S 4123: Preserves the ability of health care providers to access the independent dispute resolution process.

  
  STATE OF NEW YORK ________________________________________________________________________ 4123 2025-2026 Regular Sessions  IN SENATE February 3, 2025 ___________ Introduced by Sens. JACKSON, CLEARE, COMRIE, FERNANDEZ, HARCKHAM, MARTI- NEZ, MATTERA, PALUMBO, SEPULVEDA -- read twice and ordered printed, and when printed to be committed 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. LBD07479-01-5 
 S. 4123 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.