§ 603 — Definitions

§ 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 and\nhealth insurance pursuant to article thirty-two of the insurance law; a\ncorporation organized pursuant to article forty-three of the insurance\nlaw; a municipal cooperative health benefit plan certified pursuant to\narticle forty-seven of the insurance law; a health maintenance\norganization certified pursuant to article forty-four of the public\nhealth law; or a student health plan established or maintained pursuant\nto section one thousand one hundred twenty-four of the insurance law.\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