N.Y. ISC Law § 3217-B — New York Code / Act ISC / Article 32 / Section 3217-B
Prohibitions
Status: in_force

§ 3217-b. Prohibitions. (a) No insurer subject to this article shall\nby contract, written policy or written procedure prohibit or restrict\nany health care provider from disclosing to any insured, designated\nrepresentative or, where appropriate, prospective insured, (hereinafter\ncollectively referred to as insured) any information that such provider\ndeems appropriate regarding:\n  (1) a condition or a course of treatment with an insured including the\navailability of other therapies, consultations, or tests; or\n  (2) the provisions, terms, or requirements of the insurer's products\nas they relate to the insured.\n  (b) No insurer subject to this article shall by contract, written\npolicy, written procedure or practice prohibit or restrict any health\ncare provider from filing a complaint, making a report or commenting to\nan appropriate governmental body regarding the policies or practices of\nsuch insurer which the provider believes may negatively impact upon the\nquality of, or access to, patient care. Nor shall an insurer subject to\nthis article take any adverse action, including but not limited to\nrefusing to renew or execute a contract or agreement with a health care\nprovider as retaliation against a health care provider for filing a\ncomplaint, making a report or commenting to an appropriate governmental\nbody regarding policies or practices of such insurer which may violate\nthis chapter including paragraphs thirty, as added by chapter forty-one\nof the laws of 2014, thirty-one, thirty-one-a and thirty-five of\nsubsection (i) of section thirty-two hundred sixteen and paragraphs\nfive, six, seven, seven-a and seven-b of subsection (l) of section\nthirty-two hundred twenty-one of this article.\n  (c) No insurer subject to this article shall by contract, written\npolicy or written procedure prohibit or restrict any health care\nprovider from advocating to the insurer on behalf of the insured for\napproval or coverage of a particular course of treatment or for the\nprovision of health care services.\n  (d) No contract or agreement between an insurer subject to this\narticle and a health care provider shall contain any clause purporting\nto transfer to the health care provider by indemnification or otherwise\nany liability relating to activities, actions or omissions of the\ninsurer as opposed to the health care provider.\n  (e) Contracts entered into between an insurer and a health care\nprovider shall include terms which prescribe:\n  (1) the method by which payments to a provider, including any\nprospective or retrospective adjustments thereto, shall be calculated;\n  (2) the time periods within which such calculations will be completed,\nthe dates upon which any such payments and adjustments shall be\ndetermined to be due, and the dates upon which any such payments and\nadjustments will be made;\n  (3) a description of the records or information relied upon to\ncalculate any such payments and adjustments, and a description of how\nthe provider can access a summary of such calculations and adjustments;\n  (4) the process to be employed to resolve disputed incorrect or\nincomplete records or information and to adjust any such payments and\nadjustments which have been calculated by relying on any such incorrect\nor incomplete records or information so disputed; provided, however,\nthat nothing herein shall be deemed to authorize or require the\ndisclosure of personally identifiable patient information or information\nrelated to other individual health care providers or the plan's\nproprietary data collection systems, software or quality assurance or\nutilization review methodologies; and\n  (5) the right of either party to the contract to seek resolution of a\ndispute arising pursuant to the payment terms of such contracts through\na proceeding under article seventy-five of the civil practice law and\nrules.\n  (f) No contract entered into between an insurer and a health care\nprovider shall be enforceable if it includes terms which transfer\nfinancial risk to providers, in a manner inconsistent with the\nprovisions of paragraph (c) of subdivision one of section forty-four\nhundred three of the public health law, or penalize providers for\nunfavorable case mix so as to jeopardize the quality of or insureds'\nappropriate access to medically necessary services; provided, however,\nthat payment at less than prevailing fee for service rates or capitation\nshall not be deemed or presumed prima facie to jeopardize quality or\naccess.\n  (g)(1) No insurer shall implement an adverse reimbursement change to a\ncontract with a health care professional that is otherwise permitted by\nthe contract, unless, prior to the effective date of the change, the\ninsurer gives the health care professional with whom the insurer has\ndirectly contracted and who is impacted by the adverse reimbursement\nchange, at least ninety days written notice of the change. If the\ncontracting health care professional objects to the change that is the\nsubject of the notice by the insurer, the health care professional may,\nwithin thirty days of the date of the notice, give written notice to the\ninsurer to terminate his or her contract with the insurer effective upon\nthe implementation date of the adverse reimbursement change. For the\npurposes of this subsection, the term "adverse reimbursement change"\nshall mean a proposed change that could reasonably be expected to have a\nmaterial adverse impact on the aggregate level of payment to a health\ncare professional, and the term "health care professional" shall mean a\nhealth care professional licensed, registered or certified pursuant to\ntitle eight of the education law. The notice provisions required by this\nsubsection shall not apply where: (A) such change is otherwise required\nby law, regulation or applicable regulatory authority, or is required as\na result of changes in fee schedules, reimbursement methodology or\npayment policies established by a government agency or by the American\nMedical Association's current procedural terminology (CPT) codes,\nreporting guidelines and conventions; or (B) such change is expressly\nprovided for under the terms of the contract by the inclusion of or\nreference to a specific fee or fee schedule, reimbursement methodology\nor payment policy indexing mechanism.\n  (2) Nothing in this subsection shall create a private right of action\non behalf of a health care professional against an insurer for\nviolations of this subsection.\n  (h) Any contract provision, written policy or written procedure in\nviolation of this section shall be deemed to be void and unenforceable.\n  * (i) If a contract between an insurer and a hospital is not renewed\nor is terminated by either party, the parties shall continue to abide by\nthe terms of such contract, including reimbursement terms, for a period\nof two months from the effective date of termination or, in the case of\na non-renewal, from the end of the contract period. Notice shall be\nprovided to all insureds potentially affected by such termination or\nnon-renewal within fifteen days after commencement of the two-month\nperiod. The commissioner of health shall have the authority to waive the\ntwo-month period upon the request of either party to a contract that is\nbeing terminated for cause. This subsection shall not apply where both\nparties mutually agree in writing to the termination or non-renewal and\nthe insurer provides notice to the insured at least thirty days in\nadvance of the date of contract termination.\n  * NB Repealed June 30, 2027\n  (j) (1) No insurer shall by contract, written policy or procedure, or\nby any other means, deny payment to a general hospital certified\npursuant to article twenty-eight of the public health law for a claim\nfor medically necessary inpatient services, observation services, or\nemergency department services provided by a general hospital solely on\nthe basis that the general hospital did not comply with certain\nadministrative requirements of such insurer with respect to those\nservices.\n  (2) Nothing in this subsection shall preclude a general hospital and\nan insurer from agreeing to certain administrative requirements relating\nto payment for inpatient services, observation services, or emergency\ndepartment services, including but not limited to timely notification\nthat medically necessary inpatient services have been provided and to\nreductions in payment for failure to comply with certain administrative\nrequirements including timely notification; provided, however that: (A)\nany requirement for timely notification must provide for a reasonable\nextension of timeframes for notification for services provided on\nweekends or federal holidays, (B) any agreed to reduction in payment for\nfailure to meet administrative requirements, including timely\nnotification shall not exceed seven and one-half percent of the payment\namount otherwise due for the services provided, and (C) any agreed to\nreduction in payment for failure to meet administrative requirements\nincluding timely notification shall not be imposed if the patient's\ninsurance coverage could not be determined by the hospital after\nreasonable efforts at the time the services were provided.\n  (3) The provisions of this subsection shall not apply to the denial of\na claim: (A) based on a reasonable belief by an insurer of fraud or\nintentional misconduct resulting in misrepresentation of patient\ndiagnosis or the services provided, or abusive billing; (B) when\nrequired by a state or federal government program or coverage that is\nprovided by this state or a municipality thereof to its respective\nemployees, retirees or members; (C) that is a duplicate claim, that is a\nclaim submitted late pursuant to subsection (g) of section thirty-two\nhundred twenty-four-a of this article, or is for services for a benefit\nthat is not covered under the insured's policy or for a patient\ndetermined to be ineligible for coverage; (D) except in the case of\nmedically necessary inpatient services resulting from an emergency\nadmission, where there is not an existing participating provider\nagreement between an insurer and a general hospital; or (E) where the\nhospital has repeatedly and systematically, over the previous twelve\nmonth period, failed to seek prior authorization for services for which\nprior authorization was required.\n  (4) For purposes of this subsection, an "administrative requirement"\nshall not include requirements: (A) imposed on an insurer or provider\npursuant to federal or state laws, regulations or guidance; or (B)\nestablished by the state or federal government applicable to insurers\noffering benefits under a state or federal government program.\n  (5) The prohibition on denials set forth in this subsection shall not\napply to claims for services for which a request for preauthorization\nwas denied by the insurer prior to delivery of the service.\n  (k) An insurer shall not require a prior authorization determination\nfor services provided in a neonatal intensive care unit of a general\nhospital certified pursuant to article twenty-eight of the public health\nlaw. Nothing in this subsection shall prohibit an insurer from denying a\nclaim for such services if the services are subsequently determined not\nmedically necessary.\n  (l) At least sixty days prior to the termination of a contract between\na hospital and an insurer, the parties shall utilize a mutually agreed\nupon mediator to assist in resolving any outstanding contractual issues.\nThe results of the mediation shall not be binding on the parties.\n  * (m) A contract between an insurer and a health care provider shall\ninclude a provision that requires the health care provider to have in\nplace business processes to ensure the timely provision of provider\ndirectory information to the insurer. A health care provider shall\nsubmit such provider directory information to an insurer, at a minimum,\nwhen a provider begins or terminates a network agreement with an\ninsurer, when there are material changes to the content of the provider\ndirectory information of the health care provider, and at any other\ntime, including upon the insurer's request, as the health care provider\ndetermines to be appropriate. For purposes of this subsection, "provider\ndirectory information" shall include the name, address, specialty,\ntelephone number, and digital contact information of such health care\nprovider; whether the provider is accepting new patients; for mental\nhealth and substance use disorder services providers, any affiliations\nwith participating facilities certified or authorized by the office of\nmental health or the office of addiction services and supports, and any\nrestrictions regarding the availability of the individual provider's\nservices; and in the case of physicians, board certification, languages\nspoken, and any affiliations with participating hospitals.\n  * NB Effective until January 1, 2027\n  * (m) A contract between an insurer and a health care provider shall\ninclude a provision that requires the health care provider to have in\nplace business processes to ensure the timely provision of provider\ndirectory information to the insurer. A health care provider shall\nsubmit such provider directory information to an insurer, at a minimum,\nwhen a provider begins or terminates a network agreement with an\ninsurer, when there are material changes to the content of the provider\ndirectory information of the health care provider, and at any other\ntime, including upon the insurer's request, as the health care provider\ndetermines to be appropriate. For purposes of this subsection, "provider\ndirectory information" shall include the name, address, specialty,\ntelephone number, and digital contact information of such health care\nprovider; whether the provider is accepting new patients; for mental\nhealth and substance-related and addictive disorder services providers,\nany affiliations with participating facilities certified or authorized\nby the office of mental health or the office of addiction services and\nsupports, and any restrictions regarding the availability of the\nindividual provider's services; and in the case of physicians, board\ncertification, languages spoken, and any affiliations with participating\nhospitals.\n  * NB Effective January 1, 2027\n  (n) A contract between an insurer and a health care provider shall\ninclude a provision that states that the provider shall reimburse the\ninsured for the full amount paid by the insured in excess of the\nin-network cost-sharing amount, plus interest at an interest rate\ndetermined by the superintendent in accordance with 42 U.S.C. §\n300gg-139(b), for the services involved when the insured is provided\nwith inaccurate network status information by the insurer in a provider\ndirectory or in response to a request that stated that the provider was\na participating provider when the provider was not a participating\nprovider. In the event the insurer provides inaccurate network status\ninformation to the insured indicating the provider was a participating\nprovider when such provider was not a participating provider, the\ninsurer shall reimburse the provider for the out-of-network services\nregardless of whether the insured's coverage includes out-of-network\nservices. Nothing in this subsection shall prohibit a health care\nprovider from requiring in the terms of a contract with an insurer that\nthe insurer remove, at the time of termination of such contract, the\nprovider from the insurer's provider directory or that the insurer bear\nfinancial responsibility for providing inaccurate network status\ninformation to an insured.\n  (o) (1) No contract or agreement between a health plan subject to this\narticle and a health care provider, other than a residential health care\nfacility as defined by section two thousand eight hundred one of the\npublic health law, shall include a provision that:\n  (A) contains a most-favored-nation provision; or\n  (B) restricts the ability of a health plan, an entity that contracts\nwith a health plan for a provider network, or a health care provider to\ndisclose (i) actual claims costs or (ii) price or quality information\nrequired to be disclosed under federal law, including the allowed\namount, negotiated rates or discounts, or any other claim-related\nfinancial obligations, including, but not limited to, patient\ncost-sharing covered by the provider contract to any insured, group or\nother entity receiving health care services pursuant to the contract, or\nto any public compilation of reimbursement data such as the New York all\npayer database required by law or regulation, provided that no\ndisclosure shall include protected health information or other\ninformation covered by statutory or other privilege.\n  (2) For purposes of this subsection, the term "health plan" shall\ninclude (A) an insurer licensed pursuant to the insurance law or a\nhealth maintenance organization certified pursuant to article forty-four\nof the public health law and (B) a third-party administrator, affiliated\nwith an insurer or health maintenance organization, who administers a\nhealth benefit plan.\n  (p)(1) An insurer may pay a claim for reimbursement made by a provider\nusing a credit card, virtual credit card, or electronic funds transfer\npayment method that imposes on the provider a specifically identified\nfee or similar dedicated charge to process the payment if in advance of\nusing such reimbursement method:\n  (A) The insurer notifies the provider of the potential fees or other\ncharges associated with the use of the credit card, virtual credit card,\nor electronic funds transfer payment;\n  (B) The insurer offers the provider an alternative payment method that\ndoes not impose fees or similar charges on the provider; and\n  (C) The provider or a designee of the provider elects to accept\npayment of the claim using the credit card, virtual credit card, or\nelectronic funds transfer payment method. Such payment type election\nshall be made by the provider within thirty days of receipt of the\nnotice from the insurer. If the provider fails to make any payment type\nelection within thirty days, the insurer shall pay the provider using\nthe alternative payment method offered in the notice unless the insurer\nis unable to pay the provider using that alternative method due to the\ninsurer lacking information necessary to make the alternative payment.\nIn that instance, the insurer may use another fee-free method of payment\nin order to meet the timeframes established in section three thousand\ntwo hundred twenty-four-a of this article.\n  (2) A decision pursuant to paragraph one of this subsection shall\nremain in effect until the provider notifies the insurer, in writing, of\na change in the designated payment type.\n  (3) If an insurer contracts with a vendor to process payments of\nproviders' claims, the insurer shall require the vendor to comply with\nthe provisions of paragraph one of this subsection. This paragraph shall\nnot apply to a vendor used by the provider in order to receive payments\nfrom an insurer.\n  (4) No contract between an insurer and provider issued, renewed,\nmodified, altered or amended after the effective date of this subsection\nshall contain provisions allowing for waiver of the notice requirements\ncontained in this subsection.\n  (5) For any contract that is in effect on or before the effective date\nof this subsection or that is entered into, amended or renewed on or\nafter the effective date of this subsection, an insurer that initiates a\npayment to a provider using, or changes the payment method to, a health\ncare electronic funds transfers and remittance advice transaction shall\nnot charge a fee solely to transmit the payment to the provider unless\nthe provider elects to accept payment in accordance with subparagraph\n(C) of paragraph one of this subsection.\n  (6) For purposes of this subsection, the following terms shall have\nthe following meanings:\n  (A) "Provider" shall mean a health care professional or a group of\nhealth care professionals licensed pursuant to title eight of the\neducation law that has a participating provider contract with an insurer\nto provide health care services to an insured.\n  (B) "Virtual credit card" shall mean a single-use series of numbers\nlinked to a fixed dollar amount and provided by an insurer to a provider\nfor the purpose of paying a claim for health care services performed by\nthe provider.\n