NEW YORK

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The New York SBL became effective in 2015. Financial Services Law Article 6 and 23, NYCRR 400.

The relevant provisions of the New York law include:

• A requirement that reimbursement for emergency and inadvertent treatment be at the greatest of 1) the median in-network rate, 2) the usual method used by the health plan to pay out-of-network providers, such as UCR, and 3) the Medicare rate.
• A 3-year timeline from the date of payment to initiate arbitration.
• UCR data can be submitted and often is the prevailing position in arbitration.
• The medical provider’s billed charge for a particular CPT code must remain the demand amount for that CPT code in arbitration.
• NYSHIP, the carrier for NY State employees, has opted out of the state process, so, any claim disputes involving NYSHIP must be brought to the Federal IDR.

New York does not have an applicable All-Payer Model Agreement that would determine the out-of-network rate.

Based on the survey response, Part AA of Chapter 57 of the Laws of 2022, and CMS communications with New York Department of Financial Services and New York Department of Health staff, CMS understands that Financial Services Law Article 6 and 23 NYCRR 400 are specified state laws that will apply for purposes of determining the out-of-network rate.

These laws apply with respect to certain items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in New York.

They apply to services provided by nonparticipating physicians and providers at hospital facilities and ambulatory surgical centers, including when the patient received a referral and inpatient services which follow an emergency room visit, or at nonparticipating emergency facilities.

Therefore, the federal independent dispute resolution process under sections 2799A-1(c) of the PHS Act and 45 CFR 149.510 will not apply in those cases in New York.

Letter from CMS to Governor of New York, dated July 29, 2022.