N.Y. Financial Services Law § 603

§ 603. Definitions. For the purposes of this article:\n (a) "Emergency condition" means a medical or behavioral condition that\nmanifests itself by acute symptoms of sufficient severity, including\nsevere pain, such that a prudent layperson, possessing an average\nknowledge of medicine and health, could reasonably expect the absence of\nimmediate medical attention to result in : (1) placing the health of the\nperson afflicted with such condition in serious jeopardy, or in the case\nof a behavioral condition placing the health of such person or others in\nserious jeopardy; (2) serious impairment to such person's bodily\nfunctions; (3) serious dysfunction of any bodily organ or part of such\nperson; (4) serious disfigurement of such person; or (5) a condition\ndescribed in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the\nsocial security act 42 U.S.C. § 1395dd.\n (b) "Emergency services" means, with respect to an emergency\ncondition: (1) a medical screening examination as required under\nsection 1867 of the social security act, 42 U.S.C. § 1395dd, which is\nwithin the capability of the emergency department of a hospital,\nincluding ancillary services routinely available to the emergency\ndepartment to evaluate such emergency medical condition; and (2) within\nthe capabilities of the staff and facilities available at the hospital,\nsuch further medical examination and treatment as are required under\nsection 1867 of the social security act, 42 U.S.C. § 1395dd, to\nstabilize the patient.\n * (c) "Health care plan" means an insurer licensed to write accident\nand health insurance pursuant to article thirty-two of the insurance\nlaw; a corporation organized pursuant to article forty-three of the\ninsurance law; a municipal cooperative health benefit plan certified\npursuant to article forty-seven of the insurance law; a health\nmaintenance organization certified pursuant to article forty-four of the\npublic health law; or a student health plan established or maintained\npursuant to section one thousand one hundred twenty-four of the\ninsurance law.\n * NB Effective until August 26, 2026\n * (c) "Health care plan" means an insurer licensed to write accident\nand health insurance pursuant to article thirty-two of the insurance\nlaw; a corporation organized pursuant to article forty-three of the\ninsurance law; a municipal cooperative health benefit plan certified\npursuant to article forty-seven of the insurance law; a health\nmaintenance organization certified pursuant to article forty-four of the\npublic health law; a student health plan established or maintained\npursuant to section one thousand one hundred twenty-four of the\ninsurance law; or a health benefit plan operated pursuant to article\neleven of the civil service law.\n * NB Effective August 26, 2026 until August 26, 2031\n * (c) "Health care plan" means an insurer licensed to write accident\nand health insurance pursuant to article thirty-two of the insurance\nlaw; a corporation organized pursuant to article forty-three of the\ninsurance law; a municipal cooperative health benefit plan certified\npursuant to article forty-seven of the insurance law; a health\nmaintenance organization certified pursuant to article forty-four of the\npublic health law; or a student health plan established or maintained\npursuant to section one thousand one hundred twenty-four of the\ninsurance law.\n * NB Effective August 26, 2031\n (d) "Insured" means a patient covered under a health care plan's\npolicy or contract.\n (e) "Non-participating" means not having a contract with a health care\nplan to provide health care services to an insured.\n (f) "Participating" means having a contract with a health care plan to\nprovide health care services to an insured.\n (g) "Patient" means a person who receives health care services,\nincluding emergency services, in this state.\n (h) "Surprise bill" means a bill for health care services, other than\nemergency services, with respect to:\n (1) an insured for services rendered by a non-participating provider\nat a participating hospital or ambulatory surgical center, where a\nparticipating provider is unavailable or a non-participating provider\nrenders services without the insured's knowledge, or unforeseen medical\nservices arise at the time the health care services are rendered;\nprovided, however, that a surprise bill shall not mean a bill received\nfor health care services when a participating provider is available and\nthe insured has elected to obtain services from a non-participating\nprovider;\n (2) an insured for services rendered by a non-participating provider,\nwhere the services were referred by a participating physician to a\nnon-participating provider without explicit written consent of the\ninsured acknowledging that the participating physician is referring the\ninsured to a non-participating provider and that the referral may result\nin costs not covered by the health care plan; or\n (3) a patient who is not an insured for services rendered by a\nphysician at a hospital or ambulatory surgical center, where the patient\nhas not timely received all of the disclosures required pursuant to\nsection twenty-four of the public health law.\n (i) "Usual and customary cost" means the eightieth percentile of all\ncharges for the particular health care service performed by a provider\nin the same or similar specialty and provided in the same geographical\narea as reported in a benchmarking database maintained by a nonprofit\norganization specified by the superintendent. The nonprofit organization\nshall not be affiliated with an insurer, a corporation subject to\narticle forty-three of the insurance law, a municipal cooperative health\nbenefit plan certified pursuant to article forty-seven of the insurance\nlaw, or a health maintenance organization certified pursuant to article\nforty-four of the public health law.\n * (j) "Allowed benchmark" means the fiftieth percentile of all allowed\namounts for the particular health care service performed by a\nparticipating provider in the same or similar specialty and provided in\nthe same geographical area as reported in a benchmarking database\nmaintained by a nonprofit organization specified by the superintendent.\nThe nonprofit organization shall not be affiliated with an insurer, a\ncorporation subject to article forty-three of the insurance law, a\nmunicipal cooperative health benefit plan certified pursuant to article\nforty-seven of the insurance law, or a health maintenance organization\ncertified pursuant to article forty-four of the public health law.\n * NB Effective August 26, 2026\n * (k) "Maximum fee" means the eightieth percentile of all allowed\namounts for the particular health care service performed by a\nparticipating provider in the same or similar specialty and provided in\nthe same geographical area as reported in a benchmarking database\nmaintained by a nonprofit organization specified by the superintendent.\nThe nonprofit organization shall not be affiliated with an insurer, a\ncorporation subject to article forty-three of the insurance law, a\nmunicipal cooperative health benefit plan certified pursuant to article\nforty-seven of the insurance law, or a health maintenance organization\ncertified pursuant to article forty-four of the public health law.\n * NB Effective August 26, 2026\n