Includes certain out of home services such as transition from a hospital, nursing facility or other institutional setting to the home within home care insurance coverage.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A7953
SPONSOR: Simon TITLE OF BILL:
An act to amend the insurance law, in relation to including certain out
of home services such as transition from a hospital, nursing facility or
other institutional setting to the home within home care insurance
coverage
PURPOSE:
To update and align the Insurance Law specifications for home care
coverage with the current system of hospital and medical practice
SUMMARY OF PROVISIONS:
The current State Insurance Law provisions for home care specify cover-
age for these services when under the care of a physician, established
and approved in writing by the physician, and provided by state
certified/licensed home care agencies. The bill maintains these baseline
standards for coverage while updating the 40+ year-old specifications
for: a covered individual's receipt of services, the listed services
that certified/licensed agencies actually provide, and the cost and
utilization control mechanisms now used by insurers.
Specifically, sections one and two, respectively, amend § 3221 and §
4303 of the insurance law to update the following in each section:
*Consistent with current hospital and medical care practice, the bill
modernizes the specifications for the covered individual to be for an
individual who requires services for: (i)transition from a hospital,
nursing facility or other institutional setting to home;(ii) rehabili-
tation, recovery or medical management at home following hospitalization
or institutional care; or (iii) medical management of a condition
predisposing the covered individual to hospitalization or confinement in
a nursing facility or to the need for other out-of-home services other-
wise covered under the contract or policy if home care is not provided.
*Updates the reference to a home care agency's authorized list of
services (now specified in § 3221 and § 4303 as nursing, home health
aide, physical therapy, occupational therapy or speech therapy) to
reflect other services the agency actually provides which include social
work, respiratory therapy and nutritional counseling, which are likewise
proven vital to cost-effective and necessary care in the modern delivery
system.
*Replaces outdated mechanisms for utilization and cost controls (e.g.,
replaces the existing law's 40 visit minimum) with contemporary and more
dynamic controls used in insurance and managed care, such as management
or utilization review of home care benefits, or use of preauthorization
and appropriateness criteria as to the level and intensity of treatment
applicable to home care.
Section three provides the effective date.
JUSTIFICATION:
This bill provides long overdue updates to antiquated sections of the
State Insurance Law that stipulate the coverage for home care services.
The current home care coverage provisions, adopted in the early 1970s,
were written and set forth for the health care system as it existed at
that time.
In that era:
*Hospitals were reimbursed per diem and without today's limitations on
length of stay; many of today's complex procedures did not exist, nor
did cases of such brief, even same-day, turnarounds; patients being
discharged were nowhere near today's level of continuing, intense and
complex medical need.
*Nursing homes were the primary health system option for chronically
ill, unlike today where home care plays a dominant role. *Transition of
patients from hospitals to home, or from nursing homes (particularly
rehab patients) to home, was not the major, complex hurdle that it is
today, nor the level of priority-medical focus that today is addressed
substantially through home care-hospital-physician partnership.
*Today's technologies for delivery of services and comprehensive medical
management between physicians and home care agencies (such as
telehealth/telemedicine) did not exist.
*Home care itself was not the integrated and heavily relied-upon model
evidenced in today's system.
The type of system that framed the now 40+ year-old insurance law
provisions bears little resemblance to the health care system of today.
This bill's modernization of the law would delineate the conditions of
home care coverage consistent with today's state of the art health and
medical care practices. It would support the operation of the entire
health care system, synchronize coverage to the newest models and inno-
vations of care, promote cost-savings and efficiency, and most impor-
tantly benefit covered individuals. It would also preserve and enhance
the original statue's intent of utilizing home care to prevent avoidable
hospitalizations, emergency room use and other higher cost medical
services use.
LEGISLATIVE HISTORY:
2021-2022: A380 -referred to insurance
2019-2020: A.408 - Referred to Insurance
2017-2018: A.54 - Referred to Insurance
2015-2016: A.7706A - Referred to Insurance
FISCAL IMPLICATIONS:
This bill will promote increased cost-efficiency and savings in the
health care system.
EFFECTIVE DATE:
The bill would take effect on the first of January next succeeding the
date on which it shall have become a law and shall apply to all policies
and contracts issued, renewed, modified, altered or amended on or after
such date.
STATE OF NEW YORK
________________________________________________________________________
7953
2023-2024 Regular Sessions
IN ASSEMBLY
August 18, 2023
___________
Introduced by M. of A. SIMON -- read once and referred to the Committee
on Insurance
AN ACT to amend the insurance law, in relation to including certain out
of home services such as transition from a hospital, nursing facility
or other institutional setting to the home within home care insurance
coverage
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subparagraphs (C), (D) and (E) of paragraph 1 of subsection
2 (k) of section 3221 of the insurance law, subparagraphs (C) and (D) as
3 amended by chapter 557 of the laws of 2000, are amended to read as
4 follows:
5 (C) Home care means the care and treatment of a covered person who is
6 under the care of a physician [but only if] and who requires the
7 services of an agency described in subparagraph (D) of this paragraph
8 for: transition of the covered person from hospital, nursing facility or
9 other institutional setting to home; rehabilitation, recovery or medical
10 management of the covered person at home following hospitalization or
11 following care in a nursing facility or other institutional setting; or
12 medical management of a condition predisposing the covered individual to
13 hospitalization [or], confinement in a nursing facility [as defined in
14 subchapter XVIII of the federal Social Security Act, 42 U.S.C. §§ 1395
15 et seq, would otherwise have been required] or the need for other out-
16 of-home services otherwise covered under the contract if home care [was]
17 is not provided, and the plan covering the home health service is estab-
18 lished and approved in writing by such physician.
19 (D) Home care shall be provided by an agency possessing a valid
20 certificate of approval or license issued pursuant to article thirty-six
21 of the public health law and shall consist of one or more of the follow-
22 ing:
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD09346-01-3
A. 7953 2
1 (i) Part-time or intermittent home nursing care by or under the super-
2 vision of a registered professional nurse (R.N.).
3 (ii) Part-time or intermittent home health aide services which consist
4 primarily of caring for the patient.
5 (iii) Physical, occupational or speech therapy, social work, respir-
6 atory therapy and nutritional counseling, if provided by the home health
7 service or agency.
8 (iv) Medical supplies, drugs and medications prescribed by a physi-
9 cian, and laboratory services by or on behalf of a certified home health
10 agency or licensed home care services agency to the extent such items
11 would have been covered under the contract if the covered person had
12 been hospitalized or confined in a skilled nursing facility as defined
13 in subchapter XVIII of the federal Social Security Act, 42 U.S.C. §§
14 1395 et seq.
15 (E) For the purpose of determining the benefits for home care avail-
16 able to a covered person, [each visit by a member of a home care team
17 shall be considered as one home care visit; the contract may contain a
18 limitation on the number of home care visits, but not less than forty
19 such visits in any calendar year or in any continuous period of twelve
20 months, for each person covered under the contract; four hours of home
21 health aide service shall be considered as one home care visit] nothing
22 in this paragraph shall be construed to prevent the management or utili-
23 zation review of home care benefits, including the use of preauthori-
24 zation and appropriateness criteria as to the level and intensity of
25 treatment applicable to home care, provided however that any such deter-
26 minations may be subject to appeal under article forty-nine of this
27 chapter.
28 § 2. Paragraph 3 of subsection (a) of section 4303 of the insurance
29 law, subparagraphs (A), (B) and (C) as amended by chapter 557 of the
30 laws of 2000 and subparagraph (D) as amended by chapter 21 of the laws
31 of 1990, is amended to read as follows:
32 (3) For home care to residents in this state. Such home care coverage
33 shall be included at the inception of all new contracts and, with
34 respect to all other contracts, added at any anniversary date of the
35 contract subject to evidence of insurability. Such coverage may be
36 subject to an annual deductible of not more than fifty dollars for each
37 covered person and may be subject to a coinsurance provision which
38 provides for coverage of not less than seventy-five percent of the
39 reasonable cost of services for which payment may be made. No such
40 corporation need provide such coverage to persons eligible for medicare.
41 (A) Home care shall mean the care and treatment of a covered person
42 who is under the care of a physician [but only if:
43 (i)] and who requires the services of an agency described in subpara-
44 graph (B) of this paragraph for: transition of the covered person from
45 hospital, nursing facility or other institutional setting to home; for
46 rehabilitation, recovery or medical management of the covered person at
47 home following hospitalization or following care in a nursing facility
48 or other institutional setting; or medical management of a condition
49 predisposing the covered individual to hospitalization [or], confinement
50 in a nursing facility [as defined in subchapter XVIII of the Social
51 Security Act, 42 U.S.C. § 1395 et seq, would otherwise have been
52 required] or the need for other out-of-home services otherwise covered
53 under the policy, if home care [was] is not provided, and
54 [(ii)] the plan covering the home health service is established and
55 approved in writing by such physician.
A. 7953 3
1 (B) Home care shall be provided by an agency possessing a valid
2 certificate of approval or license issued pursuant to article thirty-six
3 of the public health law.
4 (C) Home care shall consist of one or more of the following:
5 (i) part-time or intermittent home nursing care by or under the super-
6 vision of a registered professional nurse (R.N.),
7 (ii) part-time or intermittent home health aide services which consist
8 primarily of caring for the patient,
9 (iii) physical, occupational or speech therapy, social work, respir-
10 atory therapy and nutritional counseling, if provided by the home health
11 service or agency, and
12 (iv) medical supplies, drugs and medications prescribed by a physi-
13 cian, and laboratory services by or on behalf of a certified home health
14 agency or licensed home care services agency to the extent such items
15 would have been covered or provided under the contract if the covered
16 person had been hospitalized or confined in a skilled nursing facility
17 as defined in subchapter XVIII of the Social Security Act, 42 U.S.C. §
18 1395 et seq.
19 (D) For the purpose of determining the benefits for home care avail-
20 able to a covered person, [each visit by a member of a home care team
21 shall be considered as one home care visit. The contract may contain a
22 limitation on the number of home care visits, but not less than forty
23 such visits in any calendar year or in any continuous period of twelve
24 months, for each covered person. Four hours of home health aide service
25 shall be considered as one home care visit. Every contract issued by a
26 hospital service corporation or health service corporation which
27 provides coverage supplementing part A and part B of subchapter XVIII of
28 the Social Security Act, 42 U.S.C. § 1395 et seq, must make available
29 and, if requested by a subscriber holding a direct payment contract or
30 by all subscribers in a group remittance group or by the contract holder
31 in the case of group contracts issued pursuant to section four thousand
32 three hundred five of this article, provide coverage of supplemental
33 home care visits beyond those provided by part A and part B, sufficient
34 to produce an aggregate coverage of three hundred sixty-five home care
35 visits per contract year. Such coverage shall be provided pursuant to
36 regulations prescribed by the superintendent. Written notice of the
37 availability of such coverage shall be delivered to the group remitting
38 agent or group contract holder prior to inception of such contract and
39 annually thereafter, except that this notice shall not be required where
40 a policy covers two hundred or more employees or where the benefit
41 structure was the subject of collective bargaining affecting persons who
42 are employed in more than one state] nothing in this paragraph shall be
43 construed to prevent the management or utilization review of home care
44 benefits, including the use of preauthorization and appropriateness
45 criteria as to the level and intensity of treatment applicable to home
46 care, provided however that any such determinations may be subject to
47 appeal under article forty-nine of this chapter.
48 § 3. This act shall take effect on the first of January next succeed-
49 ing the date on which it shall have become a law and shall apply to all
50 policies and contracts issued, renewed, modified, altered or amended on
51 or after such date.
