NEW YORK STATE
INSURANCE DEPARTMENT

TWENTY-EIGHTH AMENDMENT TO REGULATION 83
(11 NYCRR 68)

CHARGES FOR PROFESSIONAL HEALTH SERVICES

I, GREGORY V. SERIO, Superintendent of Insurance of the State of New York, pursuant to the authority granted by Sections 201, 301, 2601, 5221 and Article 51 of the Insurance Law, do hereby promulgate the following Twenty-Eighth Amendment to Part 68 of Title 11 of the Official Compilation of Codes, Rules and Regulations of the State of New York (Regulation 83), to take effect upon publication in the State Register, to read as follows:

MATTER IN BRACKETS IS DELETED

MATTER UNDERLINED IS NEW

Section 68.1(b) of Part 68 is hereby amended to read as follows:

(b) (1) The charges for services specified in paragraph one of subsection (a) of section 5102 of the Insurance Law and any further health service charges which are incurred as a result of the injury and which are in excess of basic economic loss, shall not exceed the charges permissible under the schedules prepared and established by the chair of the Workers’ Compensation Board for industrial accidents. However, references to workers’ compensation reporting and procedural requirements in such schedules do not apply, e.g., requirements that provide for authorization to perform surgical procedures, is not applicable to no-fault. The general instructions and ground rules in the workers’ compensation fee schedules apply, but those rules which refer to workers’ compensation claim forms, pre-authorization approval and dispute resolution guidelines do not apply, unless specified in this Part.

(2) If a fee schedule has been adopted for a licensed health provider, the fee for services provided shall be the fee adopted or established for that licensed health provider. (For example, the fee for chiropractic services performed by a chiropractor employed by a physician would be the fee applicable for chiropractic services as contained in the Chiropractic Fee Schedule). However, if the Workers’ Compensation Fee Schedule contains a specific ground rule to permit reimbursement at the physician rate then that rule will apply. (For example, the fee for services performed by a physical or occupational therapist employed by a physician would be the fee applicable at the physician rate in accordance with Ground Rule Nine contained in the Workers’ Compensation Physical Medicine Fee Schedule).

(3) A "licensed health provider" means a licensed healthcare professional acting within the scope of his or her licensure or an entity properly formed in accordance with applicable law and acting within the scope of its license.

Part E of Appendix 17-C is amended to read as follows:

Part E. [Drugs, medical equipment and supplies] Prescription drugs.

[(a)(1)]The maximum permissible charge for drugs, [medical equipment and supplies] which are provided by a licensed pharmacist [is: (i) for drugs requiring] and require a [doctor’s] prescription, is the actual cost of the drug to the druggist (not to exceed the cost shown in the American Druggist Blue Book or Drug Topic Red Book) plus a dispensing fee of [$4.85] $5.00, except that for a compounded prescription a [$1.95] $2.00 compounding fee shall be added to the dispensing fee[;].

Note: In order to minimize the administrative cost, insurers need not verify the maximum permissible charge for the first $50 of prescription drug bills received per person, per accident.

[(ii) for medicines not requiring a doctor’s prescription, the prevailing charge;

(iii) for medical equipment and supplies, 150 percent of the actual cost of the equipment or supplies to the pharmacist.

(2) The maximum permissible monthly rental charge for medical equipment and supplies provided by a licensed pharmacist on a rental basis is one sixth of the actual cost of the equipment or supplies to the pharmacist, provided further that the maximum total charge is 12 times the maximum permissible monthly rental charge.

(b)(1) For medical equipment and supplies (e.g., TENS units, soft cervical collars) provided by physician or medical equipment supplier, the maximum permissible charge is 150 percent of the documented cost of the equipment to the provider.

(2) The maximum permissible monthly rental charge for medical equipment and supplies provided on a rental basis is one ninth of the maximum permissible charge for purchase of the equipment or supplies, provided further that the maximum total charge is 12 times the maximum permissible monthly rental charge.]

Part F of Appendix 17-C is amended to read as follows:

Part F. [Prosthetic and orthotic appliance supplies and services] Durable medical equipment, medical/surgical supplies, orthopedic footwear, and orthotic and prosthetic appliances fee schedule.

(a) The maximum permissible charge for [prosthetic and orthotic appliance supplies and services is the product of the Statewide Maximum Fee and the conversion factor set forth herein] the purchase of durable medical equipment, medical/surgical supplies, orthopedic footwear and orthotic and prosthetic appliances is the fee payable for such equipment and supplies under the New York State Medicaid program at the time such equipment and supplies are provided. If the New York State Medicaid program has not established a fee payable for the specific item, then the fee payable, in accordance with Medicaid rules, shall be the lesser of:

(1) the acquisition cost (i.e. the line item cost from a manufacturer or wholesaler net of any rebates, discounts or other valuable considerations, mailing, shipping, handling, insurance costs or any sales tax) to the provider plus 50%; or

(2) the usual and customary price charged to the general public.

(b) [The conversion factor applicable to prosthetic and orthotic appliance supplies and services is 1.55.

(c) The Statewide Maximum Fee is as set forth in the New York State Orthotics, Prosthetics and Stock Orthoses Fee Schedules published and amended by the Bureau of Medicaid, State of New York Department of Health.

(d) ] The maximum permissible monthly rental charge for [prosthetic and orthotic appliance] such equipment, [and] supplies and services provided on a rental basis [is one ninth of the maximum permissible charge for purchase of the appliance or supplies, provided further that the maximum total charge is 12 times the maximum permissible monthly rental charge] shall not exceed the lower of the monthly rental charge to the general public or the price determined by the New York State Department of Health area office. The total accumulated monthly rental charges shall not exceed the fee amount allowed under the Medicaid fee schedule.

 

I, Gregory V. Serio, Superintendent of Insurance of the State of New York, do hereby certify that the foregoing is the Twenty-Eighth Amendment to Part 68 of Title 11 of the Official Compilation of Codes, Rules and Regulations of the State of New York (Regulation 83), entitled "Charges for Professional Health Services", promulgated by me on September 21, 2004, pursuant to the authority granted by Sections 201, 301, 2601, 5221 and Article 51 of the Insurance Law, to take effect upon publication in the State Register.

Pursuant to the provisions of the State Administrative Procedure Act, prior notice of the proposed amendment was published in the State Register on August 18, 2004. No other publication or prior notice is required by statute.

 

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Gregory V. Serio
Superintendent of Insurance

September 21, 2004