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New York Consolidated Laws

N.Y. Public Health Law § 19 (2026)

Reasonable charges for medicare beneficiaries

✓ current as of May 2026
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§ 19. Reasonable charges for medicare beneficiaries.  1. No physician
licensed under article one hundred thirty-one of the education law shall
charge from a beneficiary of health insurance under title XVIII of the
federal social security act (medicare) any amount in excess of the
following limitations:
  (a) Effective January first, nineteen hundred ninety-one, a
physician's charge shall not exceed one hundred fifteen percent of the
reasonable charge for that service as determined by the United States
secretary for health and human services.
  (b) Beginning January first, nineteen hundred ninety-three, a
physician's charge shall not exceed one hundred ten percent of the
reasonable charge for that service as determined by the United States
secretary for health and human services, provided however, that if the
statewide percentage of medicare part B claims billed at or below the
reasonable charge as determined by the United States secretary for
health and human services for federal fiscal year nineteen hundred
eighty-nine fails to increase by five percentage points for federal
fiscal year nineteen hundred ninety-two, such physician's charge shall,
thereafter, not exceed one hundred five percent of the reasonable charge
as determined by the United States secretary for health and human
services. If, in any subsequent federal fiscal year, such statewide
percentage of medicare part B claims billed at or below such reasonable
charge fails to maintain such five percentage point increase,
physician's charge shall thereafter not exceed one hundred five percent
of the reasonable charge as determined by the United States secretary
for health and human services.
  2. The charge limitation set forth in subdivision one of this section
shall not apply if the service which such beneficiary is to be billed is
either an office or home visit as set forth in procedure codes 90000
through 90170 in the Physician Current Procedural Terminology 4th
Edition 1989.
  3. The state office for the aging shall, through agreement with
carriers and/or intermediaries contracted with by the federal government
in this state pursuant to title XVIII of the federal social security act
(medicare), obtain the percentages of physician's bills submitted at or
below the reasonable charge as established by the United States
secretary for health and human services, and shall issue a report by
December first, nineteen hundred ninety-two and every December first,
thereafter, stating whether the percentage of bills submitted at or
below such reasonable charge for federal fiscal year nineteen hundred
ninety-two increased by five percentage points over the statewide
percentage of bills submitted at or below such reasonable charge for
federal fiscal year nineteen hundred eighty-nine and whether such
percentage has been maintained for each successive federal fiscal year
after nineteen hundred ninety-two.
  4. Notwithstanding any inconsistent provision of this chapter, a
physician who is determined, after opportunity for a hearing, to have
violated the provisions of this section shall be subject for the first
violation to a fine of not more than one thousand dollars nor less than
the greater of three times the amount collected, or, if not collected,
three times the amount charged, in excess of the limitations set forth
in subdivision one of this section, and, for each additional violation
committed within five years of the date of an immediately preceding
violation of this section, to a fine of not more than five thousand
dollars nor less than the greater of one thousand dollars or three times
the amount collected, or, if not collected, three times the amount
charged, in excess of the limitations set forth in subdivision one of
this section; provided, however, that in no event shall the fine for an
individual violation of this section be greater than five thousand
dollars. In addition, where the provisions of this section have been
violated, the physician shall refund to the beneficiary the amount
collected in excess of the limitations set forth in subdivision one of
this section.
Notes of Decisions
Cited in 8 cases, 1991–2015 · leading case: Ross v. Albany Med. Ctr., 916 F. Supp. 196 (N.D.N.Y. 1996).
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Ross v. Albany Med. Ctr., 916 F. Supp. 196 (N.D.N.Y. 1996). · cites it 6× “§ 1395w-4(g), and N.Y.Public Health Law § 19. Those statutes prohibit non-participating physicians from charging Medicare beneficiaries more than 125% (42 U.”
Med. Soc'y v. State, 633 N.E.2d 468 (NY 1994). · cites it 8× “, contend that Public Health Law § 19 became unenforceable after January 1, 1992, the effective date of certain amendments to the Medicare Act which changed the methodology used to calculate Medicare rates.”
Med. Soc'y of New York v. State of New York Dep't of Health, 189 A.D.2d 453 (N.Y. App. Div. 1993). · cites it 12× “On July 18, 1990, the Legislature enacted Public Health Law § 19 (L 1990, ch 572) which provides, in pertinent part, that no physician licensed in this State may charge Federal Medicare beneficiaries more than a fixed percentage of the "reasonable charge for that service as…”
Med. Soc. of State of NY v. Cuomo, 777 F. Supp. 1157 (S.D.N.Y. 1991). “Plaintiffs contend that Chapter 572 of the Laws of New York (codified at N.Y. Public Health Law § 19 ) is (1) preempted by the Health Insurance for the Aged Act (“Medicare Act;” the “Act”), 42 U.”
UnitedHealthcare Servs., Inc. v. Asprinio, 49 Misc. 3d 985 (N.Y. Sup. Ct. 2015). “It has done so in the Medicare context (see Public Health Law § 19), in regard to workers’ compensation (see Workers’ Compensation Law § 13), and with respect to no-fault automobile insurance (see Insurance Law § 5108).”
New York State Soc'y of Orthopaedic Surgeons, Inc. v. Gould, 796 F. Supp. 67 (E.D.N.Y 1992). “Public Health Law section 19 essentially attempts to reduce the size of this remainder.”
Medicare Beneficiaries Def. Fund v. Mem'l Sloan-Kettering Cancer Ctr., 159 Misc. 2d 442 (N.Y. Sup. Ct. 1993). · cites it 4× “The New York law, Public Health Law § 19, capped a physician’s charges at 115% of the Medicare approved amount for 1991-1992.”
Mtr. of Med. Socy. v. Doh, 633 N.E.2d 468 (NY 1994). · cites it 7× “, contend that Public Health Law § 19 became unenforceable after January 1, 1992, the effective date of certain amendments to the Medicare Act which changed the methodology used to calculate Medicare rates.”
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