2023 New York Laws › ISC - Insurance › Article 32 - Insurance Contracts - Life, Accident and Health, Annuities › 3217-B - Prohibitions.

§  3217-b.  Prohibitions. (a) No insurer subject to this article shall
by contract, written policy or written procedure  prohibit  or  restrict
any  health  care  provider  from  disclosing to any insured, designated
representative or, where appropriate, prospective insured,  (hereinafter
collectively  referred to as insured) any information that such provider
deems appropriate regarding:
(1) a condition or a course of treatment with an insured including the
availability of other therapies, consultations, or tests; or
(2) the provisions, terms, or requirements of the  insurer's  products
as they relate to the insured.
(b)  No  insurer  subject  to  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  insurer which the provider believes may negatively impact upon the
quality of, or access to, patient care. Nor shall an insurer subject  to
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 insurer which may violate
this chapter including paragraphs thirty, as added by chapter  forty-one
of  the  laws  of  2014,  thirty-one,  thirty-one-a  and  thirty-five of
subsection (i) of section  thirty-two  hundred  sixteen  and  paragraphs
five,  six,  seven,  seven-a  and  seven-b  of subsection (l) of section
thirty-two hundred twenty-one of this article.
(c) No insurer subject to this  article  shall  by  contract,  written
policy  or  written  procedure  prohibit  or  restrict  any  health care
provider from advocating to the insurer on behalf  of  the  insured  for
approval  or  coverage  of  a  particular course of treatment or for the
provision of health care services.
(d) No contract or  agreement  between  an  insurer  subject  to  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
insurer 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 dates 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 contracts  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) Any contract provision, written policy  or  written  procedure  in
violation of this section shall be deemed to be void and unenforceable.
* (i)  If  a contract between an insurer 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  insureds  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 insurer provides notice to the  insured  at  least  thirty  days  in
advance of the date of contract termination.
* NB Repealed June 30, 2025
(j)  (1) No insurer shall by 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  insurer  with  respect  to those
services.
(2) Nothing in this subsection shall preclude a general  hospital  and
an insurer 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 by  an  insurer  of  fraud  or
intentional   misconduct   resulting  in  misrepresentation  of  patient
diagnosis or  the  services  provided,  or  abusive  billing;  (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, that 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  policy  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  an  insurer 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 an insurer or provider
pursuant to federal or state  laws,  regulations  or  guidance;  or  (B)
established  by  the  state or federal government applicable to insurers
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 insurer prior to delivery of the service.
(k) An insurer 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 an insurer from denying a
claim for such services if the services are subsequently determined  not
medically necessary.
(l) At least sixty days prior to the termination of a contract between
a  hospital  and an insurer, 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.
(m)  A  contract  between  an insurer and a health care provider shall
include a provision that requires the health care provider  to  have  in
place  business  processes  to  ensure  the timely provision of provider
directory information to the  insurer.  A  health  care  provider  shall
submit  such provider directory information to an insurer, at a minimum,
when a provider  begins  or  terminates  a  network  agreement  with  an
insurer,  when there are material changes to the content of the provider
directory information of the health care  provider,  and  at  any  other
time,  including upon the insurer's request, as the health care provider
determines to be appropriate. For purposes of this subsection, "provider
directory information"  shall  include  the  name,  address,  specialty,
telephone  number,  and  digital contact information of such health care
provider; whether the provider is accepting  new  patients;  for  mental
health  and  substance use disorder services providers, any affiliations
with participating facilities certified or authorized by the  office  of
mental  health or the office of addiction services and supports, and any
restrictions regarding the availability  of  the  individual  provider's
services;  and in the case of physicians, board certification, languages
spoken, and any affiliations with participating hospitals.
(n) A contract between an insurer and a  health  care  provider  shall
include  a  provision  that states that the provider shall reimburse the
insured for the full amount  paid  by  the  insured  in  excess  of  the
in-network  cost-sharing  amount,  plus  interest  at  an  interest rate
determined  by  the  superintendent  in  accordance  with  42  U.S.C.  §
300gg-139(b),  for  the  services  involved when the insured is provided
with inaccurate network status information by the insurer in a  provider
directory  or in response to a request that stated that the provider was
a participating provider when  the  provider  was  not  a  participating
provider.  In  the  event the insurer provides inaccurate network status
information to the insured indicating the provider was  a  participating
provider  when  such  provider  was  not  a  participating provider, the
insurer shall reimburse the provider  for  the  out-of-network  services
regardless  of  whether  the  insured's coverage includes out-of-network
services. Nothing in  this  subsection  shall  prohibit  a  health  care
provider  from requiring in the terms of a contract with an insurer that
the insurer remove, at the time of termination  of  such  contract,  the
provider  from the insurer's provider directory or that the insurer bear
financial  responsibility  for  providing  inaccurate   network   status
information to an insured.
(o) (1) No contract or agreement between a health plan subject to this
article and a health care provider, other than a residential health care
facility  as  defined  by  section two thousand eight hundred one of the
public health law, shall include a provision that:
(A) contains a most-favored-nation provision; or
(B) restricts the ability of a health plan, an entity  that  contracts
with  a health plan for a provider network, or a health care provider to
disclose (i) actual claims costs or (ii) price  or  quality  information
required  to  be  disclosed  under  federal  law,  including the allowed
amount, negotiated  rates  or  discounts,  or  any  other  claim-related
financial   obligations,   including,   but   not  limited  to,  patient
cost-sharing covered by the provider contract to any insured,  group  or
other entity receiving health care services pursuant to the contract, or
to any public compilation of reimbursement data such as the New York all
payer   database  required  by  law  or  regulation,  provided  that  no
disclosure  shall  include  protected  health   information   or   other
information covered by statutory or other privilege.
(2)  For  purposes  of  this  subsection, the term "health plan" shall
include (A) an insurer licensed pursuant  to  the  insurance  law  or  a
health maintenance organization certified pursuant to article forty-four
of the public health law and (B) a third-party administrator, affiliated
with  an  insurer  or health maintenance organization, who administers a
health benefit plan.