N.Y.
Financial Services Law Section 603
Definitions
(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 Insurance Law § 1124 (Institutions of higher education exempt)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 Public Health Law § 24 (Disclosure)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.
Source:
Section 603 — Definitions, https://www.nysenate.gov/legislation/laws/FIS/603 (updated Apr. 22, 2022; accessed Oct. 26, 2024).
