Current through Register Vol. 46, No. 39, September 25, 2024
(a) Upon
receipt of a claim for emergency services, including inpatient services that
follow an emergency room visit, rendered by a non-participating physician or a
non-participating hospital, a health care plan shall:
(1)
(i) pay
the claim, within the timeframes established in Insurance Law section 3224-a,
in an amount that it deems reasonable for the services rendered by the
non-participating physician or non-participating hospital that had not
previously entered into a participating provider agreement with the health care
plan, except for the insured's co-payment, coinsurance or deductible, if any ;
or
(ii) in disputes involving a
non-participating hospital that had previously entered into a participating
provider agreement with the health care plan, pay the claim, within the
timeframes established in Insurance Law section 3224-a, in an initial amount
that is at least 25 percent greater than the amount the health care plan would
have paid for the claim had the hospital been in-network, based on the most
recent participating provider agreement between the health care plan and the
non-participating hospital, except for the insured's co-payment, coinsurance or
deductible, if any. In the event the prior participating provider agreement
between the health care plan and the non-participating hospital expired more
than 12 months prior to the payment of the disputed claim, the payment amount
shall be adjusted based upon the annual medical consumer price index,
compounded for each year subsequent to the year the contract terminated up
until the year the claim is paid. If a health care plan believes that this
initial payment amount to a non-participating hospital with which it had
previously entered into a participating provider agreement is not reasonable,
it may submit a dispute to the superintendent for review by an IDRE, as
provided in section
400.7 of this Part, and propose an
amount it deems reasonable, provided that the health care plan:
(a) notifies the non-participating hospital
of its intent to submit the dispute to the superintendent, together with the
health care plan's best and final offer and an explanation of the calculation,
including the aggregation or any other methodology used by the health care plan
to develop its best and final offer;
(b) provides the non-participating hospital
with 15 business days to respond to the health care plan with the
non-participating hospital's best and final offer before submitting the dispute
to the superintendent;
(c) includes
its best and final offer and the non-participating hospital's best and final
offer, if any, in its submission of the dispute to the superintendent;
and
(d) notifies the
non-participating hospital of the dispute at the time of the submission to the
superintendent; and
(iii) not be precluded from attempting to
negotiate the reimbursement amount with the non-participating physician or
non-participating hospital within the timeframes established in Insurance Law
section 3224-a;
(2) if
the claim is submitted by the non-participating physician or non-participating
hospital, or if payment is made to the non-participating physician or
non-participating hospital, provide notice to the non-participating physician
or non-participating hospital describing how to initiate the independent
dispute resolution process;
(3) if
the health care plan pays an amount less than the non-participating physician's
or non-participating hospital's charge, provide the insured with notice,
included on or in conjunction with, an explanation of benefits, which shall:
(i) explain that the insured shall incur no
greater out-of-pocket costs for the services than the insured would have
incurred with a participating physician or participating hospital ;
(ii) explain that the insured's cost-sharing
may increase in the event the IDRE determines that the health care plan must
pay additional amounts for the services of the non-participating physician or
nonparticipating hospital ; and
(iii) direct the insured to contact the
health care plan in the event that the non-participating physician or
non-participating hospital bills the insured for the out-of-network service
other than the insured's in-network copayment, coinsurance, or deductible;
and
(4) pay the amount
set forth in subparagraph (i) or (ii) of paragraph (1) of this subdivision
directly to the non-participating physician or non-participating hospital if an
insured assigns benefits to the non-participating physician or
non-participating hospital.
(b) Upon receipt of a claim for a surprise
bill that is submitted with an assignment of benefits form, or that the health
care plan otherwise determines is a surprise bill, the health care plan shall:
(1) Pay the non-participating physician or
non-participating referred health care provider the billed amount or attempt to
negotiate reimbursement with the non-participating physician or
non-participating referred health care provider. If the health care plan's
attempts to negotiate reimbursement for the health care services provided by
the non-participating physician or non-participating referred health care
provider do not result in a resolution of the payment dispute, the health care
plan shall pay the non-participating physician or non-participating referred
health care provider an amount the health care plan determines is reasonable
for the health care services rendered, except for the insured's copayment,
coinsurance or deductible, in accordance with the timeframes established in
Insurance Law section 3224-a.
(2)
Provide notice to the non-participating physician or, as applicable, to the
non-participating referred health care provider, describing how to initiate the
independent dispute resolution process.
(3) Provide the insured with notice, included
on or in conjunction with, an explanation of benefits, which shall:
(i) explain that the insured shall incur no
greater out-of-pocket costs for the services than the insured would have
incurred with a participating physician or health care provider;
(ii) explain that the insured's cost-sharing
may increase in the event the IDRE determines that the health care plan must
pay additional amounts for the services of the non-participating physician or
non-participating referred health care provider; and
(iii) direct the insured to contact the
health care plan in the event that the non-participating physician or
non-participating referred health care provider bills the insured for the
out-of-network service other than the insured's in-network copayment,
coinsurance, or deductible.
(c) Upon receipt of a claim for the services
of a non-participating physician or a non-participating referred health care
provider that could be a surprise bill and that is not submitted with an
assignment of benefits form, the health care plan shall provide the insured
with notice, included on or in conjunction with, an explanation of benefits,
which shall :
(1) advise the insured that the
claim could be a surprise bill ;
(2)
explain that if the claim is a surprise bill and the insured submits an
assignment of benefits form, the insured will incur no greater out-of-pocket
costs for the services than the insured would have incurred with a
participating physician or health care provider; and
(3) direct the insured to contact the health
care plan or visit the health care plan's website for additional information
regarding surprise bills and to obtain an assignment of benefits form for
surprise bills.
(d) If
the health care plan receives a claim for services of a non-participating
health care provider that could be a surprise bill that is not submitted with
an assignment of benefits form and the health care plan denies the claim
because the health care provider is a non-participating provider, the health
care plan shall, upon receipt of the assignment of benefits form, comply with
the requirements of subdivision (b) of this section.
(e) If the health care plan receives a claim
for services of a non-participating health care provider that is not submitted
with an assignment of benefits form and pays the claim, the health care plan
shall, upon receipt of the assignment of benefits form, determine whether it
will attempt to negotiate additional reimbursement with the non-participating
physician or non-participating referred health care provider. After receipt of
the assignment of benefits form, if the health care plan attempts to negotiate
additional reimbursement for the surprise bill and the attempts do not result
in a resolution of the payment dispute or the health care plan does not attempt
to negotiate the additional reimbursement for the surprise bill, the health
care plan shall:
(1) Pay the non-participating
physician or non-participating referred health care provider any additional
amount the health care plan determines is reasonable for the health care
services rendered, except for the insured's copayment, coinsurance or
deductible, in accordance with the timeframes established in Insurance Law
section 3224-a; and
(2) Provide the
insured with notice that shall:
(i) explain
that the insured will incur no greater out-of-pocket costs for the services
than the insured would have incurred with a participating physician or health
care provider;
(ii) explain that
the insured's cost-sharing may increase in the event the IDRE determines that
the health care plan must pay additional amounts for the services of the
non-participating physician or non-participating referred health care
provider;
(iii) explain that if the
health care plan paid the insured directly, then the insured must remit that
payment to the non-participating physician or non-participating referred health
care provider;
(iv) direct the
insured to contact the health care plan in the event that the non-participating
physician or non-participating referred health care provider bills the insured
for the out-of-network service other than the insured's in-network copayment,
coinsurance, or deductible ; and
(v) direct the insured to the health care
plan's website for additional information regarding surprise bills.
(f) A health care plan
shall prominently post on its website the information in paragraphs (1) - (5)
of this subdivision and include in disclosure materials provided to insureds
pursuant to Insurance Law sections 3217-a(a), 4324(a) and Public Health Law
section 4408(1) the information in paragraphs (1) - (4) of this subdivision, as
follows:
(1) a description of what
constitutes a surprise bill;
(2) a
description of the independent dispute resolution process;
(3) an assignment of benefits form for
surprise bills;
(4) the health care
plan's designated electronic and mailing address where the assignment of
benefits form can be submitted; and
(5) information on how an insured,
non-participating physician, non-participating hospital, or, as applicable, a
non-participating referred health care provider, may submit a dispute to an
IDRE.
(g) An assignment
of benefits form for surprise bills shall be in a form prescribed by the
superintendent.
(h) A health care
plan shall ensure that the insured shall incur no greater out-of-pocket costs
for the services than the insured would have incurred with a participating
physician, participating hospital, or participating health care provider:
(1) for emergency services, including
inpatient services that follow an emergency room visit ; and
(2) for a dispute involving a surprise bill
when the insured has assigned benefits to a non-participating physician or a
non-participating referred health care provider.
(i) If the IDRE directs the health care plan
to engage in negotiations with the non-participating physician,
non-participating hospital, or non-participating referred health care provider
the health care plan shall do so in good faith. If a settlement is reached, the
health care plan shall notify the IDRE within two business days of the
settlement and shall make any additional payment to the non-participating
physician, non-participating hospital, or non-participating referred health
care provider within the timeframes prescribed in Insurance Law section 3224-a.
If a settlement is not reached or the parties agree that a settlement is not
attainable, the health care plan shall promptly notify the IDRE no later than
the end of the time period granted by the IDRE for negotiation.
(j) If the IDRE issues a determination in
favor of the non-participating physician, non-participating hospital, or
non-participating referred health care provider, the health care plan shall pay
the non-participating physician, non-participating hospital, or, as applicable,
the non-participating referred health care provider, any additional amount owed
within 30 days from the date of the determination.
(k) A health care plan shall designate, and
inform the superintendent of, at least one officer and one staff member
knowledgeable about the independent dispute resolution process who shall be
responsible for oversight of the health care plan's compliance with the
independent dispute resolution process. The health care plan shall make at
least one staff person available during normal business hours for not less than
40 hours per week. The health care plan shall respond to all inquiries from the
superintendent relating to the dispute resolution process within three business
days.
(l)
(1) If a health care plan receives an
assignment of benefits form for a surprise bill and determines that the bill is
not a surprise bill, the health care plan shall provide written notice of such
determination. The notice shall include the procedures for filing a grievance
under Insurance Law section 4802 or Public Health Law section 4408-a and
information on how to file a complaint with the superintendent.
(2) If a health care plan makes a
determination on a grievance disputing that a bill is a surprise bill, the
health care plan shall comply with the Insurance Law section 4802 or Public
Health Law section 4408-a grievance requirements.
