2012 New York Consolidated Laws
ISC - Insurance
Article 48 - (4801 - 4805) MANAGED CARE HEALTH INSURANCE CONTRACTS
4805 - Access to end of life care.

 
    §  4805.  Access  to end of life care. (a) Every contract issued by an
  insurer that provides coverage for hospital, surgical  or  medical  care
  that  includes  coverage  for acute care services shall provide coverage
  for an insured diagnosed with advanced cancer (with no hope of  reversal
  of  primary  disease  and fewer than sixty days to live, as certified by
  the  patient's  attending  health  care  practitioner)  for  acute  care
  services  at  an  acute  care  facility  licensed  pursuant  to  article
  twenty-eight of the public health law specializing in the  treatment  of
  terminally   ill   patients  if  the  patient's  attending  health  care
  practitioner, in consultation with the medical director of the  facility
  determines  that  the  insured's care would appropriately be provided by
  such a facility.
    (b) Notwithstanding the  provisions  of  article  forty-nine  of  this
  chapter,  if the insurer disagrees with the admission of or provision or
  continuation of care for the insured by the facility, the insurer  shall
  initiate  an expedited external appeal in accordance with the provisions
  of paragraph three of subsection  (b)  of  section  four  thousand  nine
  hundred  fourteen  of  this  chapter,  provided further, that until such
  decision is rendered, the admission of or provision or  continuation  of
  the  care  by  the  facility  shall not be denied by the insurer and the
  insurer shall provide coverage and reimburse the facility  for  services
  provided subject to the provisions of this section and other limitations
  otherwise  applicable  under the insured's contract. The decision of the
  external appeal agent shall be binding on all parties.  If  the  insurer
  does  not  initiate  an  expedited  external  appeal  the  insurer shall
  reimburse the facility for services provided subject to  the  provisions
  of  this  section  and  other limitations otherwise applicable under the
  insured's contract.
    (c)  An  insurer  shall  provide  reimbursement  for  those   services
  prescribed  by  this section at rates negotiated between the insurer and
  the facility. In the absence of agreed upon rates, an insurer shall  pay
  for  acute  care  at  the  facility's acute care rate under the Medicare
  program (Title XVIII of the federal Social Security Act), including  the
  Part A rate for Part A services and the Part B rate for Part B services,
  and  shall  pay for alternate level care days at seventy-five percent of
  the acute care rate, including the Part A rate for Part A  services  and
  the Part B rate for Part B services.
    (d) Payment by an insurer pursuant to this section shall be payment in
  full  for  the  services provided to the insured. An acute care facility
  reimbursed pursuant to  this  section  shall  not  charge  or  seek  any
  reimbursement  from,  or  have  any  recourse against an insured for the
  services provided by the acute care facility pursuant to  this  section,
  except  for  the collection of copayments, coinsurance or visit fees, or
  deductibles for which the insured is responsible under the terms of  the
  applicable contract.
    (e)  No  provision  of  this  section shall be construed to require an
  insurer to provide coverage for benefits not otherwise covered under the
  insured's contract.