§ 4805. Access to end of life care.
(a)Every contract issued by an\ninsurer that provides coverage for hospital, surgical or medical care\nthat includes coverage for acute care services shall provide coverage\nfor an insured diagnosed with advanced cancer (with no hope of reversal\nof primary disease and fewer than sixty days to live, as certified by\nthe patient's attending health care practitioner) for acute care\nservices at an acute care facility licensed pursuant to article\ntwenty-eight of the public health law specializing in the treatment of\nterminally ill patients if the patient's attending health care\npractitioner, in consultation with the medical director of the facility\ndetermines that the insured's care would appropriately be provided by\nsuch a facility.\n (b) Notwiths
Free access — add to your briefcase to read the full text and ask questions with AI
§ 4805. Access to end of life care. (a) Every contract issued by an\ninsurer that provides coverage for hospital, surgical or medical care\nthat includes coverage for acute care services shall provide coverage\nfor an insured diagnosed with advanced cancer (with no hope of reversal\nof primary disease and fewer than sixty days to live, as certified by\nthe patient's attending health care practitioner) for acute care\nservices at an acute care facility licensed pursuant to article\ntwenty-eight of the public health law specializing in the treatment of\nterminally ill patients if the patient's attending health care\npractitioner, in consultation with the medical director of the facility\ndetermines that the insured's care would appropriately be provided by\nsuch a facility.\n (b) Notwithstanding the provisions of article forty-nine of this\nchapter, if the insurer disagrees with the admission of or provision or\ncontinuation of care for the insured by the facility, the insurer shall\ninitiate an expedited external appeal in accordance with the provisions\nof paragraph three of subsection (b) of section four thousand nine\nhundred fourteen of this chapter, provided further, that until such\ndecision is rendered, the admission of or provision or continuation of\nthe care by the facility shall not be denied by the insurer and the\ninsurer shall provide coverage and reimburse the facility for services\nprovided subject to the provisions of this section and other limitations\notherwise applicable under the insured's contract. The decision of the\nexternal appeal agent shall be binding on all parties. If the insurer\ndoes not initiate an expedited external appeal the insurer shall\nreimburse the facility for services provided subject to the provisions\nof this section and other limitations otherwise applicable under the\ninsured's contract.\n (c) An insurer shall provide reimbursement for those services\nprescribed by this section at rates negotiated between the insurer and\nthe facility. In the absence of agreed upon rates, an insurer shall pay\nfor acute care at the facility's acute care rate under the Medicare\nprogram (Title XVIII of the federal Social Security Act), including the\nPart A rate for Part A services and the Part B rate for Part B services,\nand shall pay for alternate level care days at seventy-five percent of\nthe acute care rate, including the Part A rate for Part A services and\nthe Part B rate for Part B services.\n (d) Payment by an insurer pursuant to this section shall be payment in\nfull for the services provided to the insured. An acute care facility\nreimbursed pursuant to this section shall not charge or seek any\nreimbursement from, or have any recourse against an insured for the\nservices provided by the acute care facility pursuant to this section,\nexcept for the collection of copayments, coinsurance or visit fees, or\ndeductibles for which the insured is responsible under the terms of the\napplicable contract.\n (e) No provision of this section shall be construed to require an\ninsurer to provide coverage for benefits not otherwise covered under the\ninsured's contract.\n