N.Y. Financial Services Law § 603: Definitions

§ 603. Definitions. For the purposes of this article:

(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 section one thousand one hundred twenty-four of the

insurance law.

* NB Effective until August 26, 2026

* (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; a student health plan established or maintained

pursuant to section one thousand one hundred twenty-four of the

insurance law; or a health benefit plan operated pursuant to article

eleven of the civil service law.

* NB Effective August 26, 2026 until August 26, 2031

* (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 section one thousand one hundred twenty-four of the

insurance law.

* NB Effective August 26, 2031

(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

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.

* (j) "Allowed benchmark" means the fiftieth percentile of all allowed

amounts for the particular health care service performed by a

participating 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.

* NB Effective August 26, 2026

* (k) "Maximum fee" means the eightieth percentile of all allowed

amounts for the particular health care service performed by a

participating 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.

* NB Effective August 26, 2026