602. Applicability. (a) This article shall not apply to health care services, including emergency services, where physician fees are subject to schedules or other monetary limitations under any other law, including the workers' compensation law and article fifty-one of the insurance law, and shall not preempt any such law.
(b)(1) With regard to emergency services billed under American medical association current procedural terminology (CPT) codes 99281 through 99285, 99288, 99291 through 99292, 99217 through 99220, 99224 through 99226, and 99234 through 99236, the dispute resolution process established in this article shall not apply when:
(A) the amount billed for any such CPT code meets the requirements set forth in paragraph three of this subsection, after any applicable co-insurance, co-payment and deductible; and
(B) the amount billed for any such CPT code does not exceed one hundred twenty percent of the usual and customary cost for such CPT code.
(2) The health care plan shall ensure that an insured shall not incur any greater out-of-pocket costs for emergency services billed under a CPT code as set forth in this subsection than the insured would have incurred if such emergency services were provided by a participating physician.
(3) Beginning January first, two thousand fifteen and each January first thereafter, the superintendent shall publish on a website maintained by the department of financial services, and provide in writing to each health care plan, a dollar amount for which bills for the procedure codes identified in this subsection shall be exempt from the dispute resolution process established in this article. Such amount shall equal the amount from the prior year, beginning with six hundred dollars in two thousand fourteen, adjusted by the average of the annual average inflation rates for the medical care commodities and medical care services components of the consumer price index. In no event shall an amount exceeding one thousand two hundred dollars for a specific CPT code billed be exempt from the dispute resolution process established in this article.
Last modified: February 3, 2019