2023 New York Laws › ISC - Insurance › Article 48 - Managed Care Health Insurance Contracts › 4805 - Access to End of Life Care.

§  4805.  Access  to end of life care. (a) Every contract issued by an
insurer that provides coverage for hospital, surgical  or  medical  care
that  includes  coverage  for acute care services shall provide coverage
for an insured 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)  for  acute  care
services  at  an  acute  care  facility  licensed  pursuant  to  article
twenty-eight of the public health law 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  insured's care would appropriately be provided by
such a facility.
(b) Notwithstanding the  provisions  of  article  forty-nine  of  this
chapter,  if the insurer disagrees with the admission of or provision or
continuation of care for the insured by the facility, the insurer  shall
initiate  an expedited external appeal in accordance with the provisions
of paragraph three of subsection  (b)  of  section  four  thousand  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 insurer and the
insurer shall provide coverage and reimburse the facility  for  services
provided subject to the provisions of this section and other limitations
otherwise  applicable  under the insured's contract. The decision of the
external appeal agent shall be binding on all parties.  If  the  insurer
does  not  initiate  an  expedited  external  appeal  the  insurer shall
reimburse the facility for services provided subject to  the  provisions
of  this  section  and  other limitations otherwise applicable under the
insured's contract.
(c)  An  insurer  shall  provide  reimbursement  for  those   services
prescribed  by  this section at rates negotiated between the insurer and
the facility. In the absence of agreed upon rates, an insurer 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.
(d) Payment by an insurer pursuant to this section shall be payment in
full  for  the  services provided to the insured. An acute care facility
reimbursed pursuant to  this  section  shall  not  charge  or  seek  any
reimbursement  from,  or  have  any  recourse against an insured 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 insured is responsible under the terms of  the
applicable contract.
(e)  No  provision  of  this  section shall be construed to require an
insurer to provide coverage for benefits not otherwise covered under the
insured's contract.