Bill Text: NY A03757 | 2019-2020 | General Assembly | Introduced


Bill Title: Expands health insurance coverage of physical and occupational therapy services by limiting co-payments and regulating visit limitations; expands coverage of early intervention services; expands utilization review of health insurance coverage for medically necessary care.

Spectrum: Partisan Bill (Democrat 12-0)

Status: (Introduced - Dead) 2020-01-08 - referred to insurance [A03757 Detail]

Download: New_York-2019-A03757-Introduced.html


                STATE OF NEW YORK
        ________________________________________________________________________
                                          3757
                               2019-2020 Regular Sessions
                   IN ASSEMBLY
                                    January 31, 2019
                                       ___________
        Introduced  by  M.  of  A. GUNTHER, COLTON, ENGLEBRIGHT, STIRPE, THIELE,
          SEAWRIGHT, STECK, WOERNER -- Multi-Sponsored by -- M.  of  A.  HEVESI,
          PAULIN, SIMON -- read once and referred to the Committee on Insurance
        AN  ACT  to  amend  the  insurance  law, in relation to health insurance
          coverage of physical and occupational therapy services and payment for
          early intervention services; and to amend the insurance  law  and  the
          public health law, in relation to the provision of medically necessary
          care and utilization review
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
     1    Section 1. Paragraph 23 of subsection  (i)  of  section  3216  of  the
     2  insurance  law,  as added by chapter 593 of the laws of 2000, is amended
     3  to read as follows:
     4    (23) If a policy provides for reimbursement for physical  and  occupa-
     5  tional therapy service which is within the lawful scope of practice of a
     6  duly  licensed  physical  or occupational therapist, an insured shall be
     7  entitled to reimbursement for such service whether the said  service  is
     8  performed  by a physician or through a duly licensed physical or occupa-
     9  tional therapist, provided however, that nothing contained herein  shall
    10  be  construed  to  impair any terms of such policy including appropriate
    11  utilization review and the requirement that said  service  be  performed
    12  pursuant to a medical order, or a similar or related service of a physi-
    13  cian  provided, further, that such terms shall not impose co-payments in
    14  excess of twenty percent of the total reimbursement to the  provider  of
    15  care.  Visit limits for physical and occupational therapy services shall
    16  be subject to an exceptions process, that shall  include  the  insured's
    17  physician  certifying  that  the cessation of services would most likely
    18  result in further disability or harm  to  the  insured.  Any  exceptions
    19  process shall be further determined by the superintendent.
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD00572-01-9

        A. 3757                             2
     1    §  2.  Subsection (b) of section 3235-a of the insurance law, as added
     2  by section 3 of part C of chapter 1 of the laws of 2002, is  amended  to
     3  read as follows:
     4    (b)  Where  a  policy  of  accident  and health insurance, including a
     5  contract  issued  pursuant  to  article  forty-three  of  this  chapter,
     6  provides coverage for an early intervention program service, such cover-
     7  age shall not be applied against any maximum annual or lifetime monetary
     8  limits  set  forth  in  such  policy or contract. Visit limitations [and
     9  other terms and conditions of the policy]  will  continue  to  apply  to
    10  early  intervention  services. However, any visits used for early inter-
    11  vention program services shall not reduce the number of visits otherwise
    12  available under the policy or contract for such services.
    13    § 3. Clause (ii) of subparagraph (A) of paragraph 1 of subsection f of
    14  section 4235 of the insurance law, as amended by chapter 219 of the laws
    15  of 2011, is amended to read as follows:
    16    (ii) a policy under which coverage terminates at a specified age shall
    17  not so terminate with respect to an unmarried child who is incapable  of
    18  self-sustaining  employment  by  reason of mental illness, developmental
    19  disability, mental retardation, as defined in the mental hygiene law, or
    20  physical handicap and who became so incapable prior to attainment of the
    21  age at which coverage would  otherwise  terminate  and  who  is  chiefly
    22  dependent  upon  such  employee  or  member for support and maintenance,
    23  while the insurance of the employee or member remains in force  and  the
    24  child  remains  in such condition, if the insured employee or member has
    25  within thirty-one days of such child's attainment of the termination age
    26  submitted proof of such child's incapacity as described [herein] in this
    27  clause.  No policy of group accident, group health or group accident and
    28  health insurance shall impose co-payments in excess of twenty percent of
    29  the total reimbursement to the provider of care. Visit limits for  phys-
    30  ical  and  occupational services shall be subject to an exceptions proc-
    31  ess, that shall include  an  insured's  physician  certifying  that  the
    32  cessation  of services would most likely result in further disability or
    33  harm to the insured. Any exceptions process shall be further  determined
    34  by the superintendent.
    35    § 4. Subparagraph (A) of paragraph 4 of subsection (f) of section 4235
    36  of  the insurance law, as amended by chapter 593 of the laws of 2000, is
    37  amended to read as follows:
    38    (A) any physical and occupational therapy service which is within  the
    39  lawful  scope of practice of a licensed physical and occupational thera-
    40  pist, a subscriber to such policy shall be entitled to reimbursement for
    41  such service, whether the said service is performed by  a  physician  or
    42  licensed physical and occupational therapist pursuant to prescription or
    43  referral  by  a  physician. No policy of group accident, group health or
    44  group accident and health insurance shall impose co-payments  in  excess
    45  of  twenty  percent  of the total reimbursement to the provider of care.
    46  Visit limits for physical and occupational  therapy  services  shall  be
    47  subject to an exceptions process, that shall include an insured's physi-
    48  cian  certifying that the cessation of services would most likely result
    49  in further disability or harm to the  insured.  Any  exceptions  process
    50  shall be further determined by the superintendent;
    51    § 5. Subparagraph (G) of paragraph 1 of subsection (b) of section 4301
    52  of  the insurance law, as amended by chapter 593 of the laws of 2000, is
    53  amended to read as follows:
    54    (G) physical and occupational therapy care provided  through  licensed
    55  physical  and  occupational therapists upon the prescription of a physi-
    56  cian. Co-payments related to reimbursement for such services  shall  not

        A. 3757                             3
     1  exceed  twenty  percent  of  the  total reimbursement to the provider of
     2  care. Visit limits for physical and occupational therapy services  shall
     3  be  subject  to  an  exceptions  process, that shall include the covered
     4  person's  physician certifying that the cessation of services would most
     5  likely result in further disability or harm to the covered  person.  Any
     6  exceptions process shall be further determined by the superintendent,
     7    §  6.  Paragraph 13 of subsection (b) of section 4322 of the insurance
     8  law, as added by chapter 504 of the laws of 1995, is amended and  a  new
     9  paragraph 13-a is added to read as follows:
    10    (13) Outpatient physical therapy up to ninety visits per condition per
    11  calendar  year.  Any  co-payments  related to reimbursement for physical
    12  therapy services shall not exceed twenty percent of the total reimburse-
    13  ment to the provider of care. Visit limits for physical therapy services
    14  shall be subject to  an  exceptions  process,  that  shall  include  the
    15  covered  person's  physician  certifying  that the cessation of services
    16  would most likely result in further disability or harm  to  the  covered
    17  person.    Any  exceptions  process  shall  be further determined by the
    18  superintendent.
    19    (13-a) Outpatient occupational therapy up to ninety visits per  condi-
    20  tion  per  calendar  year.  Any co-payments related to reimbursement for
    21  occupational therapy services shall not exceed  twenty  percent  of  the
    22  total  reimbursement  to  the provider of care. Visit limits for occupa-
    23  tional therapy services shall be subject to an exceptions process,  that
    24  shall include the covered person's physician certifying that such cessa-
    25  tion  of services would most likely result in further disability or harm
    26  to the covered person.  Any exceptions process shall be  further  deter-
    27  mined by the superintendent.
    28    §  7. Subsection (e) of section 4803 of the insurance law, as added by
    29  chapter 705 of the laws of 1996, is amended and a new  subsection  (a-1)
    30  is added to read as follows:
    31    (a-1)  Upon  written  request  by  a participating health care profes-
    32  sional, a health care  plan  shall  provide  specific  written  clinical
    33  review  criteria relating to a particular condition, disease, service or
    34  procedure and, where appropriate, other clinical information  which  the
    35  health  care  plan or its utilization review agent might consider in its
    36  utilization review and the health  care  plan  shall  include  with  the
    37  information  a  description  of  how  it will be used in the utilization
    38  review process; provided, however, that to the extent  such  information
    39  is  proprietary  to  the health care plan, the participating health care
    40  provider or prospective health care provider shall only use the informa-
    41  tion for the purposes of assisting the participating health care provid-
    42  er in evaluating covered  services  provided  by  the  organization,  an
    43  adverse determination or an appeal of adverse determination.
    44    (e)  No insurer shall terminate [or], threaten to terminate, refuse to
    45  renew or threaten refusal to renew a contract for participation  in  the
    46  in-network  benefits  portion of an insurer's network for a managed care
    47  product [solely] because the health care professional has (1)  advocated
    48  on  behalf of an insured; (2) has filed a complaint against the insurer;
    49  (3) has appealed a decision of the insurer; (4) provided information  or
    50  filed  a  report  pursuant  to  section  forty-four hundred six-c of the
    51  public health law; [or] (5) requested a hearing or  review  pursuant  to
    52  this section; or (6) ordered or rendered medically necessary care.
    53    §  8.  Paragraph  1 of subsection (b) of section 4901 of the insurance
    54  law, as added by chapter 705 of the laws of 1996, is amended to read  as
    55  follows:

        A. 3757                             4
     1    (1)  The  utilization  review  plan,  including but not limited to the
     2  clinical review criteria and standards and the  definition/standards  of
     3  medical  necessity used under the utilization review plan. A utilization
     4  review agent shall report any amendment or changes  to  the  utilization
     5  review  plan  to  the  superintendent  within thirty days of making such
     6  amendment or change;
     7    § 9. Paragraph 4 of subsection (a) of section 4902  of  the  insurance
     8  law,  as added by chapter 705 of the laws of 1996, is amended to read as
     9  follows:
    10    (4) Establishment of a process for rendering utilization review deter-
    11  minations which shall, at a  minimum,  include:  written  procedures  to
    12  assure  that utilization reviews and determinations are conducted within
    13  the timeframes established herein; procedures to notify an  insured,  an
    14  insured's  designee  [and/or]  and  an insured's health care provider of
    15  adverse determinations; and procedures for appeal  of  adverse  determi-
    16  nations  including the establishment of an expedited appeals process for
    17  denials of continued inpatient care or where there is imminent or  seri-
    18  ous threat to the health of the insured;
    19    §  10.  The opening paragraph of subsection (d) of section 4905 of the
    20  insurance law, as added by chapter 705 of the laws of 1996,  is  amended
    21  to read as follows:
    22    A utilization review agent or the health care plan for which the agent
    23  provides  utilization  review  shall  not,  with  respect to utilization
    24  review activities, permit or provide compensation or anything  of  value
    25  to its employees, agents, or contractors based on:
    26    §  11.  Subdivision  5  of section 4406-d of the public health law, as
    27  added by chapter 705 of the laws of 1996, is amended and a new  subdivi-
    28  sion 1-a is added to read as follows:
    29    1-a. Upon written request by a participating health care professional,
    30  a health care plan shall provide specific written clinical review crite-
    31  ria  relating  to  a particular condition, disease, service or procedure
    32  and, where appropriate, other clinical information which the health care
    33  plan or its utilization review agent might consider in  its  utilization
    34  review  and  the  health  care plan shall include with the information a
    35  description of how it will be used in the  utilization  review  process;
    36  provided, however, that to the extent such information is proprietary to
    37  the health care plan, the participating health care provider or prospec-
    38  tive  health  care  provider  shall  only  use  the  information for the
    39  purposes of assisting the participating health care provider in evaluat-
    40  ing covered services provided by the organization, an  adverse  determi-
    41  nation or an appeal of adverse determination.
    42    5.  No  health  care  plan shall terminate, or threaten to terminate a
    43  contract or employment, [or] refuse to renew,  or  threaten  refusal  to
    44  renew a contract, [solely] because a health care provider has:
    45    (a) advocated on behalf of an enrollee;
    46    (b) filed a complaint against the health care plan;
    47    (c) appealed a decision of the health care plan;
    48    (d)  provided information or filed a report pursuant to section forty-
    49  four hundred six-c of this article; [or]
    50    (e) requested a hearing or review pursuant to this section; or
    51    (f) ordered or rendered medically necessary care.
    52    § 12. Paragraph (a) of subdivision 2 of section  4901  of  the  public
    53  health  law,  as added by chapter 705 of the laws of 1996, is amended to
    54  read as follows:
    55    (a) The utilization review plan, including  but  not  limited  to  the
    56  clinical  review  criteria and standards and the definition/standards of

        A. 3757                             5
     1  medical necessity used under the utilization review plan. A  utilization
     2  review  agent  shall  report any amendment or changes to the utilization
     3  review plan to the commissioner within thirty days of making such amend-
     4  ment or change;
     5    §  13.  Paragraph  (d)  of subdivision 1 of section 4902 of the public
     6  health law, as added by chapter 705 of the laws of 1996, is  amended  to
     7  read as follows:
     8    (d) Establishment of a process for rendering utilization review deter-
     9  minations  which  shall,  at  a  minimum, include: written procedures to
    10  assure that utilization reviews and determinations are conducted  within
    11  the  timeframes established herein; procedures to notify an enrollee, an
    12  enrollee's designee [and/or] and an enrollee's health care  provider  of
    13  adverse  determinations;  and  procedures for appeal of adverse determi-
    14  nations including the establishment of an expedited appeals process  for
    15  denials  of continued inpatient care or where there is imminent or seri-
    16  ous threat to the health of the enrollee;
    17    § 14. The opening paragraph of subdivision 4 of section  4905  of  the
    18  public  health  law,  as  added  by  chapter 705 of the laws of 1996, is
    19  amended to read as follows:
    20    A utilization review agent or the health care plan for which the agent
    21  provides utilization review  shall  not,  with  respect  to  utilization
    22  review  activities,  permit or provide compensation or anything of value
    23  to its employees, agents, or contractors based on:
    24    § 15. This act shall take effect on  the  one  hundred  eightieth  day
    25  after it shall have become a law.
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