N.Y. Ins. Law § 4325

§ 4325. Prohibitions. (a) No corporation organized under this article\nshall by contract, written policy or written procedure prohibit or\nrestrict any health care provider from disclosing to any subscriber,\ndesignated representative or, where appropriate, prospective subscriber,\n(hereinafter collectively referred to as subscriber) any information\nthat such provider deems appropriate regarding:\n (1) a condition or a course of treatment with a subscriber including\nthe availability of other therapies, consultations, or tests; or\n (2) the provisions, terms, or requirements of the corporation's\nproducts as they relate to the subscriber.\n (b) No corporation organized under this article shall by contract,\nwritten policy or written procedure prohibit or restrict any health care\nprovider from filing a complaint, making a report or commenting to an\nappropriate governmental body regarding the policies or practices of\nsuch corporation which the provider believes may negatively impact upon\nthe quality of or access to patient care.\n (c) No corporation organized under this article shall by contract,\nwritten policy or written procedure prohibit or restrict any health care\nprovider from advocating to the corporation on behalf of the subscriber\nfor approval or coverage of a particular course of treatment.\n (d) No contract or agreement between a corporation organized under\nthis article and a health care provider shall contain any clause\npurporting to transfer to the health care provider by indemnification or\notherwise any liability relating to activities, actions or omissions of\nthe corporation as opposed to the health care provider.\n (e) Contracts entered into between an insurer and a health care\nprovider shall include terms which prescribe:\n (1) the method by which payments to a provider, including any\nprospective or retrospective adjustments thereto, shall be calculated;\n (2) the time periods within which such calculations will be completed,\nthe dates upon which any such payments and adjustments shall be\ndetermined to be due, and the rates upon which any such payments and\nadjustments will be made;\n (3) a description of the records or information relied upon to\ncalculate any such payments and adjustments, and a description of how\nthe provider can access a summary of such calculations and adjustments;\n (4) the process to be employed to resolve disputed incorrect or\nincomplete records or information and to adjust any such payments and\nadjustments which have been calculated by relying on any such incorrect\nor incomplete records or information so disputed; provided, however,\nthat nothing herein shall be deemed to authorize or require the\ndisclosure of personally identifiable patient information or information\nrelated to other individual health care providers or the plan's\nproprietary data collection systems, software or quality assurance or\nutilization review methodologies; and\n (5) the right of either party to the contract to seek resolution of a\ndispute arising pursuant to the payment terms of such contract through a\nproceeding under article seventy-five of the civil practice law and\nrules.\n (f) No contract entered into between an insurer and a health care\nprovider shall be enforceable if it includes terms which transfer\nfinancial risk to providers, in a manner inconsistent with the\nprovisions of paragraph (c) of subdivision one of section forty-four\nhundred three of the public health law, or penalize providers for\nunfavorable case mix so as to jeopardize the quality of or insureds'\nappropriate access to medically necessary services; provided, however,\nthat payment at less than prevailing fee for service rates or capitation\nshall not be deemed or presumed prima facie to jeopardize quality or\naccess.\n (g)(1) No insurer shall implement an adverse reimbursement change to a\ncontract with a health care professional that is otherwise permitted by\nthe contract, unless, prior to the effective date of the change, the\ninsurer gives the health care professional with whom the insurer has\ndirectly contracted and who is impacted by the adverse reimbursement\nchange, at least ninety days written notice of the change. If the\ncontracting health care professional objects to the change that is the\nsubject of the notice by the insurer, the health care professional may,\nwithin thirty days of the date of the notice, give written notice to the\ninsurer to terminate his or her contract with the insurer effective upon\nthe implementation date of the adverse reimbursement change. For the\npurposes of this subsection, the term "adverse reimbursement change"\nshall mean a proposed change that could reasonably be expected to have a\nmaterial adverse impact on the aggregate level of payment to a health\ncare professional, and the term "health care professional" shall mean a\nhealth care professional licensed, registered or certified pursuant to\ntitle eight of the education law. The notice provisions required by this\nsubsection shall not apply where: (A) such change is otherwise required\nby law, regulation or applicable regulatory authority, or is required as\na result of changes in fee schedules, reimbursement methodology or\npayment policies established by a government agency or by the American\nMedical Association's current procedural terminology (CPT) codes,\nreporting guidelines and conventions; or (B) such change is expressly\nprovided for under the terms of the contract by the inclusion of or\nreference to a specific fee or fee schedule, reimbursement methodology\nor payment policy indexing mechanism.\n (2) Nothing in this subsection shall create a private right of action\non behalf of a health care professional against an insurer for\nviolations of this subsection.\n (h) No corporation or insurer organized or licensed under this chapter\nwhich provides coverage for prescription drugs shall require, or enter\ninto a contract which permits, a copayment which exceeds the usual and\ncustomary cost of such prescribed drug.\n (i) Any contract provision, written policy or written procedure in\nviolation of this section shall be deemed to be void and unenforceable.\n * (j) If a contract between a corporation and a hospital is not\nrenewed or is terminated by either party, the parties shall continue to\nabide by the terms of such contract, including reimbursement terms, for\na period of two months from the effective date of termination or, in the\ncase of a non-renewal, from the end of the contract period. Notice shall\nbe provided to all subscribers potentially affected by such termination\nor non-renewal within fifteen days after commencement of the two-month\nperiod. The commissioner of health shall have the authority to waive the\ntwo-month period upon the request of either party to a contract that is\nbeing terminated for cause. This subsection shall not apply where both\nparties mutually agree in writing to the termination or non-renewal and\nthe corporation provides notice to the subscriber at least thirty days\nin advance of the date of contract termination.\n * NB Repealed June 30, 2017\n (k) (1) A corporation organized under this article shall not deny\npayment to a general hospital certified pursuant to article twenty-eight\nof the public health law for a claim for medically necessary inpatient\nservices resulting from an emergency admission provided by a general\nhospital solely on the basis that the general hospital did not timely\nnotify such insurer that the services had been provided.\n (2) Nothing in this subsection shall preclude a general hospital and a\ncorporation from agreeing to requirements for timely notification that\nmedically necessary inpatient services resulting from an emergency\nadmission have been provided and to reductions in payment for failure to\ntimely notify; provided, however that: (i) any requirement for timely\nnotification must provide for a reasonable extension of timeframes for\nnotification for emergency services provided on weekends or federal\nholidays, (ii) any agreed to reduction in payment for failure to timely\nnotify shall not exceed the lesser of two thousand dollars or twelve\npercent of the payment amount otherwise due for the services provided,\nand (iii) any agreed to reduction in payment shall not be imposed if the\npatient's insurance coverage could not be determined by the hospital\nafter reasonable efforts at the time the inpatient services were\nprovided.\n