Legislation

* § 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,
including:

(a) whether there is a gross disparity between the fee charged by the
provider for services rendered as compared to:

(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
participating;

(d) the circumstances and complexity of the particular case, including
time and place of the service;

(e) individual patient characteristics;

(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.

* NB Effective until August 26, 2026

* § 604. Criteria for determining a reasonable fee. (a) In determining
the appropriate amount for a health care plan other than a health
benefit plan operated pursuant to article eleven of the civil service
law to pay for a health care service, an independent dispute resolution
entity shall consider all relevant factors, including:

(1) whether there is a gross disparity between the fee charged by the
provider for services rendered as compared to:

(A) 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

(B) 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;

(2) 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;

(3) the provider's usual charge for comparable services with regard to
patients in health care plans in which the provider is not
participating;

(4) the circumstances and complexity of the particular case, including
time and place of the service;

(5) individual patient characteristics;

(6) 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

(7) with regard to physician services, the usual and customary cost of
the service.

(b) (1) In determining the appropriate amount for a health benefit
plan operated pursuant to article eleven of the civil service law to pay
for a health care service, an independent dispute resolution entity
shall select either the health care plan's payment or the
non-participating provider's fee depending on which one is closest to
the allowed benchmark, provided, however, that the independent dispute
resolution entity may choose the health care plan's payment or the
non-participating provider's fee if it is not closest to the allowed
benchmark if:

(A) the health care plan's payment or the non-participating provider's
fee are equally distant from the allowed benchmark; or

(B) the independent dispute resolution entity determines that any of
the following information submitted by either party clearly demonstrates
that the allowed benchmark is not appropriate:

(i) 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;

(ii) the circumstances and complexity of the particular case,
including time and place of the service; or

(iii) individual patient characteristics.

(2) If the independent dispute resolution entity selects the health
care plan's payment or the non-participating provider's fee that is not
closest to the allowed benchmark, such decision shall not be on the
basis of:

(A) whether there is a gross disparity between the fee charged by the
provider for services rendered as compared to:

(i) 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; or

(ii) 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 provider's usual charge for comparable services with regard to
patients in health care plans in which the provider is not
participating; or

(C) with regard to physician services, the usual and customary cost of
the service.

(3) If an independent dispute resolution entity makes a determination
pursuant to subparagraph (B) of paragraph one of subsection (b) of this
section, its written decision shall include an explanation of the
factors in subparagraph (B) of paragraph one of subsection (b) of this
section that demonstrated the health care plan's payment or
non-participating provider's fee closest to the allowed benchmark was
materially different from the appropriate payment for the health care
service.

(4) If the independent dispute resolution entity determines the
non-participating provider's fee is a reasonable fee for the services
rendered, in no circumstances shall the amount owed by a health care
plan exceed the maximum fee.

(5) Notwithstanding the foregoing, disputes involving health care
services provided by a physician employed by a general hospital licensed
under article twenty-eight of the public health law or such hospital's
affiliated medical school, or is part of a group practice that is
established as a captive professional services corporation whose
shareholders are employees of such hospital, shall be subject to
subsection (a) of this section even if paid for by a health benefit plan
operated pursuant to article eleven of the civil service law.

(c) No fee for services rendered shall be awarded pursuant to this
article:

(1) if the health care plan can demonstrate that it has a contract
with the provider or a subsidiary or other entity owned or operated by
the provider that is in effect at the time the disputed service or
services were provided to provide the same service or services at the
same location; or

(2) if the health care plan can demonstrate that a notice of
determination for prior authorization has been issued to the patient's
health care provider pursuant to section forty-nine hundred three of the
insurance law and section forty-nine hundred three of the public health
law identifying the health care service or services in dispute as
out-of-network, or, for patients covered by a health care plan not
subject to section forty-nine hundred three of the insurance law or
section forty-nine hundred three of the public health law, if a notice
of determination for prior authorization has been issued to the
patient's health care provider that includes all of the disclosures set
forth in such laws and that clearly identifies the health care service
or services in dispute as out-of-network.

* NB Effective August 26, 2026 until August 26, 2031

* § 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,
including:

(a) whether there is a gross disparity between the fee charged by the
provider for services rendered as compared to:

(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
participating;

(d) the circumstances and complexity of the particular case, including
time and place of the service;

(e) individual patient characteristics;

(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.

* NB Effective August 26, 2026