N.Y. Comp. Codes R. & Regs. tit. 11 § 68.7

Current through Register Vol. 46, No. 51, December 18, 2024

Section 68.7 - Restriction on health provider charges

(a) No provider of health services specified in section 5102 (a)(1) of the Insurance Law may demand or request any payment in addition to the charges permitted by the provisions of this Part. If the insured also possesses health insurance coverage and such health insurance contract does not exclude payment for no-fault benefits, payment by the health insurer for health services under such contract is restricted by the limitations of section 5108 of the Insurance Law, unless such limitation would impair the terms of a provider's contract with the health insurer, in which case payment by the health insurer to the provider may be made in accordance with the provider's contract; however, the provider may not receive duplicate payment.

(b) If coverage for health services specified in section 5102 (a)(1) of the Insurance Law is provided pursuant to section 5103 (g) of the Insurance Law, charges for such health services are restricted by the limitation of section 5108 of the Insurance Law.

(c) This subdivision is applicable to accidents that occurred between December 1, 1977 and December 5, 1980, regardless of the date service was rendered; and to services rendered prior to June 6, 1983 for accidents that occurred on or after December 5, 1980. If a health service provider accepts an assignment of an eligible injured person's Medicare benefits, the provider, for purposes of this Part, is deemed to have contracted with the Social Security Administration. Reimbursement for services rendered to a patient eligible for both No-Fault and Medicare is illustrated by the following example: assume a procedure where a physician's usual and customary charge is $50, the Medicare allowable charge is $40 and the No-Fault fee schedule amount is $30:

(1) If the physician takes a Medicare assignment:

(i) Medicare would pay $32 (80%);

(ii) No-Fault should be billed $8 (20%);

(iii) the No-Fault insurer would be responsible for the amount credited by Medicare to the patient's deductible; and

(iv) physicians should bill Medicare first in the manner they customarily would have billed prior to December 1, 1977.

(2) If the physician does not take Medicare assignments, no contract exists with Medicare, therefore the Insurance Law, section 5108 limitations apply:

(i) Medicare must be billed $30 (No-Fault allowance), of which $24 (80%) will be paid the physician;

(ii) No-Fault should be billed $6 (20%); and

(iii) the No-Fault insurer would be responsible for the amount credited by Medicare to the patient's deductible.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 68.7