NY Pub Health L § 4406-E (2021)
2021 New York Laws PBH - Public Health Article 44 - Health Maintenance Organizations 4406-E - 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.