NY Ins L § 4325 (2021)
2021 New York Laws ISC - Insurance Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations 4325 - Prohibitions.

§  4325. Prohibitions. (a) No corporation organized under this article shall by contract, written  policy  or  written  procedure  prohibit  or restrict  any  health  care  provider from disclosing to any subscriber, designated representative or, where appropriate, prospective subscriber, (hereinafter collectively referred to  as  subscriber)  any  information that such provider deems appropriate regarding:  (1)  a  condition or a course of treatment with a subscriber including the availability of other therapies, consultations, or tests; or  (2) the  provisions,  terms,  or  requirements  of  the  corporation's products as they relate to the subscriber.  (b)  No  corporation  organized  under this article shall by contract, written policy, written procedure or practice 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 corporation which the provider believes may negatively impact upon the quality of or  access  to  patient  care.  Nor  shall  a corporation  organized  under  this  article  take  any  adverse action, including but not limited to refusing to renew or execute a contract  or agreement  with  a  health care provider as retaliation against a health care provider for filing a complaint, making a report or  commenting  to an appropriate governmental body regarding policies or practices of such corporation  which  may  violate  this chapter including subsection (g), (k), (1), (1-1) or (1-2) of section forty-three hundred  three  of  this article.  (c)  No  corporation  organized  under this article shall by contract, written policy or written procedure prohibit or restrict any health care provider from advocating to the corporation on behalf of the  subscriber for approval or coverage of a particular course of treatment.  (d)  No  contract  or  agreement between a corporation organized under this article and  a  health  care  provider  shall  contain  any  clause purporting to transfer to the health care provider by indemnification or otherwise  any liability relating to activities, actions or omissions of the corporation as opposed to the health care provider.  (e) Contracts entered into  between  an  insurer  and  a  health  care provider shall include terms which prescribe:  (1)  the  method  by  which  payments  to  a  provider,  including any prospective or retrospective adjustments thereto, shall be calculated;  (2) 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 rates upon which any such payments and adjustments will be made;  (3) 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;  (4) the process to  be  employed  to  resolve  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 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  (5)  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.  (f)  No  contract  entered  into  between an insurer and a health care provider 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  the  public  health  law,  or penalize providers for unfavorable case mix so as to jeopardize the  quality  of  or  insureds' 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.  (g)(1) No insurer 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 insurer  gives  the  health  care professional with whom the insurer 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 insurer, the health care professional may, within thirty days of the date of the notice, give written notice to the insurer to terminate his or her contract with the insurer effective upon the implementation date of the adverse  reimbursement  change.  For  the purposes  of  this  subsection,  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 subsection  shall not apply where: (A) 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 (B) 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.  (2) Nothing in this subsection shall create a private right of  action on  behalf  of  a  health  care  professional  against  an  insurer  for violations of this subsection.  (h) No corporation or insurer organized or licensed under this chapter 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.  (i) Any contract provision, written policy  or  written  procedure  in violation of this section shall be deemed to be void and unenforceable.   * (j)  If  a  contract  between  a  corporation  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 subscribers potentially affected by such  termination or  non-renewal  within fifteen days after commencement of the two-month period. The commissioner of health 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 subsection shall not apply where both parties mutually agree in writing to the termination or non-renewal  and the  corporation  provides notice to the subscriber at least thirty days in advance of the date of contract termination.    * NB Repealed June 30, 2023  (k)  (1)  No corporation organized under this article shall by written contract, written policy or procedure,  or  by  any  other  means,  deny payment to a general hospital certified pursuant to article twenty-eight of  the  public health law for a claim for medically necessary inpatient services,  observation  services,  or  emergency   department   services provided  by  a  general  hospital  solely on the basis that the general hospital did not comply with certain administrative requirements of such corporation with respect to those services.  (2) Nothing in this subsection shall preclude a general hospital and a corporation  from  agreeing  to  certain   administrative   requirements relating  to  payment  for  inpatient services, observation services, or emergency department services, including,  but  not  limited  to  timely notification  that  medically  necessary  inpatient  services  have been provided and to reductions in payment for failure to comply with certain administrative requirements  including  timely  notification;  provided, however  that:  (A) any requirement for timely notification must provide for a reasonable extension of timeframes for notification  for  services provided on weekends or federal holidays, (B) any agreed to reduction in payment for failure to meet administrative requirements including timely notification  shall not exceed seven and one-half percent of the payment amount otherwise due for the services provided, and (C)  any  agreed  to reduction  in  payment  for  failure to meet administrative requirements including timely notification shall not  be  imposed  if  the  patient's insurance  coverage  could  not  be  determined  by  the  hospital after reasonable efforts at the time the services were provided.  (3) The provisions of this subsection shall not apply to the denial of a claim: (A) based on a reasonable belief of a corporation of  fraud  or intentional   misconduct   resulting  in  misrepresentation  of  patient diagnosis or the services provided, or abusive billing by a corporation; (B) when required by a state or federal government program  or  coverage that  is  provided  by  this  state  or  a  municipality  thereof to its respective employees, retirees or  members;  (C)  that  is  a  duplicate claim,  is  a claim submitted late pursuant to subsection (g) of section thirty-two hundred twenty-four-a of this article, or is for services for a benefit that is not covered under the  insured's  contract  or  for  a patient determined to be ineligible for coverage; (D) except in the case of  medically  necessary  inpatient services resulting from an emergency admission,  where  there  is  not  an  existing  participating  provider agreement  between such corporation and a general hospital; or (E) where the hospital has repeatedly and systematically, over the previous twelve month period, failed to seek prior authorization for services for  which prior authorization was required.  (4)  For  purposes of this subsection, an "administrative requirement" shall not include requirements: (A) imposed on a corporation or provider pursuant  to  federal  or  state  laws,  regulations  or  guidance;  (B) established   by   the   state   or  federal  government  applicable  to corporations offering benefits  under  a  state  or  federal  government program.  (5)  The prohibition on denials set forth in this subsection shall not apply to claims for services for which a  request  for  preauthorization was denied by the corporation prior to delivery of the service.  (l)  A  corporation  organized  under this article shall not require a prior authorization determination for services provided  in  a  neonatal intensive  care unit of a general hospital certified pursuant to article twenty-eight of the public health law. Nothing in this subsection  shall prohibit a corporation organized under this article from denying a claim  for  such  services  if  the  services  are  subsequently determined not medically necessary.  (m) At least sixty days prior to the termination of a contract between a  hospital  and  an  organization, the parties shall utilize a mutually agreed upon mediator to assist in resolving any outstanding  contractual issues.  The  results  of  the  mediation  shall  not  be binding on the parties.