S T A T E O F N E W Y O R K ________________________________________________________________________ 2573 2015-2016 Regular Sessions I N A S S E M B L Y January 20, 2015 ___________ Introduced by M. of A. BRENNAN, SCARBOROUGH, JAFFEE -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law and the public health law, in relation to physical therapy services and utilization practices 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 THAT SUCH TERMS SHALL NOT IMPOSE DIFFERENT DEDUCTIBLES, 14 CO-PAYMENTS OR CO-INSURANCE AMOUNTS ON THE BASIS OF THE SETTING IN WHICH 15 SUCH PHYSICAL THERAPY SERVICES ARE RENDERED OR WHETHER THE SERVICES ARE 16 PERFORMED BY A PHYSICAL THERAPIST OR PHYSICIAN. 17 S 2. Clause (ii) of subparagraph (A) of paragraph 1 of subsection (f) 18 of section 4235 of the insurance law, as amended by chapter 219 of the 19 laws of 2011, is amended to read as follows: 20 (ii) a policy under which coverage terminates at a specified age shall 21 not so terminate with respect to an unmarried child who is incapable of 22 self-sustaining employment by reason of mental illness, developmental 23 disability, mental retardation, as defined in the mental hygiene law, or 24 physical handicap and who became so incapable prior to attainment of the 25 age at which coverage would otherwise terminate and who is chiefly EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD02452-01-5 A. 2573 2 1 dependent upon such employee or member for support and maintenance, 2 while the insurance of the employee or member remains in force and the 3 child remains in such condition, if the insured employee or member has 4 within thirty-one days of such child's attainment of the termination age 5 submitted proof of such child's incapacity as described herein. NO 6 POLICY OF GROUP ACCIDENT, GROUP HEALTH OR GROUP ACCIDENT AND HEALTH 7 INSURANCE SHALL IMPOSE DIFFERENT DEDUCTIBLES, CO-PAYMENTS OR CO-INSU- 8 RANCE AMOUNTS ON THE BASIS OF THE SETTING IN WHICH SUCH PHYSICAL THERAPY 9 SERVICES ARE RENDERED OR WHETHER THE SERVICES ARE PERFORMED BY A PHYS- 10 ICAL THERAPIST OR PHYSICIAN. 11 S 3. Subparagraph (A) of paragraph 4 of subsection (f) of section 4235 12 of the insurance law, as amended by chapter 593 of the laws of 2000, is 13 amended to read as follows: 14 (A) any physical and occupational therapy service which is within the 15 lawful scope of practice of a licensed physical and occupational thera- 16 pist, a subscriber to such policy shall be entitled to reimbursement for 17 such service, whether the said service is performed by a physician or 18 licensed physical and occupational therapist pursuant to prescription or 19 referral by a physician; AND A POLICY OF GROUP ACCIDENT, GROUP HEALTH OR 20 GROUP ACCIDENT AND HEALTH INSURANCE SHALL NOT IMPOSE DIFFERENT DEDUCT- 21 IBLES, CO-PAYMENTS OR CO-INSURANCE AMOUNTS ON THE BASIS OF THE SETTING 22 IN WHICH SUCH PHYSICAL THERAPY SERVICES ARE RENDERED OR WHETHER THE 23 SERVICES ARE PERFORMED BY A PHYSICAL THERAPIST OR PHYSICIAN. 24 S 4. Subparagraph (G) of paragraph 1 of subsection (b) of section 4301 25 of the insurance law, as amended by chapter 593 of the laws of 2000, is 26 amended to read as follows: 27 (G) physical and occupational therapy care provided through licensed 28 physical and occupational therapists upon the prescription of a physi- 29 cian AND ANY CO-PAYMENTS, DEDUCTIBLES, OR CO-INSURANCE AMOUNTS RELATED 30 TO REIMBURSEMENT FOR PHYSICAL THERAPY SERVICES SHALL NOT DIFFER ON THE 31 BASIS OF THE SETTING IN WHICH SUCH PHYSICAL THERAPY SERVICES ARE 32 RENDERED OR WHETHER THE SERVICES ARE PERFORMED BY A PHYSICAL THERAPIST 33 OR PHYSICIAN, 34 S 5. Paragraph 13 of subsection (b) of section 4322 of the insurance 35 law, as added by chapter 504 of the laws of 1995, is amended to read as 36 follows: 37 (13) Outpatient physical therapy up to ninety visits per condition per 38 calendar year AND ANY CO-PAYMENTS, DEDUCTIBLES OR CO-INSURANCE AMOUNTS 39 RELATED TO REIMBURSEMENT OF PHYSICAL THERAPY SERVICES SHALL NOT DIFFER 40 ON THE BASIS OF THE SETTING IN WHICH SUCH PHYSICAL THERAPY SERVICES ARE 41 RENDERED OR WHETHER THE SERVICES ARE PERFORMED BY A PHYSICAL THERAPIST 42 OR PHYSICIAN. 43 S 6. The opening paragraph of subdivision 4 of section 4905 of the 44 public health law, as added by chapter 705 of the laws of 1996, is 45 amended to read as follows: 46 A utilization review agent OR THE HEALTH CARE PLAN FOR WHICH THE AGENT 47 PROVIDES UTILIZATION REVIEW shall not, with respect to utilization 48 review activities, permit or provide compensation or anything of value 49 to its employees, agents, or contractors based on: 50 S 7. The opening paragraph of subsection (d) of section 4905 of the 51 insurance law, as added by chapter 705 of the laws of 1996, is amended 52 to read as follows: 53 A utilization review agent OR THE HEALTH CARE PLAN FOR WHICH THE AGENT 54 PROVIDES UTILIZATION REVIEW shall not, with respect to utilization 55 review activities, permit or provide compensation or anything of value 56 to its employees, agents, or contractors based on: A. 2573 3 1 S 8. Subdivision 5 of section 4406-d of the public health law, as 2 added by chapter 705 of the laws of 1996, is amended to read as follows: 3 5. No health care plan shall terminate, OR THREATEN TO TERMINATE a 4 contract or employment, [or] refuse to renew, OR THREATEN REFUSAL TO 5 RENEW a contract, [solely] because a health care provider has: 6 (a) advocated on behalf of an enrollee; 7 (b) filed a complaint against the health care plan; 8 (c) appealed a decision of the health care plan; 9 (d) provided information or filed a report pursuant to section forty- 10 four hundred six-c of this article; [or] 11 (e) requested a hearing or review pursuant to this section; OR 12 (F) ORDERED OR RENDERED MEDICALLY NECESSARY CARE. 13 S 9. Subsection (e) of section 4803 of the insurance law, as added by 14 chapter 705 of the laws of 1996, is amended to read as follows: 15 (e) No insurer shall terminate [or], THREATEN TO TERMINATE, refuse to 16 renew OR THREATEN REFUSAL TO RENEW a contract for participation in the 17 in-network benefits portion of an insurer's network for a managed care 18 product [solely] because the health care professional has (1) advocated 19 on behalf of an insured; (2) has filed a complaint against the insurer; 20 (3) has appealed a decision of the insurer; (4) provided information or 21 filed a report pursuant to section forty-four hundred six-c of the 22 public health law; [or] (5) requested a hearing or review pursuant to 23 this section; OR (6) ORDERED OR RENDERED MEDICALLY NECESSARY CARE. 24 S 10. Paragraph (d) of subdivision 1 of section 4902 of the public 25 health law, as added by chapter 705 of the laws of 1996, is amended to 26 read as follows: 27 (d) Establishment of a process for rendering utilization review deter- 28 minations which shall, at a minimum, include: written procedures to 29 assure that utilization reviews and determinations are conducted within 30 the timeframes established herein; procedures to notify an enrollee, an 31 enrollee's designee [and/or] AND an enrollee's health care provider of 32 adverse determinations; and procedures for appeal of adverse determi- 33 nations including the establishment of an expedited appeals process for 34 denials of continued inpatient care or where there is imminent or seri- 35 ous threat to the health of the enrollee; 36 S 11. Paragraph 4 of subsection (a) of section 4902 of the insurance 37 law, as added by chapter 705 of the laws of 1996, is amended to read as 38 follows: 39 (4) Establishment of a process for rendering utilization review deter- 40 minations which shall, at a minimum, include: written procedures to 41 assure that utilization reviews and determinations are conducted within 42 the timeframes established herein; procedures to notify an insured, an 43 insured's designee [and/or] AND an insured's health care provider of 44 adverse determinations; and procedures for appeal of adverse determi- 45 nations including the establishment of an expedited appeals process for 46 denials of continued inpatient care or where there is imminent or seri- 47 ous threat to the health of the insured; 48 S 12. Paragraph (a) of subdivision 2 of section 4901 of the public 49 health law, as added by chapter 705 of the laws of 1996, is amended to 50 read as follows: 51 (a) The utilization review plan, INCLUDING BUT NOT LIMITED TO THE 52 CLINICAL REVIEW CRITERIA AND STANDARDS AND THE DEFINITION/STANDARDS OF 53 MEDICAL NECESSITY USED UNDER THE UTILIZATION REVIEW PLAN. A UTILIZATION 54 REVIEW AGENT SHALL REPORT ANY AMENDMENT OR CHANGES TO THE UTILIZATION 55 REVIEW PLAN TO THE COMMISSIONER WITHIN THIRTY DAYS OF MAKING SUCH AMEND- 56 MENT OR CHANGE; A. 2573 4 1 S 13. Paragraph 1 of subsection (b) of section 4901 of the insurance 2 law, as added by chapter 705 of the laws of 1996, is amended to read as 3 follows: 4 (1) The utilization review plan, INCLUDING BUT NOT LIMITED TO THE 5 CLINICAL REVIEW CRITERIA AND STANDARDS AND THE DEFINITION/STANDARDS OF 6 MEDICAL NECESSITY USED UNDER THE UTILIZATION REVIEW PLAN. A UTILIZATION 7 REVIEW AGENT SHALL REPORT ANY AMENDMENT OR CHANGES TO THE UTILIZATION 8 REVIEW PLAN TO THE SUPERINTENDENT WITHIN THIRTY DAYS OF MAKING SUCH 9 AMENDMENT OR CHANGE; 10 S 14. Section 4406-d of the public health law is amended by adding a 11 new subdivision 1-a to read as follows: 12 1-A. UPON WRITTEN REQUEST BY A PARTICIPATING HEALTH CARE PROFESSIONAL, 13 A HEALTH CARE PLAN SHALL PROVIDE SPECIFIC WRITTEN CLINICAL REVIEW CRITE- 14 RIA RELATING TO A PARTICULAR CONDITION, DISEASE, SERVICE OR PROCEDURE 15 AND, WHERE APPROPRIATE, OTHER CLINICAL INFORMATION WHICH THE HEALTH CARE 16 PLAN OR ITS UTILIZATION REVIEW AGENT MIGHT CONSIDER IN ITS UTILIZATION 17 REVIEW AND THE HEALTH CARE PLAN SHALL INCLUDE WITH THE INFORMATION A 18 DESCRIPTION OF HOW IT WILL BE USED IN THE UTILIZATION REVIEW PROCESS; 19 PROVIDED, HOWEVER, THAT TO THE EXTENT SUCH INFORMATION IS PROPRIETARY TO 20 THE HEALTH CARE PLAN, THE PARTICIPATING HEALTH CARE PROVIDER OR PROSPEC- 21 TIVE HEALTH CARE PROVIDER SHALL ONLY USE THE INFORMATION FOR THE 22 PURPOSES OF ASSISTING THE PARTICIPATING HEALTH CARE PROVIDER IN EVALUAT- 23 ING COVERED SERVICES PROVIDED BY THE ORGANIZATION, AN ADVERSE DETERMI- 24 NATION OR AN APPEAL OF ADVERSE DETERMINATION. 25 S 15. Section 4803 of the insurance law is amended by adding a new 26 subsection (a-1) to read as follows: 27 (A-1) UPON WRITTEN REQUEST BY A PARTICIPATING HEALTH CARE PROFES- 28 SIONAL, A HEALTH CARE PLAN SHALL PROVIDE SPECIFIC WRITTEN CLINICAL 29 REVIEW CRITERIA RELATING TO A PARTICULAR CONDITION, DISEASE, SERVICE OR 30 PROCEDURE AND, WHERE APPROPRIATE, OTHER CLINICAL INFORMATION WHICH THE 31 HEALTH CARE PLAN OR ITS UTILIZATION REVIEW AGENT MIGHT CONSIDER IN ITS 32 UTILIZATION REVIEW AND THE HEALTH CARE PLAN SHALL INCLUDE WITH THE 33 INFORMATION A DESCRIPTION OF HOW IT WILL BE USED IN THE UTILIZATION 34 REVIEW PROCESS; PROVIDED, HOWEVER, THAT TO THE EXTENT SUCH INFORMATION 35 IS PROPRIETARY TO THE HEALTH CARE PLAN, THE PARTICIPATING HEALTH CARE 36 PROVIDER OR PROSPECTIVE HEALTH CARE PROVIDER SHALL ONLY USE THE INFORMA- 37 TION FOR THE PURPOSES OF ASSISTING THE PARTICIPATING HEALTH CARE PROVID- 38 ER IN EVALUATING COVERED SERVICES PROVIDED BY THE ORGANIZATION, AN 39 ADVERSE DETERMINATION OR AN APPEAL OF ADVERSE DETERMINATION. 40 S 16. Section 4406-c of the public health law is amended by adding a 41 new subdivision 5-e to read as follows: 42 5-E. NO HEALTH CARE PLAN SHALL BY CONTRACT, WRITTEN POLICY OR WRITTEN 43 PROCEDURE REFUSE TO HONOR, PROHIBIT OR IN ANY WAY RESTRICT THE ABILITY 44 OF AN ENROLLEE TO ASSIGN HIS OR HER BENEFITS ALLOWABLE OR OTHERWISE 45 PAYABLE TO THE ENROLLEE AS PAYMENT FOR PROFESSIONAL SERVICES RENDERED. 46 S 17. The insurance law is amended by adding a new section 4803-a to 47 read as follows: 48 S 4803-A. PROHIBITIONS. 1. NO MANAGED CARE HEALTH INSURANCE CONTRACT 49 OR MANAGED CARE PRODUCT SHALL BY CONTRACT, WRITTEN POLICY OR WRITTEN 50 PROCEDURE REFUSE TO HONOR, PROHIBIT OR IN ANY WAY RESTRICT THE ABILITY 51 OF AN ENROLLEE TO ASSIGN HIS OR HER BENEFITS ALLOWABLE OR OTHERWISE 52 PAYABLE TO THE ENROLLEE AS PAYMENT FOR PROFESSIONAL SERVICES RENDERED. 53 2. ANY CONTRACT PROVISION, WRITTEN POLICY OR WRITTEN PROCEDURE IN 54 VIOLATION OF THIS SECTION SHALL BE DEEMED TO BE VOID AND UNENFORCEABLE. 55 S 18. Section 4905 of the public health law is amended by adding a new 56 subdivision 16 to read as follows: A. 2573 5 1 16. A HEALTH CARE PLAN SHALL PROVIDE NOTICE TO PARTICIPATING PROVIDERS 2 SIXTY DAYS IN ADVANCE OF A CHANGE IN UTILIZATION REVIEW AGENTS. 3 S 19. Section 4905 of the insurance law is amended by adding a new 4 subsection (p) to read as follows: 5 (P) A HEALTH CARE PLAN SHALL PROVIDE NOTICE TO PARTICIPATING PROVIDERS 6 SIXTY DAYS IN ADVANCE OF A CHANGE IN UTILIZATION REVIEW AGENTS. 7 S 20. This act shall take effect on the one hundred eightieth day 8 after it shall have become a law.