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A07120 Summary:

BILL NOA07120
 
SAME ASSAME AS S05638
 
SPONSORWeprin
 
COSPNSRWoerner, Thiele, Fall, Reyes, Stern, Solages, Darling, Aubry, DeStefano, Smith, Mikulin, Blumencranz, Giglio JA, Durso, Simon, Simone
 
MLTSPNSR
 
Amd 603 & 604, Fin Serv L
 
Preserves the ability of health care providers to access the independent dispute resolution process.
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A07120 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          7120
 
                               2023-2024 Regular Sessions
 
                   IN ASSEMBLY
 
                                      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:
 
     1    Section  1.  Subsection  (c)  of section 603 of the financial services
     2  law, as added by section 26 of part H of chapter 60 of the laws of 2014,
     3  is amended to read as follows:
     4    (c) "Health care plan" means an insurer licensed to write accident and
     5  health insurance pursuant to article thirty-two of the insurance law;  a
     6  corporation  organized  pursuant to article forty-three of the insurance
     7  law; a municipal cooperative health benefit plan certified  pursuant  to
     8  article forty-seven of the insurance law; a health maintenance organiza-
     9  tion  certified pursuant to article forty-four of the public health law;
    10  [or] a student health plan established or maintained pursuant to section
    11  one thousand one hundred  twenty-four  of  the  insurance  law;  or  any
    12  provision  of health benefits under section one hundred sixty-two of the
    13  civil service law.
    14    § 2. Section 604 of the financial services law, as amended by  section
    15  4  of subpart A of part AA of chapter 57 of the laws of 2022, is amended
    16  to read as follows:
    17    § 604. Criteria for determining a reasonable fee. In  determining  the
    18  appropriate  amount  to  pay  for  a health care service, an independent
    19  dispute resolution entity shall consider all relevant  factors,  includ-
    20  ing:
    21    (a)  whether there is a gross disparity between the fee charged by the
    22  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    (1) fees paid to the involved provider for the same services  rendered
     2  by  the  provider  to  other  patients in health care plans in which the
     3  provider is not participating, and
     4    (2)  in  the case of a dispute involving a health care plan, fees paid
     5  by the health care plan to reimburse similarly qualified  providers  for
     6  the  same services in the same region who are not participating with the
     7  health care plan;
     8    (b) the level of training, education and experience of the health care
     9  professional, and in the case of a hospital, the teaching  staff,  scope
    10  of services and case mix;
    11    (c) the provider's usual charge for comparable services with regard to
    12  patients  in  health care plans in which the provider is not participat-
    13  ing;
    14    (d) the circumstances and complexity of the particular case, including
    15  time and place of the service;
    16    (e) individual patient characteristics; and
    17    (f) [the median of the rate recognized by  the  health  care  plan  to
    18  reimburse similarly qualified providers for the same or similar services
    19  in the same region that are participating with the health care plan; and
    20    (g)]  with  regard to physician services, the usual and customary cost
    21  of the service.
    22    § 3. This act shall take effect immediately.
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