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. LBD00572-01-9A. 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 [and9other 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 notA. 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 ofA. 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.
