§ 4406-e. Access to end of life care.
1.For the purposes of this\nsection, "health care plan" means a health maintenance organization\nlicensed pursuant to article forty-three of the insurance law or\ncertified pursuant to this article.\n 2. Every health care plan that provides coverage for hospital,\nsurgical or medical care that includes coverage for acute care services\nshall provide an enrollee diagnosed with advanced cancer (with no hope\nof reversal of primary disease and fewer than sixty days to live, as\ncertified by the patient's attending health care practitioner) with\ncoverage for acute care services at an acute care facility licensed\npursuant to article twenty-eight of this chapter specializing in the\ntreatment of terminally ill patients, if the patient's attending healt
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§ 4406-e. Access to end of life care. 1. For the purposes of this\nsection, "health care plan" means a health maintenance organization\nlicensed pursuant to article forty-three of the insurance law or\ncertified pursuant to this article.\n 2. Every health care plan that provides coverage for hospital,\nsurgical or medical care that includes coverage for acute care services\nshall provide an enrollee diagnosed with advanced cancer (with no hope\nof reversal of primary disease and fewer than sixty days to live, as\ncertified by the patient's attending health care practitioner) with\ncoverage for acute care services at an acute care facility licensed\npursuant to article twenty-eight of this chapter specializing in the\ntreatment of terminally ill patients, if the patient's attending health\ncare practitioner, in consultation with the medical director of the\nfacility, determines that the enrollee's care would appropriately be\nprovided by the facility.\n 3. Notwithstanding the provisions of article forty-nine of this\nchapter, if the health care plan disagrees with the admission of or\nprovision or continuation of care for the enrollee by the facility, the\nhealth care plan shall initiate an expedited external appeal in\naccordance with the provisions of paragraph (c) of subdivision two of\nsection forty-nine hundred fourteen of this chapter, provided further,\nthat until such decision is rendered, the admission of or provision or\ncontinuation of the care by the facility shall not be denied by the\nhealth care plan and the health care plan shall provide coverage and\nreimburse the facility for services provided subject to the provisions\nof this section and other limitations otherwise applicable under the\nenrollee's contract. The decision of the external appeal agent shall be\nbinding on all parties. If the health care plan does not initiate an\nexpedited external appeal, the health care plan shall reimburse the\nfacility for services provided subject to the provisions of this section\nand other limitations otherwise applicable under the enrollee's\ncontract.\n 4. A health care plan shall provide reimbursement for those services\nprescribed by this section at rates negotiated between the health care\nplan and the facility. In the absence of agreed upon rates, a health\ncare plan shall pay for acute care at the facility's acute care rate\nunder the Medicare program (Title XVIII of the federal Social Security\nAct), including the Part A rate for Part A services and the Part B rate\nfor Part B services, and shall pay for alternate level care days at\nseventy-five percent of the acute care rate, including the Part A rate\nfor Part A services and the Part B rate for Part B services.\n 5. Payment by a health care plan pursuant to this section shall be\npayment in full for the services provided to the enrollee. An acute care\nfacility reimbursed pursuant to this section shall not charge or seek\nany reimbursement from, or have any recourse against an enrollee 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 enrollee is responsible under the terms of the\napplicable contract.\n 6. No provision of this section shall be construed to require a health\ncare plan to provide coverage for benefits not otherwise covered under\nthe enrollee's contract.\n