2006 New York Code - Access To End Of Life Care.

 
    §  4406-e.  Access  to  end  of life care. 1. For the purposes of this
  section, "health care plan"  means  a  health  maintenance  organization
  licensed  pursuant  to  article  forty-three  of  the  insurance  law or
  certified pursuant to this article.
    2. Every  health  care  plan  that  provides  coverage  for  hospital,
  surgical  or medical care that includes coverage for acute care services
  shall provide an enrollee 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)  with
  coverage  for  acute  care  services  at an acute care facility licensed
  pursuant to article twenty-eight of this  chapter  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  enrollee's care would appropriately be
  provided by the facility.
    3. Notwithstanding  the  provisions  of  article  forty-nine  of  this
  chapter,  if  the  health  care  plan disagrees with the admission of or
  provision or continuation of care for the enrollee by the facility,  the
  health  care  plan  shall  initiate  an  expedited  external  appeal  in
  accordance with the provisions of paragraph (c) of  subdivision  two  of
  section  forty-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
  health care plan and the health care plan  shall  provide  coverage  and
  reimburse  the  facility for services provided subject to the provisions
  of this section and other limitations  otherwise  applicable  under  the
  enrollee's contract.  The decision of the external appeal agent shall be
  binding  on  all  parties.  If the health care plan does not initiate an
  expedited external appeal, the health  care  plan  shall  reimburse  the
  facility for services provided subject to the provisions of this section
  and   other   limitations  otherwise  applicable  under  the  enrollee's
  contract.
    4. A health care plan shall provide reimbursement for  those  services
  prescribed  by  this section at rates negotiated between the health care
  plan and the facility. In the absence of agreed  upon  rates,  a  health
  care  plan  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.
    5. Payment by a health care plan pursuant to  this  section  shall  be
  payment in full for the services provided to the enrollee. An acute care
  facility  reimbursed  pursuant  to this section shall not charge or seek
  any reimbursement from, or have any recourse against an enrollee 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 enrollee is responsible under the terms of the
  applicable contract.
    6. No provision of this section shall be construed to require a health
  care plan to provide coverage for benefits not otherwise  covered  under
  the enrollee's contract.