2023 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, with respect to:
(1)  an  insured for services rendered by a non-participating provider
at a participating hospital  or  ambulatory  surgical  center,  where  a
participating  provider  is  unavailable or a non-participating provider
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 provider is available and
the insured has elected to  obtain  services  from  a  non-participating
provider;
(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.