What's happening
This bill requires health plans to pay out-of-network clinical laboratories directly when a patient is referred by an in-network provider.
Why it matters
Prevents patients from being stuck in the middle of billing disputes. By requiring insurers to pay out-of-network labs directly (when referred by an in-network provider), the bill reduces the risk that patients will be billed for the full lab cost or have to chase reimbursement themselves.
Supports continuity of care and provider referrals. In-network providers may refer patients to specific labs for clinical or logistical reasons; this bill ensures those referrals don’t create financial obstacles or administrative headaches for patients.
Addresses "assignment of benefits" loopholes. Some insurers pay patients instead of the labs, which can lead to unpaid lab bills or pressure on patients to forward payments; the bill closes this loophole by requiring payment straight to the lab.
Clarifies patient financial responsibility. Patients are still responsible for usual cost-sharing (copays, coinsurance, deductibles), but the bill ensures they aren’t liable for the entire out-of-network lab bill if the referral came from an in-network provider.
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Who cares
Headline styles
Pay Out-of-Network Lab Providers
Plain English, a few words. Used as the page title.
Sponsors
Senator · Senate District 55
No co-sponsors yet.
History
- Referred to health
- Referred to health
Companion bill
The same bill in the other chamber. A bill becomes law when one version passes both houses and the governor signs it, so either number can carry it.
Pay Out-of-Network Lab Bills
In Assembly Committee · Insurance · Sponsor David Weprin
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
948
2017-2018 Regular Sessions
IN SENATE
January 5, 2017
Introduced by Sen. FUNKE -- read twice and ordered printed, and when printed to be committed to the Committee on Health
AN ACT to amend the public health law and the insurance law, in relation to the reimbursement of out-of-network providers of clinical laboratory services by organizations providing or offering comprehensive health services plans
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Section 4406 of the public health law is amended by adding a new subdivision 6 to read as follows:
6. Notwithstanding any other provision of law, if an enrollee is referred by an in-plan provider to a provider of clinical laboratory services not participating in the plan (a "non-participating provider") for any service covered under the terms of the plan, the organization shall be responsible for payment directly to the non-participating provider for those services in accordance with the time frame for such payments set forth in section three thousand two hundred twenty-four-a of the insurance law; provided, however, that the enrollee shall be responsible for any applicable copay, coinsurance or deductible for such services. Clinical laboratories seeking reimbursement pursuant to this section for services rendered shall directly bill the organization whose enrollee received the services. Any payment made by an organization directly to the enrollee rather than to the clinical laboratory seeking reimbursement shall not satisfy the organization's payment obligation to the clinical laboratory.
§ 2. Section 4804 of the insurance law is amended by adding a new subsection (g) to read as follows:
(g) Notwithstanding any other provision of law, if an enrollee is referred by an in-plan provider to a provider of clinical laboratory services not participating in the plan (a "non-participating provider") for any service covered under the terms of the plan, the organization
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD04265-01-7
S. 948 2
shall be responsible for payment directly to the non-participating provider for those services in accordance with the time frame for such payments set forth in section three thousand two hundred twenty-four-a of this chapter; provided, however, that the enrollee shall be responsible for any applicable copay, coinsurance or deductible for such services. Clinical laboratories seeking reimbursement pursuant to this section for services rendered shall directly bill the organization whose enrollee received the services. Any payment made by an organization directly to the enrollee rather than to the clinical laboratory seeking reimbursement shall not satisfy the organization's payment obligation to the clinical laboratory.
§ 3. This act shall take effect immediately.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
Title of bill
An act to amend the public health law and the insurance law, in relation to the reimbursement of out-of-network providers of clinical laboratory services by organizations providing or offering comprehensive health services plans
Purpose of bill
To provide that organizations providing or offering comprehensive health service plans, such as managed care organizations and health maintenance organizations, directly reimburse out-of-network providers of clinical laboratory services when plan participants are referred to out-of-network providers by in-network organizations or providers.
Summary of specific provisions
Section 1. Section 4406 of the public health law by adding a new subdivision 6. The new subdivision provides when the participant or enrollee is referred to non-participating medical providers by in-network medical providers, the services must be reimbursable under the plan; requiring the out-of-network to bill the in-network organization directly for services performed. Any payment made by the medical provider directly to the participant rather than to the out-of-network provider will not satisfy the organization's payment obligation to the clinical laboratory.
Section 4804 of the insurance law is amended by adding a new subsection (g) to with provisions that are identical to the foregoing.
Justification
In an effort to provide the best health care available, health care organizations and providers regularly refer patients to providers outside of such patients' organization's networks. Under current law, however, such organizations are not required to directly reimburse out-of-network providers for clinical laboratory services rendered. Instead, out-of-network providers of clinical laboratory services must look directly to the patients for payment of their fees, even though patients are less likely to pay for the services once rendered and may assume that the organization is required to pay for the services. This provides a disincentive to out-of-network providers to render services to such patients even in cases where the out of network provider may offer better services. This practice also thwarts the medical advice and direction of the patient's medical care giver and limits patient healthcare options.
This legislation would expand the health care service options available to the residents of the state and promote the referral of patients to providers deemed to be the best for the medical care of such patients, whether in or out-of-network
Prior legislative history
S.5374/A.3527 of 2015-2016; Referred to Health S.1083/A.636 of 2013-2014; Referred to Health S.2817/A.3802 of 2011-2012; Committee Discharged and Committed to Rules
Fiscal implications for state and local governments
None.
Effective date
This act shall take effect immediately
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.