N.Y. Public Health Law § 4406-e: Access to end of life care

§ 4406-e. Access to end of life care. 1. For the purposes of this

section, "health care plan" means a health maintenance organization

licensed pursuant to article forty-three of the insurance law or

certified pursuant to this article.

2. Every health care plan that provides coverage for hospital,

surgical or medical care that includes coverage for acute care services

shall provide an enrollee diagnosed with advanced cancer (with no hope

of reversal of primary disease and fewer than sixty days to live, as

certified by the patient's attending health care practitioner) with

coverage for acute care services at an acute care facility licensed

pursuant to article twenty-eight of this chapter specializing in the

treatment of terminally ill patients, if the patient's attending health

care practitioner, in consultation with the medical director of the

facility, determines that the enrollee's care would appropriately be

provided by the facility.

3. Notwithstanding the provisions of article forty-nine of this

chapter, if the health care plan disagrees with the admission of or

provision or continuation of care for the enrollee by the facility, the

health care plan shall initiate an expedited external appeal in

accordance with the provisions of paragraph (c) of subdivision two of

section forty-nine hundred fourteen of this chapter, provided further,

that until such decision is rendered, the admission of or provision or

continuation of the care by the facility shall not be denied by the

health care plan and the health care plan shall provide coverage and

reimburse the facility for services provided subject to the provisions

of this section and other limitations otherwise applicable under the

enrollee's contract. The decision of the external appeal agent shall be

binding on all parties. If the health care plan does not initiate an

expedited external appeal, the health care plan shall reimburse the

facility for services provided subject to the provisions of this section

and other limitations otherwise applicable under the enrollee's

contract.

4. A health care plan shall provide reimbursement for those services

prescribed by this section at rates negotiated between the health care

plan and the facility. In the absence of agreed upon rates, a health

care plan shall pay for acute care at the facility's acute care rate

under the Medicare program (Title XVIII of the federal Social Security

Act), including the Part A rate for Part A services and the Part B rate

for Part B services, and shall pay for alternate level care days at

seventy-five percent of the acute care rate, including the Part A rate

for Part A services and the Part B rate for Part B services.

5. Payment by a health care plan pursuant to this section shall be

payment in full for the services provided to the enrollee. An acute care

facility reimbursed pursuant to this section shall not charge or seek

any reimbursement from, or have any recourse against an enrollee for the

services provided by the acute care facility pursuant to this section,

except for the collection of copayments, coinsurance or visit fees, or

deductibles for which the enrollee is responsible under the terms of the

applicable contract.

6. No provision of this section shall be construed to require a health

care plan to provide coverage for benefits not otherwise covered under

the enrollee's contract.