Bill Text: NY A09835 | 2015-2016 | General Assembly | Amended

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Bill Title: Relates to payments from the New York state medical indemnity fund.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Introduced - Dead) 2016-06-16 - substituted by s7873b [A09835 Detail]

Download: New_York-2015-A09835-Amended.html

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                STATE OF NEW YORK
        ________________________________________________________________________
                                         9835--B
                   IN ASSEMBLY
                                     April 12, 2016
                                       ___________
        Introduced by M. of A. ABINANTI -- read once and referred to the Commit-
          tee on Health -- committee discharged, bill amended, ordered reprinted
          as  amended  and  recommitted to said committee -- again reported from
          said committee with  amendments,  ordered  reprinted  as  amended  and
          recommitted to said committee
        AN  ACT to amend the public health law, in relation to payments from the
          New York state medical indemnity fund
          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:
     1    Section  1.  Section  2999-j  of  the  public health law is amended by
     2  adding two new subdivisions 2-a and 7-a to read as follows:
     3    2-a. A request for review of a denial of a claim  or  a  denial  of  a
     4  request  for  prior  authorization for the payment or reimbursement from
     5  the fund for qualifying health care costs must be made by  the  claimant
     6  no later than sixty days from receipt of the denial and, at a claimant's
     7  option, by either (a) making application to the court wherein the judge-
     8  ment  was  awarded or the case was settled, or (b) following the process
     9  established by regulations of the commissioner  for  the  administrative
    10  review of a denial of a claim or request for prior authorization.
    11    7-a. A request for a review of a determination by the fund administra-
    12  tor that the relevant provisions of subdivision six of this section have
    13  not  been  met  and/or that the plaintiff or claimant is not a qualified
    14  plaintiff may be made by any of the parties, no later  than  sixty  days
    15  from  receipt  of the denial, by making application to the court wherein
    16  the judgment was awarded or the case was settled.
    17    § 2. Subdivisions 2 and 4 of section 2999-j of the public health  law,
    18  as  added by section 52 of part H of chapter 59 of the laws of 2011, are
    19  amended to read as follows:
    20    2. The provision of qualifying health care costs to  qualified  plain-
    21  tiffs  shall  not be subject to prior authorization, except as described
    22  by the commissioner in regulation; provided, however[, that]:
    23    (a) such  regulation  shall  not  prevent  qualified  plaintiffs  from
    24  receiving  care  or  assistance  that would, at a minimum, be authorized
    25  under the medicaid program; [and provided, further, that]
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD14645-13-6
        A. 9835--B                          2
     1    (b) if any prior authorization is required  by  such  regulation,  the
     2  regulation  shall require that requests for prior authorization be proc-
     3  essed within a reasonably prompt period of  time  and,  subject  to  the
     4  provisions  of subdivision two-a of this section, shall identify a proc-
     5  ess  for  prompt  administrative  review  of any denial of a request for
     6  prior authorization[.]; and
     7    (c) such regulations shall not prohibit qualifying health  care  costs
     8  on  the  grounds  that the qualifying health care cost is not limited to
     9  the direct need of the patient and may  benefit  other  members  of  the
    10  household.
    11    4. The amount of qualifying health care costs to be paid from the fund
    12  shall  be  calculated[: (a) with respect to services provided in private
    13  physician practices on the basis of one hundred percent of the usual and
    14  customary rates,] on the basis of one hundred percent of the  usual  and
    15  customary  cost.  For the purposes of this section, "usual and customary
    16  costs" shall mean the  eightieth  percentile  of  all  charges  for  the
    17  particular  health  care  service performed by a provider in the same or
    18  similar specialty and provided in the same geographical area as reported
    19  in a benchmarking database maintained by a nonprofit organization speci-
    20  fied by the superintendent of financial services. If no such  rates  are
    21  available  qualifying health care costs shall be calculated on the basis
    22  of no less than one hundred thirty percent of Medicaid or Medicare rates
    23  of reimbursement, whichever is higher. If no  such  rate  exists,  costs
    24  shall  be  reimbursed  as defined by the commissioner in regulation[; or
    25  (b) with respect to all other services, on the basis of  Medicaid  rates
    26  of  reimbursement  or,  where no such rates are available, as defined by
    27  the commissioner in regulation].
    28    § 3.  Subdivisions 1 and 3 of section 2999-h of the public health law,
    29  as added by section 52 of part H of chapter 59 of the laws of 2011,  are
    30  amended to read as follows:
    31    1. "Birth-related neurological injury" means an injury to the brain or
    32  spinal  cord  of  a  live  infant caused by the deprivation of oxygen or
    33  mechanical injury occurring in the course of labor, delivery or resusci-
    34  tation, or by other medical services provided  or  not  provided  during
    35  delivery  admission,  that  rendered  the  infant  with  a permanent and
    36  substantial motor impairment or with a developmental disability as  that
    37  term is defined by section 1.03 of the mental hygiene law, or both. This
    38  definition shall apply to live births only.
    39    3.  "Qualifying health care costs" means the future medical, hospital,
    40  surgical, nursing, dental, rehabilitation, habilitation, respite, custo-
    41  dial, durable medical equipment, home modifications, assistive technolo-
    42  gy, vehicle modifications, transportation for purposes  of  health  care
    43  related appointments, prescription and non-prescription medications, and
    44  other  health  care costs actually incurred for services rendered to and
    45  supplies utilized by qualified plaintiffs, which are necessary  to  meet
    46  their  health  care  needs,  including providing therapeutic benefit, as
    47  determined by their treating physicians, physician assistants, or  nurse
    48  practitioners  and  as  otherwise  defined  by the commissioner in regu-
    49  lation.
    50    § 4.  The public health law is amended by adding a new section  2999-k
    51  to read as follows:
    52    §  2999-k.  Consumer  and  stakeholder workgroup. The department shall
    53  convene a workgroup comprised of qualified plaintiffs or representatives
    54  of qualified plaintiffs,  physicians,  advocates  and  other  interested
    55  parties.  Such workgroup shall be co-chaired by the commissioner and the
    56  superintendent of financial services, and shall be composed of not  less
        A. 9835--B                          3
     1  than  nine  members  appointed  by  the  governor, of which two shall be
     2  appointed upon recommendation of the temporary president of  the  senate
     3  and two shall be appointed upon the recommendation of the speaker of the
     4  assembly.  If  the commissioner seeks to make any regulations under this
     5  title, he or she shall submit the proposed regulations to the  workgroup
     6  for  its  input  and comments. The commissioner shall consider the input
     7  and comments of the workgroup prior to  the  adoption  of  any  proposed
     8  regulation, and if he or she shall act in a manner inconsistent with the
     9  workgroup's  input  and  comments,  the  commissioner  shall provide the
    10  reasons therefor in writing.
    11    § 5. This act shall take effect on the forty-fifth day after it  shall
    12  have become a law.