NY Fin Serv L § 603 (2021)
2021 New York Laws FIS - Financial Services Law Article 6 - Emergency Medical Services and Surprise Bills 603 - Definitions.

§ 603. Definitions. For the purposes of this article:  (a) "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 : (1) 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;  (2)  serious  impairment  to  such  person's  bodily functions; (3) serious dysfunction of any bodily organ or part  of  such person;  (4)  serious  disfigurement  of such person; or (5) a condition described in clause (i), (ii) or (iii) of section 1867(e)(1)(A)  of  the social security act 42 U.S.C. § 1395dd.  (b)   "Emergency   services"  means,  with  respect  to  an  emergency condition:   (1) a  medical  screening  examination  as  required  under section  1867  of  the social security act, 42 U.S.C. § 1395dd, which is within the  capability  of  the  emergency  department  of  a  hospital, including  ancillary  services  routinely  available  to  the  emergency department to evaluate such emergency medical condition; and (2)  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.  § 1395dd, to stabilize the patient.  (c) "Health care plan" means an insurer licensed to write accident and health insurance pursuant to article thirty-two of the insurance law;  a corporation  organized  pursuant to article forty-three of the insurance law; a municipal cooperative health benefit plan certified  pursuant  to article   forty-seven   of  the  insurance  law;  a  health  maintenance organization certified pursuant to  article  forty-four  of  the  public health  law; or a student health plan established or maintained pursuant to section one thousand one hundred twenty-four of the insurance law.  (d) "Insured" means a patient  covered  under  a  health  care  plan's policy or contract.  (e) "Non-participating" means not having a contract with a health care plan to provide health care services to an insured.  (f) "Participating" means having a contract with a health care plan to provide health care services to an insured.  (g)  "Patient"  means  a  person  who  receives  health care services, including emergency services, in this state.  (h) "Surprise bill" means a bill for health care services, other  than emergency services, received by:  (1)  an insured for services rendered by a non-participating physician at a participating hospital  or  ambulatory  surgical  center,  where  a participating  physician is unavailable or a non-participating physician renders services without the insured's knowledge, or unforeseen  medical services  arise  at  the  time  the  health  care services are rendered; provided, however, that a surprise bill shall not mean a  bill  received for health care services when a participating physician is available and the  insured  has  elected  to  obtain services from a non-participating physician;  (2) an insured for services rendered by a non-participating  provider, where  the  services  were  referred  by  a participating physician to a non-participating provider  without  explicit  written  consent  of  the insured  acknowledging that the participating physician is referring the insured to a non-participating provider and that the referral may result in costs not covered by the health care plan; or  (3) a patient who is  not  an  insured  for  services  rendered  by  a physician at a hospital or ambulatory surgical center, where the patient  has  not  timely  received  all  of the disclosures required pursuant to section twenty-four of the public health law.  (i)  "Usual  and customary cost" means the eightieth percentile of all charges for the particular health care service performed by  a  provider in  the  same or similar specialty and provided in the same geographical area as reported in a benchmarking database maintained  by  a  nonprofit organization specified by the superintendent. The nonprofit organization shall  not  be  affiliated  with  an  insurer,  a corporation subject to article forty-three of the insurance law, a municipal cooperative health benefit plan certified pursuant to article forty-seven of the  insurance law,  or a health maintenance organization certified pursuant to article forty-four of the public health law.