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This entry was published on 2015-04-10
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SECTION 603
Definitions
Financial Services Law (FIS) CHAPTER 18-A, ARTICLE 6
§ 603. Definitions. For the purposes of this article:

(a) "Emergency condition" means a medical or behavioral condition that
manifests itself by acute symptoms of sufficient severity, including
severe pain, such that a prudent layperson, possessing an average
knowledge of medicine and health, could reasonably expect the absence of
immediate medical attention to result in : (1) placing the health of the
person afflicted with such condition in serious jeopardy, or in the case
of a behavioral condition placing the health of such person or others in
serious jeopardy; (2) serious impairment to such person's bodily
functions; (3) serious dysfunction of any bodily organ or part of such
person; (4) serious disfigurement of such person; or (5) a condition
described in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the
social security act 42 U.S.C. § 1395dd.

(b) "Emergency services" means, with respect to an emergency
condition: (1) a medical screening examination as required under
section 1867 of the social security act, 42 U.S.C. § 1395dd, which is
within the capability of the emergency department of a hospital,
including ancillary services routinely available to the emergency
department to evaluate such emergency medical condition; and (2) within
the capabilities of the staff and facilities available at the hospital,
such further medical examination and treatment as are required under
section 1867 of the social security act, 42 U.S.C. § 1395dd, to
stabilize the patient.

(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
organization 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.

(d) "Insured" means a patient covered under a health care plan's
policy or contract.

(e) "Non-participating" means not having a contract with a health care
plan to provide health care services to an insured.

(f) "Participating" means having a contract with a health care plan to
provide health care services to an insured.

(g) "Patient" means a person who receives health care services,
including emergency services, in this state.

(h) "Surprise bill" means a bill for health care services, other than
emergency services, received by:

(1) an insured for services rendered by a non-participating physician
at a participating hospital or ambulatory surgical center, where a
participating physician is unavailable or a non-participating physician
renders services without the insured's knowledge, or unforeseen medical
services arise at the time the health care services are rendered;
provided, however, that a surprise bill shall not mean a bill received
for health care services when a participating physician is available and
the insured has elected to obtain services from a non-participating
physician;

(2) an insured for services rendered by a non-participating provider,
where the services were referred by a participating physician to a
non-participating provider without explicit written consent of the
insured acknowledging that the participating physician is referring the
insured to a non-participating provider and that the referral may result
in costs not covered by the health care plan; or

(3) a patient who is not an insured for services rendered by a
physician at a hospital or ambulatory surgical center, where the patient
has not timely received all of the disclosures required pursuant to
section twenty-four of the public health law.

(i) "Usual and customary cost" means the eightieth percentile of all
charges for the particular health care service performed by a provider
in the same or similar specialty and provided in the same geographical
area as reported in a benchmarking database maintained by a nonprofit
organization specified by the superintendent. The nonprofit organization
shall not be affiliated with an insurer, a corporation subject to
article forty-three of the insurance law, a municipal cooperative health
benefit plan certified pursuant to article forty-seven of the insurance
law, or a health maintenance organization certified pursuant to article
forty-four of the public health law.