Amd SS4803 & 4804, Ins L; amd SS4403 & 4406-d, Pub Health L
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.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A366B
SPONSOR: Dinowitz (MS) TITLE OF BILL: An act to amend the insurance law and the public
health law, in relation to access to health care providers in managed
care plans
PURPOSE OR GENERAL IDEA OF BILL: To provide patients who are enroll-
ing in a managed care plan the opportunity to have access to their
current health care provider and, similarly, to allow patients whose
health care providers are excluded from a managed care plan's panel of
providers to continue to see that health care professional for a limited
period of time.
SUMMARY OF SPECIFIC PROVISIONS:
Section 1 amends subsection (c) of section 1803 of the insurance law to
provide that an insurer may not terminate a contract for participation
in the in-network benefits portion of an insurer's managed care network,
or refuse to renew such contract, solely because a health care provider
has issued an opinion relating to whether or not a patient is terminally
ill.
Section 2 amends subsection (e) of section 4804 of the insurance law to
provide that if a health care provider in an insurer's in-network bene-
fits portion of a managed care product either leaves the network or is
excluded from the HMO's panel of providers, after having been affiliated
with such managed care product, that provider's patients !nay continue
to receive health care services from him or her for a period of up to
one year, or, in the case of terminally, ill patients, until such time
of the patient's death.
Section 2 also amends subsection (f) of section 4804 of the Insurance
Law to provide new insured's in an insurer's in-network benefits portion
of a provider network the option to continue to receive health care
services from his or her current health care provider for a period of up
to one year, or, if the insured has entered the second trimester of
pregnancy until the patient has received post-partum care directly
related to the delivery, or, in the case of terminally ill patients,
until such time of the patient's death. In both instances, this access
to continuity of care will not be available if the health care provider
has been dis-enrolled from the managed care plan for reason involving.;
imminent harm to a patient, fraud or disciplinary action by a state
licensing board. Moreover, the access to continuity of care will only
take effect upon the attending health care provider's agreement to
accept the reimbursement rate established by the HMO, adhere to the
plan's quality assurance requirements and adhere to the organization's
other policies and procedures.
Section 3 amends section 4804 of the insurance Law by adding new subdi-
visions (g) and (h) to define the term "terminal illness or condition"
and, in keeping with the provisions the Legislature enacted with the
mastectomy treatment legislation, to prohibit offensive financial
arrangements.
Section 4 amends paragraph (e) of subdivision 6 of section 4903 of the
Public Health law to provide that if a health care provider in a health
maintenance organization network either leaves the network or is
excluded from the HMO's panel of providers, after having been affiliated
with such HMO, that provider's patients may continue to receive health
care services from him or her for a period of up to one year, or, if the
insured has entered the second trimester of pregnancy until the patient
has received post-partum care directly related to the delivery, or, in
the case of terminally ill patients, until such time of the patient's
death.
Section 5 also amends paragraph (f) of subdivision 6 of section 4-403 of
the Public Health Law to provide new enrollees in an HMO the option to
continue to receive health care services from his or her current health-
care provider for a period of up to one year, or, if the insured has
entered the second trimester of pregnancy until the patient has received
post-partum care directly related to the delivery, or, in the ease of
terminally ill patients, until such time of the patient's death.
In both paragraphs, this access to continuity of care will not be avail-
able if the health care provider has been disenrolled from the managed
care plan for a reason involving imminent harm to a patient, fraud or
disciplinary action by a state licensing board. Additionally, the
access to continuity of care will only take effect upon the attending
health care provider's agreement to accept the reimbursement rate estab-
lished by the HMO, adhere to the plan's quality assurance requirements
and adhere to the organization's other policies and procedures.
Section 5 amends section 4403 of the Public Health Law by adding new
subdivisions 7 and 8 to define the term "terminal illness or condition"
and, in keeping with the provisions the Legislature enacted with the
mastectomy treatment legislation, to prohibit offensive financial
arrangements.
Section 6 amends subdivision 5 of section 4406-d of the Public Health
Law to provide that a health care plan may not terminate a contract for
employment, or refuse to renew such contract, solely because a health
care provider has issued an opinion relating to whether or not a patient
is terminally ill.
Section 7 sets the effective date
JUSTIFICATION: This bill proposed to build upon the historic changes
made on behalf of health care consumers in the 1995 Managed Care Reform
Act.
Included among the numerous provisions of that Act was a provision that
patients undergoing a course of treatment could continue that treatment
with their health care provider for 90 days, if the provider became
disaffiliated with the HMO provider panel or for 60 days if the person
enrolled in an HMO which did not have a provider on its panel. In addi-
tion, the Act provided for continuity of care for pregnant women who had
entered their second trimester of pregnancy, through the provision of
post-partum care.
This bill would expand those provisions in ways which meaningfully add
to the continuity of a patient's care. It would do so by allowing a
patient to continue an established relationship with his or her health-
care provider for up to one year following a change which would other-
wise deny access to the provider, In the case of terminally ill
patients, this proposal would allow such patient's to continue to
receive care from their current provider until the time of their death.
In virtually every situation where a patient has an established, ongoing
relationship with his or her health care provider (which would likely
cause such patient to exercise the option provided by this bill) the
provision of health care services is both enhanced and streamlined with
the provider's familiarity with the patient. A deep understanding of a
patient's history, previous treatments and attitude are important
factors which assist a health care provider in making clinical decisions
which are likely to be of benefit to the patient.
In the case of terminally ill patients; this proposal would allow such
people to have the comfort of being ministered to by a familiar provid-
er, which may help to ease the trauma and increase the comfort of the
terminal patient.
Importantly, this bill would not add to the expense of health insurance
either purchased by the individual or by employer) because it does not
mandate coverage where none exists.
In addition, this measure would not add to the cost of the HMO or other
managed care entity providing care. In every instance addressed in this
bill, the insurer is receiving payment for the health care of the
insured in question. The only issue addressed is who will provide treat-
ment to the patient. Inasmuch as this bill would not change current law
which mandates the provider to continue to accept the reimbursement set
by the insurer (which cannot be more than the reimbursement paid to
in-plan providers) there is no added expense to the insurer, with the
minor exception of some additional administrative work.
This bill further protects both the patient and the HMO by making the
continuity of care an option to be exercised by the patient (not a
mandatory benefit) and providing that this option would not apply to
providers who have been disenrolled for reasons related to incompetence,
criminal action or professional misconduct,
Finally, this bill increases the applicability of provisions prohibiting
offensive financial arrangements enacted in early 1997 so that incen-
tives to induce providers to act in a manner contrary to these statutes
would be prohibited.
PRIOR LEGISLATIVE HISTORY: 2011-12- A.1808- Passed Assembly 2009-10-
A.633- Passed Assembly/S.5049- Referred to Insurance 2005-06- A.1240-
Passed Assembly/S.2759- Referred to Insurance 2003-04- A.1 161- Passed
Assembly 2001-02- A.5830- Passed Assembly/S4845- Referred to. Insurance
FISCAL IMPLICATIONS: None to the State.
EFFECTIVE THIS ACT SHALL LAKE EFFECT 120 CLAYS AFTER IT BECOMES LAW.
STATE OF NEW YORK
________________________________________________________________________
366--B
2013-2014 Regular Sessions
IN ASSEMBLY(Prefiled)
January 9, 2013
___________
Introduced by M. of A. DINOWITZ, GALEF, HOOPER, GOTTFRIED -- Multi-Spon-
sored by -- M. of A. BOYLAND, BRENNAN, COLTON, JACOBS, LIFTON, SWEE-
NEY -- read once and referred to the Committee on Health -- committee
discharged, bill amended, ordered reprinted as amended and recommitted
to said committee -- again reported from said committee with amend-
ments, ordered reprinted as amended and recommitted to said committee
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, as
14 added by chapter 705 of the laws of 1996, are amended to read as
15 follows:
16 (e) (1) If an insured's health care provider leaves the insurer's
17 in-network benefits portion of its network of providers for a managed
18 care product for reasons other than those for which the provider would
19 not be eligible to receive a hearing pursuant to paragraph one of
20 subsection (b) of section [forty-eight] four thousand eight hundred
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD01167-04-3
A. 366--B 2
1 three of this [chapter] article, the insurer shall permit the insured to
2 continue [an ongoing course of treatment with] to receive health care
3 procedures, treatments, and services from the insured's current health
4 care provider during a transitional period of (i) up to [ninety days]
5 one year from the date of notice to the insured of the provider's disaf-
6 filiation from the insurer's network[;] or (ii) if the insured has
7 entered the second trimester of pregnancy at the time of the provider's
8 disaffiliation, for a transitional period that includes the provision of
9 post-partum care directly related to the delivery; or a terminal illness
10 or condition, until the time of such insured's death.
11 (2) Notwithstanding the provisions of paragraph one of this
12 subsection, such care shall be authorized by the insurer during the
13 transitional period only if the health care provider agrees (i) to
14 continue to accept reimbursement from the insurer at the rates applica-
15 ble prior to the start of the transitional period as payment in full;
16 (ii) to adhere to the insurer's quality assurance requirements and to
17 provide to the insurer necessary medical information related to such
18 care; and (iii) to otherwise adhere to the insurer's policies and proce-
19 dures, including, but not limited to, procedures regarding referrals and
20 obtaining pre-authorization and a treatment plan approved by the insur-
21 er.
22 (f) If a new insured whose health care provider is not a member of the
23 insurer's in-network benefits portion of the provider network enrolls in
24 the managed care product, the insurer shall permit the insured to
25 continue [an ongoing course of treatment with] to receive health care
26 procedures, treatments, and services from the insured's current health
27 care provider during a transitional period of up to [sixty days] one
28 year from the effective date of enrollment or, if (1) the insured has a
29 [life-threatening disease or condition or a degenerative and disabling
30 disease or condition] terminal illness or condition, until the time of
31 such insured's death, or (2) the insured has entered the second trimes-
32 ter of pregnancy at the time of enrollment, in which case the transi-
33 tional period shall include the provision of post-partum care directly
34 related to the delivery. If an insured elects to continue to receive
35 care from such health care provider pursuant to this [paragraph]
36 subsection, such care shall be authorized by the insurer for the transi-
37 tional period only if the health care provider agrees (A) to accept
38 reimbursement from the insurer at rates established by the insurer as
39 payment in full, which rates shall be no more than the level of
40 reimbursement applicable to similar providers within the in-network
41 benefits portion of the insurer's network for such services; (B) to
42 adhere to the insurer's quality assurance requirements and agrees to
43 provide to the insurer necessary medical information related to such
44 care; and (C) to otherwise adhere to the insurer's policies and proce-
45 dures, including, but not limited to, procedures regarding referrals and
46 obtaining pre-authorization and a treatment plan approved by the insur-
47 er. In no event shall this subsection be construed to require an insur-
48 er to provide coverage for benefits not otherwise covered or to diminish
49 or impair pre-existing condition limitations contained within the
50 insured's contract.
51 § 3. Section 4804 of the insurance law is amended by adding two new
52 subsections (g) and (h) to read as follows:
53 (g) For the purposes of this section, the term "terminal illness or
54 condition" shall mean an illness or condition which, in the opinion of
55 the physician of the patient suffering from such terminal illness or
A. 366--B 3
1 condition, is likely to cause or be a major contributing factor in caus-
2 ing such patient's death within three years.
3 (h) Provider incentives (monetary or otherwise) to a health care
4 provider relating to procedures, treatments, or services pursuant to
5 this section, which are intended to have the effect of inducing such
6 provider to provide care to an insured in a manner inconsistent with
7 this section, are prohibited.
8 § 4. Paragraphs (e) and (f) of subdivision 6 of section 4403 of the
9 public health law, as added by chapter 705 of the laws of 1996, are
10 amended to read as follows:
11 (e) (1) If an enrollee's health care provider leaves the health main-
12 tenance organization's network of providers for reasons other than those
13 for which the provider would not be eligible to receive a hearing pursu-
14 ant to paragraph [a] (a) of subdivision two of section forty-four
15 hundred six-d of this [chapter] article, the health maintenance organ-
16 ization shall permit the enrollee to continue [an ongoing course of
17 treatment with] to receive health care procedures, treatments, and
18 services from the enrollee's current health care provider during a tran-
19 sitional period of (i) up to [ninety days] one year from the date of
20 notice to the enrollee of the provider's disaffiliation from the organ-
21 ization's network[;] or (ii) if the enrollee has entered the second
22 trimester of pregnancy at the time of the provider's disaffiliation, for
23 a transitional period that includes the provision of post-partum care
24 directly related to the delivery, or (iii) if the enrollee has a termi-
25 nal illness or condition, until the time of such enrollee's death.
26 (2) Notwithstanding the provisions of subparagraph one of this para-
27 graph, such care shall be authorized by the health maintenance organiza-
28 tion during the transitional period only if the health care provider
29 agrees (i) to continue to accept reimbursement from the health mainte-
30 nance organization at the rates applicable prior to the start of the
31 transitional period as payment in full; (ii) to adhere to the organiza-
32 tion's quality assurance requirements and to provide to the organization
33 necessary medical information related to such care; and (iii) to other-
34 wise adhere to the organization's policies and procedures, including,
35 but not limited to, procedures regarding referrals and obtaining pre-au-
36 thorization and a treatment plan approved by the organization.
37 (f) If a new enrollee whose health care provider is not a member of
38 the health maintenance organization's provider network enrolls in the
39 health maintenance organization, the organization shall permit the
40 enrollee to continue [an ongoing course of treatment with] to receive
41 health care procedures, treatments, and services from the enrollee's
42 current health care provider during a transitional period of up to
43 [sixty days] one year from the effective date of enrollment, or if (i)
44 the enrollee has a [life-threatening disease or condition or a degenera-
45 tive and disabling disease or condition] terminal illness or condition,
46 until the time of such enrollee's death, or (ii) the enrollee has
47 entered the second trimester of pregnancy at the effective date of
48 enrollment, in which case the transitional period shall include the
49 provision of post-partum care directly related to the delivery. If an
50 enrollee elects to continue to receive care from such health care
51 provider pursuant to this paragraph, such care shall be authorized by
52 the health maintenance organization for the transitional period only if
53 the health care provider agrees (A) to accept reimbursement from the
54 health maintenance organization at rates established by the health main-
55 tenance organization as payment in full, which rates shall be no more
56 than the level of reimbursement applicable to similar providers within
A. 366--B 4
1 the health maintenance organization's network for such services; (B) to
2 adhere to the organization's quality assurance requirements and agrees
3 to provide to the organization necessary medical information related to
4 such care; and (C) to otherwise adhere to the organization's policies
5 and procedures, including, but not limited to, procedures regarding
6 referrals and obtaining pre-authorization and a treatment plan approved
7 by the organization. In no event shall this paragraph be construed to
8 require a health maintenance organization to provide coverage for bene-
9 fits not otherwise covered or to diminish or impair pre-existing condi-
10 tion limitations contained within the subscriber's contract.
11 § 5. Section 4403 of the public health law is amended by adding two
12 new subdivisions 9 and 10 to read as follows:
13 9. For the purposes of this section, "terminal illness or condition"
14 shall mean an illness or condition which, in the opinion of the physi-
15 cian of the patient suffering from such terminal illness or condition,
16 is likely to cause or be a major contributing factor in causing such
17 patient's death within three years.
18 10. Provider incentives (monetary or otherwise) to a health care
19 provider relating to procedures, treatments, or services provided pursu-
20 ant to this section, which are intended to induce or have the effect of
21 inducing such provider to provide care to an enrollee in a manner incon-
22 sistent with this section, are prohibited.
23 § 6. Subdivision 5 of section 4406-d of the public health law, as
24 added by chapter 705 of the laws of 1996, is amended to read as follows:
25 5. No health care plan shall terminate a contract or employment, or
26 refuse to renew a contract, solely because a health care provider has:
27 (a) advocated on behalf of an enrollee;
28 (b) filed a complaint against the health care plan;
29 (c) appealed a decision of the health care plan;
30 (d) provided information or filed a report pursuant to section forty-
31 four hundred six-c of this article; [or]
32 (e) requested a hearing or review pursuant to this section; or
33 (f) rendered an opinion regarding whether a patient's illness is
34 terminal pursuant to section forty-four hundred three of this article.
35 § 7. This act shall take effect on the one hundred twentieth day after
36 it shall have become a law and shall apply to all contracts issued,
37 renewed, modified or amended on and after such date.
