH
DAY THAT A CONTRACT IS IN VIOLATION OF THIS SUBSECTION.
§ 6. Section 4413 of the insurance law is amended by adding a new
subsection (h) to read as follows:
(H) ANY EMPLOYEE WELFARE FUND ORGANIZED UNDER THIS ARTICLE THAT OFFERS
COVERAGE FOR APPLICABLE SERVICES AS DEFINED IN SUBDIVISION ONE OF
SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR OF THE PUBLIC HEALTH LAW THAT
REIMBURSES OR ENTERS INTO CONTRACTS THAT INCLUDE PROVISIONS TO REIMBURSE
A HEALTH CARE PROVIDER FOR ANY APPLICABLE SERVICES IN AMOUNTS IN EXCESS
OF THE RATES SET FORTH IN SUBDIVISION TWO OF SECTION TWENTY-EIGHT
HUNDRED THIRTY-FOUR OF THE PUBLIC HEALTH LAW OR FOR SERVICES BILLED IN
VIOLATION OF PARAGRAPH (A) OF SUBDIVISION TWO OF SECTION TWENTY-EIGHT
HUNDRED THIRTY-FOUR OF THE PUBLIC HEALTH LAW. THE SUPERINTENDENT, AFTER
NOTICE AND HEARING, MAY IMPOSE A PENALTY OF UP TO FIFTY THOUSAND DOLLARS
PER DAY FOR EACH DAY THAT A CONTRACT IS IN VIOLATION OF THIS SUBSECTION.
A. 2140--A 6
§ 7. The insurance law is amended by adding a new section 4715 to read
as follows:
§ 4715. FAIR PRICING. NO MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN
ORGANIZED UNDER THIS ARTICLE THAT PROVIDES COVERAGE FOR APPLICABLE
SERVICES AS DEFINED IN SUBDIVISION ONE OF SECTION TWENTY-EIGHT HUNDRED
THIRTY-FOUR OF THE PUBLIC HEALTH LAW SHALL REIMBURSE OR ENTER INTO
CONTRACTS THAT INCLUDE PROVISIONS TO REIMBURSE A HEALTH CARE PROVIDER
FOR ANY APPLICABLE SERVICES IN AMOUNTS IN EXCESS OF THE RATES SET FORTH
IN SUBDIVISION TWO OF SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR OF THE
PUBLIC HEALTH LAW OR FOR SERVICES BILLED IN VIOLATION OF PARAGRAPH (A)
OF SUBDIVISION TWO OF SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR OF THE
PUBLIC HEALTH LAW. THE SUPERINTENDENT, AFTER NOTICE AND HEARING, MAY
IMPOSE A PENALTY OF UP TO FIFTY THOUSAND DOLLARS PER DAY FOR EACH DAY
THAT A CONTRACT IS IN VIOLATION OF THIS SECTION.
§ 8. Section 4406-c of the public health law is amended by adding a
new subdivision 15 to read as follows:
15. NO HEALTH CARE PLAN THAT PROVIDES COVERAGE FOR APPLICABLE SERVICES
AS DEFINED IN SUBDIVISION ONE OF SECTION TWENTY-EIGHT HUNDRED THIRTY-
FOUR OF THIS CHAPTER SHALL REIMBURSE OR ENTER INTO CONTRACTS THAT
INCLUDE PROVISIONS TO REIMBURSE A HEALTH CARE PROVIDER FOR ANY APPLICA-
BLE SERVICES IN AMOUNTS IN EXCESS OF THE RATES SET FORTH IN SUBDIVISION
TWO OF SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR OF THIS CHAPTER OR FOR
SERVICES BILLED IN VIOLATION OF PARAGRAPH (A) OF SUBDIVISION TWO OF
SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR OF THIS CHAPTER. THE DEPARTMENT
MAY IMPOSE A PENALTY OF UP TO FIFTY THOUSAND DOLLARS PER DAY FOR EACH
DAY THAT A CONTRACT IS IN VIOLATION OF THIS SUBDIVISION.
§ 9. Subparagraph (A) of paragraph 1 of subsection (e) of section 3231
of the insurance law, as amended by chapter 107 of the laws of 2010 and
as further amended by section 104 of part A of chapter 62 of the laws of
2011, is amended to read as follows:
(A) An insurer desiring to increase or decrease premiums for any poli-
cy form subject to this section shall submit a rate filing or applica-
tion to the superintendent.
An insurer shall send written notice of the proposed rate adjustment,
including the specific change requested, to each policy holder and
certificate holder affected by the adjustment on or before the date the
rate filing or application is submitted to the superintendent. The
notice shall prominently include mailing and website addresses for both
the department of financial services and the insurer through which a
person may, within thirty days from the date the rate filing or applica-
tion is submitted to the superintendent, contact the department of
financial services or insurer to receive additional information or to
submit written comments to the department of financial services on the
rate filing or application. The superintendent shall establish a process
to post on the department's website, in a timely manner, all relevant
written comments received pertaining to rate filings or applications.
The insurer shall provide a copy of the notice to the superintendent
with the rate filing or application. The superintendent shall immediate-
ly cause the notice to be posted on the department of financial
services' website. The superintendent shall determine whether the filing
or application shall become effective as filed, shall become effective
as modified, or shall be disapproved. The superintendent may modify or
disapprove the rate filing or application if the superintendent finds
that the premiums are unreasonable, excessive, inadequate, or unfairly
discriminatory, and may consider the financial condition of the insurer
when approving, modifying or disapproving any premium adjustment. The
A. 2140--A 7
determination of the superintendent shall be supported by sound actuari-
al assumptions and methods, and shall be rendered in writing between
thirty and sixty days from the date the rate filing or application is
submitted to the superintendent. IN ADDITION, THE DETERMINATION OF THE
SUPERINTENDENT SHALL MODIFY THE FINAL RATE DETERMINATION TO REFLECT THE
REDUCED PAYMENTS TO HEALTH CARE PROVIDERS AS A RESULT OF THE REQUIRE-
MENTS IN SECTION TWENTY-EIGHT HUNDRED THIRTY-FOUR OF THE PUBLIC HEALTH
LAW. Should the superintendent require additional information from the
insurer in order to make a determination, the superintendent shall
require the insurer to furnish such information, and in such event, the
sixty days shall be tolled and shall resume as of the date the insurer
furnishes the information to the superintendent. If the superintendent
requests additional information less than ten days from the expiration
of the sixty days (exclusive of tolling), the superintendent may extend
the sixty day period an additional twenty days to make a determination.
The application or rate filing will be deemed approved if a determi-
nation is not rendered within the time allotted under this section. An
insurer shall not implement a rate adjustment unless the insurer
provides at least sixty days advance written notice of the premium rate
adjustment approved by the superintendent to each policy holder and
certificate holder affected by the rate adjustment.
§ 10. Paragraph 2 of subsection (c) of section 4308 of the insurance
law, as amended by chapter 107 of the laws of 2010 and as further
amended by section 104 of part A of chapter 62 of the laws of 2011, is
amended to read as follows:
(2) A corporation desiring to increase or decrease premiums for any
contract subject to this subsection shall submit a rate filing or appli-
cation to the superintendent. A corporation shall send written notice of
the proposed rate adjustment, including the specific change requested,
to each contract holder and subscriber affected by the adjustment on or
before the date the rate filing or application is submitted to the
superintendent. The notice shall prominently include mailing and website
addresses for both the department of financial services and the corpo-
ration through which a person may, within thirty days from the date the
rate filing or application is submitted to the superintendent, contact
the department of financial services or corporation to receive addi-
tional information or to submit written comments to the department of
financial services on the rate filing or application. The superintendent
shall establish a process to post on the department's website, in a
timely manner, all relevant written comments received pertaining to rate
filings or applications. The corporation shall provide a copy of the
notice to the superintendent with the rate filing or application. The
superintendent shall immediately cause the notice to be posted on the
department of financial services' website. The superintendent shall
determine whether the filing or application shall become effective as
filed, shall become effective as modified, or shall be disapproved. The
superintendent may modify or disapprove the rate filing or application
if the superintendent finds that the premiums are unreasonable, exces-
sive, inadequate, or unfairly discriminatory, and may consider the
financial condition of the corporation in approving, modifying or disap-
proving any premium adjustment. The determination of the superintendent
shall be supported by sound actuarial assumptions and methods, and shall
be rendered in writing between thirty and sixty days from the date the
rate filing or application is submitted to the superintendent. IN ADDI-
TION, THE DETERMINATION OF THE SUPERINTENDENT SHALL MODIFY THE FINAL
RATE DETERMINATION TO REFLECT THE REDUCED PAYMENTS TO HEALTH CARE
A. 2140--A 8
PROVIDERS AS A RESULT OF THE REQUIREMENTS IN SECTION TWENTY-EIGHT
HUNDRED THIRTY-FOUR OF THE PUBLIC HEALTH LAW. Should the superintendent
require additional information from the corporation in order to make a
determination, the superintendent shall require the corporation to
furnish such information, and in such event, the sixty days shall be
tolled and shall resume as of the date the corporation furnishes the
information to the superintendent. If the superintendent requests addi-
tional information less than ten days from the expiration of the sixty
days (exclusive of tolling), the superintendent may extend the sixty day
period an additional twenty days, to make a determination. The applica-
tion or rate filing will be deemed approved if a determination is not
rendered within the time allotted under this section. A corporation
shall not implement a rate adjustment unless the corporation provides at
least sixty days advance written notice of the premium rate adjustment
approved by the superintendent to each contract holder and subscriber
affected by the rate adjustment.
§ 11. The commissioner of health and the superintendent of financial
services shall promulgate joint regulations necessary to implement the
provisions of this act.
§ 12. Severability. If any clause, sentence, paragraph, subdivision,
section or part of this act shall be adjudged by any court of competent
jurisdiction to be invalid, such judgment shall not affect, impair, or
invalidate the remainder thereof, but shall be confined in its operation
to the clause, sentence, paragraph, subdivision, section or part thereof
directly involved in the controversy in which such judgment shall have
been rendered. It is hereby declared to be the intent of the legislature
that this act would have been enacted even if such invalid provisions
had not been included herein.
§ 13. This act shall take effect on the first of January next succeed-
ing the date upon which it shall have become a law, and shall apply to
policies and contracts issued, amended, or renewed on or after such
date. Effective immediately, the addition, amendment and/or repeal of
any rule or regulation necessary for the implementation of this act on
its effective date are authorized to be made and completed on or before
such effective date.