(b) Notwithstanding the provisions of article forty-nine of this
chapter, if the insurer disagrees with the admission of or provision or
continuation of care for the insured by the facility, the insurer shall
initiate an expedited external appeal in accordance with the provisions
of paragraph three of subsection (b) of section four thousand nine
hundred fourteen of this chapter, provided further, that until such
decision is rendered, the admission of or provision or continuation of
the care by the facility shall not be denied by the insurer and the
insurer shall provide coverage and reimburse the facility for services
provided subject to the provisions of this section and other limitations
otherwise applicable under the insured's contract. The decision of the
external appeal agent shall be binding on all parties. If the insurer
does not initiate an expedited external appeal the insurer shall
reimburse the facility for services provided subject to the provisions
of this section and other limitations otherwise applicable under the
insured's contract.
(c) An insurer shall provide reimbursement for those services
prescribed by this section at rates negotiated between the insurer and
the facility. In the absence of agreed upon rates, an insurer shall pay
for acute care at the facility's acute care rate under the Medicare
program (Title XVIII of the federal Social Security Act), including the
Part A rate for Part A services and the Part B rate for Part B services,
and shall pay for alternate level care days at seventy-five percent of
the acute care rate, including the Part A rate for Part A services and
the Part B rate for Part B services.
(d) Payment by an insurer pursuant to this section shall be payment in
full for the services provided to the insured. An acute care facility
reimbursed pursuant to this section shall not charge or seek any
reimbursement from, or have any recourse against an insured for the
services provided by the acute care facility pursuant to this section,
except for the collection of copayments, coinsurance or visit fees, or
deductibles for which the insured is responsible under the terms of the
applicable contract.
(e) No provision of this section shall be construed to require an
insurer to provide coverage for benefits not otherwise covered under the
insured's contract.