2023 New York Laws › PBH - Public Health › Article 1 - Short Title and Definitions: General Provisions › Title 2 - General Provisions › 19 - Reasonable Charges for Medicare Beneficiaries.

§  19. Reasonable charges for medicare beneficiaries.  1. No physician
licensed under article one hundred thirty-one of the education law shall
charge from a beneficiary of health insurance under title XVIII  of  the
federal  social  security  act  (medicare)  any  amount in excess of the
following limitations:
(a)  Effective  January  first,   nineteen   hundred   ninety-one,   a
physician's  charge  shall not exceed one hundred fifteen percent of the
reasonable charge for that service as determined by  the  United  States
secretary for health and human services.
(b)   Beginning   January  first,  nineteen  hundred  ninety-three,  a
physician's charge shall not exceed  one  hundred  ten  percent  of  the
reasonable  charge  for  that service as determined by the United States
secretary for health and human services, provided however, that  if  the
statewide  percentage  of  medicare part B claims billed at or below the
reasonable charge as determined  by  the  United  States  secretary  for
health  and  human  services  for  federal  fiscal year nineteen hundred
eighty-nine fails to increase by  five  percentage  points  for  federal
fiscal  year nineteen hundred ninety-two, such physician's charge shall,
thereafter, not exceed one hundred five percent of the reasonable charge
as determined by the  United  States  secretary  for  health  and  human
services.  If,  in  any  subsequent  federal fiscal year, such statewide
percentage of medicare part B claims billed at or below such  reasonable
charge   fails   to   maintain  such  five  percentage  point  increase,
physician's charge shall thereafter not exceed one hundred five  percent
of  the  reasonable  charge as determined by the United States secretary
for health and human services.
2. The charge limitation set forth in subdivision one of this  section
shall not apply if the service which such beneficiary is to be billed is
either  an  office  or  home visit as set forth in procedure codes 90000
through 90170  in  the  Physician  Current  Procedural  Terminology  4th
Edition 1989.
3.  The  state  office  for  the  aging  shall, through agreement with
carriers and/or intermediaries contracted with by the federal government
in this state pursuant to title XVIII of the federal social security act
(medicare), obtain the percentages of physician's bills submitted at  or
below  the  reasonable  charge  as  established  by  the  United  States
secretary for health and human services, and shall  issue  a  report  by
December  first,  nineteen  hundred ninety-two and every December first,
thereafter, stating whether the percentage  of  bills  submitted  at  or
below  such  reasonable  charge for federal fiscal year nineteen hundred
ninety-two increased  by  five  percentage  points  over  the  statewide
percentage  of  bills  submitted  at or below such reasonable charge for
federal fiscal  year  nineteen  hundred  eighty-nine  and  whether  such
percentage  has  been maintained for each successive federal fiscal year
after nineteen hundred ninety-two.
4. Notwithstanding any  inconsistent  provision  of  this  chapter,  a
physician  who  is  determined, after opportunity for a hearing, to have
violated the provisions of this section shall be subject for  the  first
violation  to a fine of not more than one thousand dollars nor less than
the greater of three times the amount collected, or, if  not  collected,
three  times  the amount charged, in excess of the limitations set forth
in subdivision one of this section, and, for each  additional  violation
committed  within  five  years  of  the date of an immediately preceding
violation of this section, to a fine of  not  more  than  five  thousand
dollars nor less than the greater of one thousand dollars or three times
the  amount  collected,  or,  if  not  collected, three times the amount
charged, in excess of the limitations set forth in  subdivision  one  of
this  section; provided, however, that in no event shall the fine for an

individual violation of this  section  be  greater  than  five  thousand
dollars.  In  addition,  where  the provisions of this section have been
violated, the physician shall  refund  to  the  beneficiary  the  amount
collected  in  excess of the limitations set forth in subdivision one of
this section.