Requires hospitals to inform emergency care patients whether the attending physician participates in the insured's insurance policy; requires insurance companies to cover the cost of out-of-network care for patients who are unconscious or otherwise unable to provide informed consent.
TITLE OF BILL: An act to amend the public health law and the insurance law, in relation to requiring hospitals to inform emergency care patients whether the attending physician participates with the patient's insurance policy and requiring insurance companies to cover the cost of out-of-network care for patients who are unconscious or otherwise unable to provide informed consent
PURPOSE: The bill requires hospitals to inform patients if they are to be treated by an out-of network doctor. The bill also provides that in certain circumstances if emergency services provided by an out-of network provider the cost sharing requirements will be the same if the services were provided by an in-network provider.
SUMMARY OF PROVISIONS: Section 1. The bill requires that every general hospital which patients receive emergency care must adopt regulations requiring its staff to inform patients whether the attending physician participates with the patient's insurance policy. The patient can then decide if they want to be treated by the out-of network physician or request treatment by an in-network physician.
Section 2. Requires that every policy that provides coverage for services to treat an emergency condition in a hospital facility that meets the specified criteria and services are provided by a non-participating provider, the cost-sharing requirement shall be the same requirement that would apply if the services were provided by a participating provider.
JUSTIFICATION: In 2011, Nathan Roethstein was bite by a dog and sought medical treatment at a provider hospital. Due to the severity of the bite his parents were told that he would have to be seen by a plastic surgeon. The Roethsteins were not aware that the plastic surgeon on-call at the time was not an in-network provider. The Roethstein were made aware of this when Nathan went to the surgeon to get his stitches out and his parents were presented with a large medical bill, which their insurance would only cover a small portion off. The Roethsteins are not the only family in New York whom after receiving emergency care received a large medical bill because the attending physician that they saw was out-of network. This bill attempts to solve this problem. By requiring hospitals to inform patients if the physician on-call is in their network will provide patients with the choice to see the physician or to request an in-network physician. This will help patients to make an informed choice to hopefully decrease the number of New Yorkers who struggle to pay high medical bills. The bill will also alleviate this financial burden by requiring that in certain emergency situations the cost-sharing requirement for services provided by a non-participating provider be the same
requirement that would apply if the services were provided by a participating provider.
New York's families are already struggling in this hard economic time. Many cannot afford the huge medical bills that are associated with being treated by an out of network doctor in an emergency situation. This bill takes the necessary steps to try and cut down on cost of emergency care.
LEGISLATIVE HISTORY: 2011-12 - S.6189 - Referred to Health
FISCAL IMPLICATIONS: Needs to be determined.
EFFECTIVE DATE: This law shall take effect on the one hundred twentieth day after it shall become law.
STATE OF NEW YORK ________________________________________________________________________ 1197 2013-2014 Regular Sessions IN SENATE (PREFILED) January 9, 2013 ___________Introduced by Sen. CARLUCCI -- 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 requiring hospitals to inform emergency care patients whether the attending physician participates with the patient's insurance policy and requiring insurance companies to cover the cost of out-of-network care for patients who are unconscious or otherwise unable to provide informed consent THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Section 2805-b of the public health law is amended by adding a new subdivision 1-a to read as follows: 1-A. EVERY GENERAL HOSPITAL IN WHICH INSURED PATIENTS ARE ADMITTED FOR EMERGENCY CARE SHALL ADOPT REGULATIONS REQUIRING ITS STAFF TO INFORM SUCH PATIENTS WHETHER THE ATTENDING PHYSICIAN PARTICIPATES WITH THE PATIENT'S INSURANCE POLICY. IN THE EVENT SUCH ATTENDING PHYSICIAN DOES NOT PARTICIPATE WITH THE PATIENT'S INSURANCE POLICY, THE PATIENT SHALL BE PERMITTED TO DECIDE WHETHER TO BE TREATED BY THE OUT-OF-NETWORK ATTENDING PHYSICIAN OR TO REQUEST TREATMENT BY AN IN-NETWORK PHYSICIAN, WHO MUST TREAT SUCH PATIENT WITH ALL CONVENIENT SPEED. S 2. Subsection (i) of section 3216 of the insurance law is amended by adding a new paragraph 9-a to read as follows: (9-A)(A) EVERY POLICY THAT PROVIDES COVERAGE FOR SERVICES TO TREAT AN EMERGENCY CONDITION IN HOSPITAL FACILITIES: (I) WITHOUT THE NEED FOR ANY PRIOR AUTHORIZATION DETERMINATION; (II) IN THE CASE OF PATIENTS WHO ARE UNCONSCIOUS OR OTHERWISE UNABLE TO PROVIDE INFORMED CONSENT, REGARDLESS OF WHETHER THE HEALTH CARE PROVIDER FURNISHING SUCH SERVICES IS A PARTICIPATING PROVIDER WITH RESPECT TO SUCH SERVICES;EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD05326-01-3 S. 1197 2
(III) IF THE EMERGENCY SERVICES ARE PROVIDED BY A NON-PARTICIPATING PROVIDER, WITHOUT IMPOSING ANY ADMINISTRATIVE REQUIREMENT OR LIMITATION ON COVERAGE THAT IS MORE RESTRICTIVE THAN THE REQUIREMENTS OR LIMITA- TIONS THAT APPLY TO EMERGENCY SERVICES RECEIVED FROM PARTICIPATING PROVIDERS; AND (IV) IF THE EMERGENCY SERVICES ARE PROVIDED BY A NON-PARTICIPATING PROVIDER, THE COST-SHARING REQUIREMENT (EXPRESSED AS A COPAYMENT OR COINSURANCE) SHALL BE THE SAME REQUIREMENT THAT WOULD APPLY IF SUCH SERVICES WERE PROVIDED BY A PARTICIPATING PROVIDER. (B) ANY REQUIREMENTS OF SECTION 2719A(B) OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG19A(B) AND REGULATIONS THEREUNDER THAT EXCEED THE REQUIREMENTS OF THIS PARAGRAPH WITH RESPECT TO COVERAGE OF EMERGENCY SERVICES SHALL BE APPLICABLE TO EVERY POLICY SUBJECT TO THIS PARAGRAPH. (C) FOR PURPOSES OF THIS PARAGRAPH, AN "EMERGENCY CONDITION" MEANS A MEDICAL OR BEHAVIORAL CONDITION THAT MANIFESTS ITSELF BY ACUTE SYMPTOMS OF SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, SUCH THAT A PRUDENT LAYPERSON, POSSESSING AN AVERAGE KNOWLEDGE OF MEDICINE AND HEALTH, COULD REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO RESULT IN (I) PLACING THE HEALTH OF THE PERSON AFFLICTED WITH SUCH CONDITION IN SERIOUS JEOPARDY, OR IN THE CASE OF A BEHAVIORAL CONDITION PLACING THE HEALTH OF SUCH PERSON OR OTHERS IN SERIOUS JEOPARDY; (II) SERIOUS IMPAIRMENT TO SUCH PERSON'S BODILY FUNCTIONS; (III) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART OF SUCH PERSON; (IV) SERIOUS DISFIGUREMENT OF SUCH PERSON; OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. (D) FOR PURPOSES OF THIS PARAGRAPH, "EMERGENCY SERVICES" MEANS, WITH RESPECT TO AN EMERGENCY CONDITION: (I) A MEDICAL SCREENING EXAMINATION AS REQUIRED UNDER SECTION 1867 OF THE SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, WHICH IS WITHIN THE CAPABILITY OF THE EMERGENCY DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY AVAILABLE TO THE EMER- GENCY DEPARTMENT TO EVALUATE SUCH EMERGENCY MEDICAL CONDITION; AND (II) WITHIN THE CAPABILITIES OF THE STAFF AND FACILITIES AVAILABLE AT THE HOSPITAL, SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT AS ARE REQUIRED UNDER SECTION 1867 OF THE SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, TO STABILIZE THE PATIENT. (E) FOR PURPOSES OF THIS PARAGRAPH, "TO STABILIZE" MEANS, WITH RESPECT TO AN EMERGENCY CONDITION, TO PROVIDE SUCH MEDICAL TREATMENT OF THE CONDITION AS MAY BE NECESSARY TO ASSURE, WITHIN REASONABLE MEDICAL PROB- ABILITY, THAT NO MATERIAL DETERIORATION OF THE CONDITION IS LIKELY TO RESULT FROM OR OCCUR DURING THE TRANSFER OF THE INSURED FROM A FACILITY OR TO DELIVER A NEWBORN CHILD (INCLUDING THE PLACENTA). S 3. This act shall take effect on the one hundred twentieth day after it shall have become a law.