Bill Text: NY S06576 | 2023-2024 | General Assembly | Introduced
Bill Title: Extends period during which health maintenance organization enrollees may continue to receive services from a health care provider who disaffiliates from 60 or 90 days to 1 year, or in case of terminal illness, until the time of such insured's death; bars incentives which induce a provider to provide health care to an enrollee in a manner inconsistent with law.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced) 2024-01-03 - REFERRED TO INSURANCE [S06576 Detail]
Download: New_York-2023-S06576-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 6576 2023-2024 Regular Sessions IN SENATE April 27, 2023 ___________ Introduced by Sen. COMRIE -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance AN ACT to amend the insurance law and the public health law, in relation to access to health care providers in managed care plans The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subsection (e) of section 4803 of the insurance law, as 2 added by chapter 705 of the laws of 1996, is amended to read as follows: 3 (e) No insurer shall terminate or refuse to renew a contract for 4 participation in the in-network benefits portion of an insurer's network 5 for a managed care product solely because the health care professional 6 has: (1) advocated on behalf of an insured; (2) [has] filed a complaint 7 against the insurer; (3) [has] appealed a decision of the insurer; (4) 8 provided information or filed a report pursuant to section forty-four 9 hundred six-c of the public health law; [or] (5) requested a hearing or 10 review pursuant to this section; or (6) rendered an opinion regarding 11 whether an insured's illness is terminal pursuant to section four thou- 12 sand eight hundred four of this article. 13 § 2. Subsections (e) and (f) of section 4804 of the insurance law, 14 subsection (e) as amended by section 9 of subpart B of part AA of chap- 15 ter 57 of the laws of 2022 and subsection (f) as added by chapter 705 of 16 the laws of 1996, are amended to read as follows: 17 (e) (1) If an insured's health care provider leaves the insurer's 18 in-network benefits portion of its network of providers for a managed 19 care product for reasons other than those for which the provider would 20 not be eligible to receive a hearing pursuant to paragraph one of 21 subsection (b) of section [forty-eight] four thousand eight hundred 22 three of this [chapter] article, the insurer shall provide written 23 notice to the insured of the provider's disaffiliation and permit the 24 insured to continue [an ongoing course of treatment with] to receive 25 health care procedures, treatments, and services from the insured's EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD09883-01-3S. 6576 2 1 current health care provider during a transitional period of: (A) [nine-2ty days] one year from the later of the date of the notice to the 3 insured of the provider's disaffiliation from the insurer's network or 4 the effective date of the provider's disaffiliation from the insurer's 5 network; [or] (B) if the insured is pregnant at the time of the provid- 6 er's disaffiliation, the duration of the pregnancy and post-partum care 7 directly related to the delivery; or (C) a terminal illness or condi- 8 tion, until the time of such insured's death. 9 (2) During the transitional period the health care provider shall: (A) 10 continue to accept reimbursement from the insurer at the rates applica- 11 ble prior to the start of the transitional period, and continue to 12 accept the in-network cost-sharing from the insured, if any, as payment 13 in full; (B) adhere to the insurer's quality assurance requirements and 14 provide to the insurer necessary medical information related to such 15 care; and (C) otherwise adhere to the insurer's policies and procedures 16 including, but not limited to, procedures regarding referrals and 17 obtaining pre-authorization and a treatment plan approved by the insur- 18 er. 19 (f) If a new insured whose health care provider is not a member of the 20 insurer's in-network benefits portion of the provider network enrolls in 21 the managed care product, the insurer shall permit the insured to 22 continue [an ongoing course of treatment with] to receive health care 23 procedures, treatments, and services from the insured's current health 24 care provider during a transitional period of up to [sixty days] one 25 year from the effective date of enrollment or, if (1) the insured has a 26 [life-threatening disease or condition or a degenerative and disabling27disease or condition] terminal illness or condition, until the time of 28 such insured's death, or (2) the insured has entered the second trimes- 29 ter of pregnancy at the time of enrollment, in which case the transi- 30 tional period shall include the provision of post-partum care directly 31 related to the delivery. If an insured elects to continue to receive 32 care from such health care provider pursuant to this [paragraph] 33 subsection, such care shall be authorized by the insurer for the transi- 34 tional period only if the health care provider agrees (A) to accept 35 reimbursement from the insurer at rates established by the insurer as 36 payment in full, which rates shall be no more than the level of 37 reimbursement applicable to similar providers within the in-network 38 benefits portion of the insurer's network for such services; (B) to 39 adhere to the insurer's quality assurance requirements and agrees to 40 provide to the insurer necessary medical information related to such 41 care; and (C) to otherwise adhere to the insurer's policies and proce- 42 dures, including, but not limited to, procedures regarding referrals and 43 obtaining pre-authorization and a treatment plan approved by the insur- 44 er. In no event shall this subsection be construed to require an insur- 45 er to provide coverage for benefits not otherwise covered or to diminish 46 or impair pre-existing condition limitations contained within the 47 insured's contract. 48 § 3. Section 4804 of the insurance law is amended by adding two new 49 subsections (g) and (h) to read as follows: 50 (g) For the purposes of this section, the term "terminal illness or 51 condition" shall mean an illness or condition which, in the opinion of 52 the physician of the patient suffering from such terminal illness or 53 condition, is likely to cause or be a major contributing factor in caus- 54 ing such patient's death within three years. 55 (h) Provider incentives (monetary or otherwise) to a health care 56 provider relating to procedures, treatments, or services pursuant toS. 6576 3 1 this section, which are intended to have the effect of inducing such 2 provider to provide care to an insured in a manner inconsistent with 3 this section, are prohibited. 4 § 4. Paragraphs (e) and (f) of subdivision 6 of section 4403 of the 5 public health law, paragraph (e) as amended by section 10 of subpart B 6 of part AA of chapter 57 of the laws of 2022 and paragraph (f) as added 7 by chapter 705 of the laws of 1996, are amended to read as follows: 8 (e) (1) If an enrollee's health care provider leaves the health main- 9 tenance organization's network of providers for reasons other than those 10 for which the provider would not be eligible to receive a hearing pursu- 11 ant to paragraph a of subdivision two of section forty-four hundred 12 six-d of this [chapter] article, the health maintenance organization 13 shall provide written notice to the enrollee of the provider's disaffil- 14 iation and permit the enrollee to continue an [ongoing course of treat-15ment with] to receive health care procedures, treatments, and services 16 from the enrollee's current health care provider during a transitional 17 period of: (i) [ninety days] one year from the later of the date of the 18 notice to the enrollee of the provider's disaffiliation from the organ- 19 ization's network or the effective date of the provider's disaffiliation 20 from the organization's network[;] or (ii) if the enrollee is pregnant 21 at the time of the provider's disaffiliation, the duration of the preg- 22 nancy and post-partum care directly related to the delivery, or (iii) if 23 the enrollee has a terminal illness or condition, until the time of such 24 enrollee's death. 25 (2) During the transitional period the health care provider shall: (i) 26 continue to accept reimbursement from the health maintenance organiza- 27 tion at the rates applicable prior to the start of the transitional 28 period, and continue to accept the in-network cost-sharing from the 29 enrollee, if any, as payment in full; (ii) adhere to the organization's 30 quality assurance requirements and to provide to the organization neces- 31 sary medical information related to such care; and (iii) otherwise 32 adhere to the organization's policies and procedures, including but not 33 limited to procedures regarding referrals and obtaining pre-authoriza- 34 tion and a treatment plan approved by the organization. 35 (f) If a new enrollee whose health care provider is not a member of 36 the health maintenance organization's provider network enrolls in the 37 health maintenance organization, the organization shall permit the 38 enrollee to continue [an ongoing course of treatment with] to receive 39 health care procedures, treatments, and services from the enrollee's 40 current health care provider during a transitional period of up to 41 [sixty days] one year from the effective date of enrollment, or if (i) 42 the enrollee has a [life-threatening disease or condition or a degenera-43tive and disabling disease or condition] terminal illness or condition, 44 until the time of such enrollee's death, or (ii) the enrollee has 45 entered the second trimester of pregnancy at the effective date of 46 enrollment, in which case the transitional period shall include the 47 provision of post-partum care directly related to the delivery. If an 48 enrollee elects to continue to receive care from such health care 49 provider pursuant to this paragraph, such care shall be authorized by 50 the health maintenance organization for the transitional period only if 51 the health care provider agrees (A) to accept reimbursement from the 52 health maintenance organization at rates established by the health main- 53 tenance organization as payment in full, which rates shall be no more 54 than the level of reimbursement applicable to similar providers within 55 the health maintenance organization's network for such services; (B) to 56 adhere to the organization's quality assurance requirements and agreesS. 6576 4 1 to provide to the organization necessary medical information related to 2 such care; and (C) to otherwise adhere to the organization's policies 3 and procedures, including, but not limited to, procedures regarding 4 referrals and obtaining pre-authorization and a treatment plan approved 5 by the organization. In no event shall this paragraph be construed to 6 require a health maintenance organization to provide coverage for bene- 7 fits not otherwise covered or to diminish or impair pre-existing condi- 8 tion limitations contained within the subscriber's contract. 9 § 5. Section 4403 of the public health law is amended by adding two 10 new subdivisions 10 and 11 to read as follows: 11 10. For the purposes of this section, "terminal illness or condition" 12 shall mean an illness or condition which, in the opinion of the physi- 13 cian of the patient suffering from such terminal illness or condition, 14 is likely to cause or be a major contributing factor in causing such 15 patient's death within three years. 16 11. Provider incentives (monetary or otherwise) to a health care 17 provider relating to procedures, treatments, or services provided pursu- 18 ant to this section, which are intended to induce or have the effect of 19 inducing such provider to provide care to an enrollee in a manner incon- 20 sistent with this section, are prohibited. 21 § 6. Subdivision 5 of section 4406-d of the public health law, as 22 added by chapter 705 of the laws of 1996, is amended to read as follows: 23 5. No health care plan shall terminate a contract or employment, or 24 refuse to renew a contract, solely because a health care provider has: 25 (a) advocated on behalf of an enrollee; 26 (b) filed a complaint against the health care plan; 27 (c) appealed a decision of the health care plan; 28 (d) provided information or filed a report pursuant to section forty- 29 four hundred six-c of this article; [or] 30 (e) requested a hearing or review pursuant to this section; or 31 (f) rendered an opinion regarding whether a patient's illness is 32 terminal pursuant to section forty-four hundred three of this article. 33 § 7. This act shall take effect on the one hundred twentieth day after 34 it shall have become a law and shall apply to all contracts issued, 35 renewed, modified or amended on and after such date.
