2012 New York Consolidated Laws
PBH - Public Health
Article 44 - (4400 - 4414) HEALTH MAINTENANCE ORGANIZATIONS
4406-C - Prohibitions.

 
    §  4406-c. Prohibitions. 1. For purposes of this section, "health care
  plan" shall mean a health maintenance organization licensed pursuant  to
  article  forty-three  of the insurance law or certified pursuant to this
  article or an independent practice association certified  or  recognized
  pursuant to this article or a medical group.
    2.  No health care plan shall by contract or written policy or written
  procedure prohibit or restrict any health care provider from  disclosing
  to  any  subscriber,  enrollee,  patient,  designated representative or,
  where  appropriate,  prospective  enrollee,  (hereinafter   collectively
  referred  to  as  enrollee)  any  information  that  such provider deems
  appropriate regarding:
    (a) a condition or a course of treatment with  an  enrollee  including
  the availability of other therapies, consultations, or tests; or
    (b)  the  provisions, terms, or requirements of the health care plan's
  products as they relate to the enrollee, where applicable.
    3. No health care plan shall by contract, written  policy  or  written
  procedure  prohibit  or  restrict any health care provider from filing a
  complaint, making a report or commenting to an appropriate  governmental
  body  regarding the policies or practices of such health care plan which
  the provider believes may negatively impact  upon  the  quality  of,  or
  access to, patient care.
    4.  No  health  care plan shall by contract, written policy or written
  procedure prohibit or restrict any health care provider from  advocating
  to  the  health  care  plan  on  behalf  of the enrollee for approval or
  coverage of a particular course of treatment or  for  the  provision  of
  health care services.
    5.  No  contract  or agreement between a health care plan and a health
  care provider shall contain any clause purporting  to  transfer  to  the
  health  care provider, other than a medical group, by indemnification or
  otherwise any liability relating to activities, actions or omissions  of
  the health care plan as opposed to those of the health care provider.
    5-a.  Contracts entered into between a plan and a health care provider
  shall include terms which prescribe:
    (a) the  method  by  which  payments  to  a  provider,  including  any
  prospective or retrospective adjustments thereto, shall be calculated;
    (b) the time periods within which such calculations will be completed,
  the  dates  upon  which  any  such  payments  and  adjustments  shall be
  determined to be due, and the dates upon which  any  such  payments  and
  adjustments will be made;
    (c)  a  description  of  the  records  or  information  relied upon to
  calculate any such payments and adjustments, and a  description  of  how
  the provider can access a summary of such calculations and adjustments;
    (d)  the  process  to  be  employed  to resolved disputed incorrect or
  incomplete records or information and to adjust any  such  payments  and
  adjustments  which have been calculated by relying on any such incorrect
  or incomplete records or information and to adjust any such payments and
  adjustments which have been calculated by relying on any such  incorrect
  or  incomplete  records  or  information so disputed; provided, however,
  that nothing  herein  shall  be  deemed  to  authorize  or  require  the
  disclosure of personally identifiable patient information or information
  related  to  other  individual  health  care  providers  or  the  plan's
  proprietary data collection systems, software or  quality  assurance  or
  utilization review methodologies; and
    (e)  the right of either party to the contract to seek resolution of a
  dispute arising pursuant to the payment terms of such contract through a
  proceeding under article seventy-five of  the  civil  practice  law  and
  rules.

    5-b.  No  contract  entered  into  with health care providers shall be
  enforceable if it  includes  terms  which  transfer  financial  risk  to
  providers, in a manner inconsistent with the provisions of paragraph (c)
  of  subdivision one of section forty-four hundred three of this article,
  or  penalize  providers for unfavorable case mix so as to jeopardize the
  quality of or  enrollees'  appropriate  access  to  medically  necessary
  services;  provided,  however,  that payment at less than prevailing fee
  for service rates or capitation shall not be deemed  or  presumed  prima
  facie to jeopardize quality or access.
    5-c.  (a) No health care plan shall implement an adverse reimbursement
  change to a contract with a health care professional that  is  otherwise
  permitted  by  the  contract, unless, prior to the effective date of the
  change, the health care plan gives the  health  care  professional  with
  whom the health care plan has directly contracted and who is impacted by
  the adverse reimbursement change, at least ninety days written notice of
  the  change.  If the contracting health care professional objects to the
  change that is the subject of the notice by the health  care  plan,  the
  health  care  professional  may,  within  thirty days of the date of the
  notice, give written notice to the health care plan to terminate his  or
  her contract with the health care plan effective upon the implementation
  date  of  the  adverse  reimbursement  change.  For the purposes of this
  subdivision, the  term  "adverse  reimbursement  change"  shall  mean  a
  proposed  change  that  could  reasonably be expected to have a material
  adverse impact on the aggregate  level  of  payment  to  a  health  care
  professional,  and  the  term  "health  care  professional" shall mean a
  health care professional licensed, registered or certified  pursuant  to
  title eight of the education law. The notice provisions required by this
  subdivision shall not apply where: (i) such change is otherwise required
  by law, regulation or applicable regulatory authority, or is required as
  a  result  of  changes  in  fee  schedules, reimbursement methodology or
  payment policies established by a government agency or by  the  American
  Medical   Association's  current  procedural  terminology  (CPT)  codes,
  reporting guidelines and conventions; or (ii) such change  is  expressly
  provided  for  under  the  terms  of the contract by the inclusion of or
  reference to a specific fee or fee schedule,  reimbursement  methodology
  or payment policy indexing mechanism.
    (b) Nothing in this subdivision shall create a private right of action
  on  behalf  of a health care professional against a health care plan for
  violations of this subdivision.
    * 5-d. If a contract between a plan and a hospital is not  renewed  or
  is  terminated  by  either party, the parties shall continue to abide by
  the terms of such contract, including reimbursement terms, for a  period
  of  two months from the effective date of termination or, in the case of
  a non-renewal, from the end of the  contract  period.  Notice  shall  be
  provided  to  all  enrollees potentially affected by such termination or
  non-renewal within fifteen days  after  commencement  of  the  two-month
  period. The commissioner shall have the authority to waive the two-month
  period  upon  the  request  of  either party to a contract that is being
  terminated for cause.  This  subdivision  shall  not  apply  where  both
  parties  mutually agree in writing to the termination or non-renewal and
  the plan provides notice to the enrollee at least thirty days in advance
  of the date of contract termination.
    * NB Repealed June 30, 2013
    6. No health care plan which provides coverage for prescription  drugs
  shall require, or enter into a contract which permits, a copayment which
  exceeds the usual and customary cost of such prescribed drug.
    * 7.  No  health  maintenance organization which provides coverage for
  prescription  drugs  and  for   which   cost-sharing,   deductibles   or

  co-insurance  obligations  are  determined  by  category of prescription
  drugs shall impose cost-sharing, deductibles or co-insurance obligations
  for  any  prescription  drug  that  exceeds   the   dollar   amount   of
  cost-sharing,  deductibles or co-insurance obligations for non-preferred
  brand  drugs  or  its  equivalent  (or  brand  drugs  if  there  is   no
  non-preferred brand drug category).
    * NB There are 2 sub 7's
    * 7.  Any  contract  provision, written policy or written procedure in
  violation of this section shall be deemed to be void and unenforceable.
    * NB There are 2 sub 7's
    * 8. (a) A health care plan  shall  not  deny  payment  to  a  general
  hospital  certified pursuant to article twenty-eight of this chapter for
  a claim for medically necessary inpatient  services  resulting  from  an
  emergency  admission  provided by a general hospital solely on the basis
  that the general hospital did not timely notify such  health  care  plan
  that the services had been provided.
    (b)  Nothing in this subdivision shall preclude a general hospital and
  a health care plan from agreeing to requirements for timely notification
  that medically necessary inpatient services resulting from an  emergency
  admission have been provided and to reductions in payment for failure to
  timely  notify;  provided,  however that: (i) any requirement for timely
  notification must provide for a reasonable extension of  timeframes  for
  notification  for  emergency  services  provided  on weekends or federal
  holidays, (ii) any agreed to reduction in payment for failure to  timely
  notify  shall  not  exceed  the lesser of two thousand dollars or twelve
  percent of the payment amount otherwise due for  the  service  provided,
  and (iii) any agreed to reduction in payment shall not be imposed if the
  patient's  coverage  could  not  be  determined  by  the  hospital after
  reasonable efforts at the time the inpatient services were provided.
    * NB Effective July 1, 2013