Bill S1083-2013

Relates to the reimbursement of out-of-network providers of clinical laboratory services

Relates to the reimbursement of out-of-network providers of clinical laboratory services by organizations providing or offering comprehensive health services plans.

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  • Jan 8, 2014: REFERRED TO HEALTH
  • Jan 9, 2013: REFERRED TO HEALTH

Memo

BILL NUMBER:S1083

TITLE OF BILL: An act to amend the public health law and the insurance law, in relation to the reimbursement of out-of-network providers of clinical laboratory services by organizations providing or offering comprehensive health services plans

PURPOSE: The purpose of this legislation is to provide that organizations providing or offering comprehensive health services plans, such as managed care organizations and health maintenance organizations, directly reimburse out-of-network providers of clinical laboratory services when plan participants are referred to out-of-network providers by in-network organizations or providers.

SUMMARY OF PROVISIONS: Section 1. Section 4406 of the public health law by adding a new subdivision 6. The new subdivision provides when the participant or enrollee is referred to non-participating medical providers by in-network medical providers, the services must be reimbursable under the plan; requiring the out-of-network to bill the in-network organization directly for services performed. Any payment made by the medical provider directly to the participant rather than to the out-of-network provider will not satisfy the organization's payment obligation to the clinical laboratory.

Section 4804 of the insurance law is amended by adding a new subsection (g) to with provisions that are identical to the foregoing.

JUSTIFICATION: In an effort to provide the best health care available, health care organizations and providers outside of such patients' organization's networks. Under current law, however, such organizations are not required to directly reimburse out-of-network providers for clinical laboratory services rendered. Instead, out-of-network providers of clinical laboratory services must look directly to the patients for payment of their fees, even though patients are less likely to pay for the services once rendered and may assume that the organization is required to pay for the services. This provides a disincentive to out-of-network providers to render services to such patients even in cases where the out of network provider may offer better services. This practice also thwarts the medical advice and direction of the patient's medical care giver and limits patient healthcare options.

This legislation would expand the health care service options available to the residents of the state and promote the referral of patients to providers deemed to be the best for the medical care of such patients, whether in or out-of-network.

LEGISLATIVE HISTORY:

S2817/A3802 of 2011-12; Committed to Rules

FISCAL IMPLICATIONS:

None.

EFFECTIVE DATE: This act shall take effect immediately.


Text

STATE OF NEW YORK ________________________________________________________________________ 1083 2013-2014 Regular Sessions IN SENATE (PREFILED) January 9, 2013 ___________
Introduced by Sen. MAZIARZ -- read twice and ordered printed, and when printed to be committed to the Committee on Health AN ACT to amend the public health law and the insurance law, in relation to the reimbursement of out-of-network providers of clinical laborato- ry services by organizations providing or offering comprehensive health services plans THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Section 4406 of the public health law is amended by adding a new subdivision 6 to read as follows: 6. NOTWITHSTANDING ANY OTHER PROVISION OF LAW, IF AN ENROLLEE IS REFERRED BY AN IN-PLAN PROVIDER TO A PROVIDER OF CLINICAL LABORATORY SERVICES NOT PARTICIPATING IN THE PLAN (A "NON-PARTICIPATING PROVIDER") FOR ANY SERVICE COVERED UNDER THE TERMS OF THE PLAN, THE ORGANIZATION SHALL BE RESPONSIBLE FOR PAYMENT DIRECTLY TO THE NON-PARTICIPATING PROVIDER FOR THOSE SERVICES IN ACCORDANCE WITH THE TIME FRAME FOR SUCH PAYMENTS SET FORTH IN SECTION THREE THOUSAND TWO HUNDRED TWENTY-FOUR-A OF THE INSURANCE LAW; PROVIDED, HOWEVER, THAT THE ENROLLEE SHALL BE RESPONSIBLE FOR ANY APPLICABLE COPAY, COINSURANCE OR DEDUCTIBLE FOR SUCH SERVICES. CLINICAL LABORATORIES SEEKING REIMBURSEMENT PURSUANT TO THIS SECTION FOR SERVICES RENDERED SHALL DIRECTLY BILL THE ORGANIZATION WHOSE ENROLLEE RECEIVED THE SERVICES. ANY PAYMENT MADE BY AN ORGANIZATION DIRECTLY TO THE ENROLLEE RATHER THAN TO THE CLINICAL LABORATORY SEEKING REIMBURSEMENT SHALL NOT SATISFY THE ORGANIZATION'S PAYMENT OBLIGATION TO THE CLINICAL LABORATORY. S 2. Section 4804 of the insurance law is amended by adding a new subsection (g) to read as follows: (G) NOTWITHSTANDING ANY OTHER PROVISION OF LAW, IF AN ENROLLEE IS REFERRED BY AN IN-PLAN PROVIDER TO A PROVIDER OF CLINICAL LABORATORY SERVICES NOT PARTICIPATING IN THE PLAN (A "NON-PARTICIPATING PROVIDER")
FOR ANY SERVICE COVERED UNDER THE TERMS OF THE PLAN, THE ORGANIZATION SHALL BE RESPONSIBLE FOR PAYMENT DIRECTLY TO THE NON-PARTICIPATING PROVIDER FOR THOSE SERVICES IN ACCORDANCE WITH THE TIME FRAME FOR SUCH PAYMENTS SET FORTH IN SECTION THREE THOUSAND TWO HUNDRED TWENTY-FOUR-A OF THIS CHAPTER; PROVIDED, HOWEVER, THAT THE ENROLLEE SHALL BE RESPONSI- BLE FOR ANY APPLICABLE COPAY, COINSURANCE OR DEDUCTIBLE FOR SUCH SERVICES. CLINICAL LABORATORIES SEEKING REIMBURSEMENT PURSUANT TO THIS SECTION FOR SERVICES RENDERED SHALL DIRECTLY BILL THE ORGANIZATION WHOSE ENROLLEE RECEIVED THE SERVICES. ANY PAYMENT MADE BY AN ORGANIZATION DIRECTLY TO THE ENROLLEE RATHER THAN TO THE CLINICAL LABORATORY SEEKING REIMBURSEMENT SHALL NOT SATISFY THE ORGANIZATION'S PAYMENT OBLIGATION TO THE CLINICAL LABORATORY. S 3. This act shall take effect immediately.

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