A01212 Summary:

BILL NOA01212
 
SAME ASSAME AS S04751
 
SPONSORLavine
 
COSPNSRAbinanti, Colton, Schimel, Titone, Zebrowski, Seawright
 
MLTSPNSRRa
 
Amd S4406-d, Pub Health L; amd S4803, Ins L
 
Relates to health care professional applications and terminations.
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A01212 Actions:

BILL NOA01212
 
01/08/2015referred to health
02/03/2015reported referred to codes
02/09/2015reported
02/19/2015advanced to third reading cal.27
03/11/2015passed assembly
03/11/2015delivered to senate
03/11/2015REFERRED TO HEALTH
01/06/2016DIED IN SENATE
01/06/2016RETURNED TO ASSEMBLY
01/06/2016ordered to third reading cal.57
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A01212 Memo:

NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A1212
 
SPONSOR: Lavine
  TITLE OF BILL: An act to amend the public health law and the insur- ance law, in relation to health care professional applications and terminations   PURPOSE OF BILL: To provide health care practitioners with due process protections in order to allow and encourage a meaningful continuity of care to health insurance enrollees.   SUMMARY OF PROVISIONS: Section one amends section 4406-d of the Public Health Law to clarify the due process protections afforded to a health care professional for' contract terminations. This section also refines the process by which members of a hearing panel are chosen to require that one member is appointed by the insurer, one member is appointed by the subject of the hearing and that the third panelist is chosen by the other two panel members. Section two amends section 4803 of the Insurance Law to clarify that the due process protections afforded to a health care professional for contract terminations. This section also refines the process by which members of a hearing panel are chosen to require that one member is appointed by the insurer, one member is appointed by the subject of the hearing and that the third panelist is chosen by the other two panel members. Section three contains the effective date, which is immediate.   JUSTIFICATION: The relationship between a patient and his or her physician is integral to the effective, efficient provision of quality health care services. The better a physician knows a patient, knows the patient's history, is aware of the patient's level of participation in improving his or her own health and can meld these factors with the scientific practice of medicine, the more likely the patient will receive the best and most efficient health care. As part of New York's Managed Care Bill of Rights, the Legislature recognized the value gained by preserving the patient's relationships with their provider by establishing meaningful due process protections for all providers by prohibiting plans from terminating a provider with- out out notice and without an opportunity to be heard by a panel of clinical peers. However, in some instances insurers have avoided trig- gering these important protections by waiting to drop physicians from their panels until the expiration of their participating contract for reasons that may be related to these physicians challenging the insur- er's payment practices or the physician's referral of patients to certain needed specialists. This bill would extend these important stat- utory due process protections, currently applicable to contract termi- nations, to contract non-renewals to assure that such non-renewals occur for valid reasons.   PRIOR LEGISLATIVE HISTORY: 2004: A4000- Passed Assembly 2014: A6498- Passed Assembly   FISCAL IMPLICATIONS: None.   EFFECTIVE DATE: Immediately.
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A01212 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          1212
 
                               2015-2016 Regular Sessions
 
                   IN ASSEMBLY
 
                                     January 8, 2015
                                       ___________
 
        Introduced by M. of A. LAVINE -- read once and referred to the Committee
          on Health
 
        AN ACT to amend the public health law and the insurance law, in relation
          to health care professional applications and terminations
 
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
 
     1    Section 1. Section 4406-d of the public health law, as added by  chap-
     2  ter  705 of the laws of 1996, subdivision 1 as amended by chapter 237 of
     3  the laws of 2009, is amended to read as follows;
     4    § 4406-d. Health care professional applications and terminations.   1.
     5  (a)  A health care plan shall, upon request, make available and disclose
     6  to health care professionals written application procedures and  minimum
     7  qualification requirements which a health care professional must meet in
     8  order  to  be considered by the health care plan. The plan shall consult
     9  with appropriately qualified health care professionals in developing its
    10  qualification requirements. A health care plan shall complete review  of
    11  the health care professional's application to participate in the in-net-
    12  work  portion of the health care plan's network and shall, within ninety
    13  days of receiving a health care professional's completed application  to
    14  participate  in  the  health care plan's network, notify the health care
    15  professional as to: (i) whether he  or  she  is  credentialed;  or  (ii)
    16  whether additional time is necessary to make a determination in spite of
    17  the  health  care plan's best efforts or because of a failure of a third
    18  party to provide necessary  documentation,  or  non-routine  or  unusual
    19  circumstances  require  additional  time  for  review. In such instances
    20  where additional time is  necessary  because  of  a  lack  of  necessary
    21  documentation,  a  health  plan  shall  make every effort to obtain such
    22  information as soon as possible.
    23    (b) If the completed  application  of  a  newly-licensed  health  care
    24  professional or a health care professional who has recently relocated to
    25  this  state  from another state and has not previously practiced in this
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD03317-01-5

        A. 1212                             2
 
     1  state, who joins a group practice of health care professionals  each  of
     2  whom  participates  in  the  in-network  portion of a health care plan's
     3  network, is neither approved nor declined within ninety days pursuant to
     4  paragraph (a) of this subdivision, the health care professional shall be
     5  deemed  "provisionally  credentialed" and may participate in the in-net-
     6  work portion of the health care plan's network; provided, however,  that
     7  a  provisionally  credentialed  physician  may  not  be designated as an
     8  enrollee's primary care physician until such time as the  physician  has
     9  been  fully  credentialed. The network participation for a provisionally
    10  credentialed health care professional shall begin on the  day  following
    11  the ninetieth day of receipt of the completed application and shall last
    12  until  the  final credentialing determination is made by the health care
    13  plan. A health care professional shall only be eligible for  provisional
    14  credentialing  if  the group practice of health care professionals noti-
    15  fies the health care plan in writing that, should the application  ulti-
    16  mately  be  denied,  the health care professional or the group practice:
    17  (i) shall refund any payments made by the health care plan  for  in-net-
    18  work  services  provided  by  the provisionally credentialed health care
    19  professional that exceed any out-of-network benefits payable  under  the
    20  enrollee's contract with the health care plan; and (ii) shall not pursue
    21  reimbursement  from  the  enrollee, except to collect the copayment that
    22  otherwise would have been payable had  the  enrollee  received  services
    23  from  a health care professional participating in the in-network portion
    24  of a health care plan's network.  Interest  and  penalties  pursuant  to
    25  section  three  thousand  two hundred twenty-four-a of the insurance law
    26  shall not be assessed based on the denial of a  claim  submitted  during
    27  the  period  when the health care professional was provisionally creden-
    28  tialed; provided, however, that nothing herein shall  prevent  a  health
    29  care  plan  from  paying  a claim from a health care professional who is
    30  provisionally credentialed upon submission of such claim. A health  care
    31  plan  shall  not  deny, after appeal, a claim for services provided by a
    32  provisionally credentialed health care professional solely on the ground
    33  that the claim was not timely filed.
    34    2. (a) A health care plan shall not terminate or not renew a  contract
    35  with  a health care professional unless the health care plan provides to
    36  the health care professional a written explanation of  the  reasons  for
    37  the  proposed  contract  termination  and an opportunity for a review or
    38  hearing as hereinafter provided. This section shall not apply  in  cases
    39  involving  imminent harm to patient care, a determination of fraud, or a
    40  final disciplinary action by a state licensing board  or  other  govern-
    41  mental  agency  that  impairs  the health care professional's ability to
    42  practice.
    43    (b) The notice of the proposed  contract  termination  or  non-renewal
    44  provided  by  the health care plan to the health care professional shall
    45  include:
    46    (i) the reasons for the proposed action;
    47    (ii) notice that the health care professional has the right to request
    48  a hearing or review, at the professional's discretion,  before  a  panel
    49  [appointed  by  the  health  care plan] comprised of no fewer than three
    50  health care professionals licensed to practice in the state of New York;
    51    (iii) a time limit of not less than thirty days within which a  health
    52  care professional may request a hearing; and
    53    (iv)  a time limit for a hearing date which must be held within thirty
    54  days after the date of receipt of a request for a hearing.
    55    (c) The hearing panel shall be comprised of three  [persons  appointed
    56  by  the health care plan] health care professionals licensed to practice

        A. 1212                             3
 
     1  by the state of New York in the same profession as the  subject  of  the
     2  review, one of whom is appointed by the health care plan, one of whom is
     3  appointed  by  the  health  care  professional who is the subject of the
     4  hearing.  the remaining member of the panel shall be chosen by the other
     5  two panel members. At least one person on such panel shall be a clinical
     6  peer in the same discipline and the same or  similar  specialty  as  the
     7  health  care professional under review. The hearing panel may consist of
     8  more than three persons, provided however that the  number  of  clinical
     9  peers  on  such  panel  shall  constitute one-third or more of the total
    10  membership of the panel and provided  further  that  the  ratio  of  the
    11  number of health care professionals appointed by the health care plan to
    12  the  number of health care professionals appointed by the subject of the
    13  hearing to the number of health care professionals chosen by  the  other
    14  panel members remains one to one to one.
    15    (d)  The  hearing panel shall render a decision on the proposed action
    16  in a timely manner. Such decision shall  include  reinstatement  of  the
    17  health  care  professional  by  the  health care plan, provisional rein-
    18  statement subject to conditions set forth by the  health  care  plan  or
    19  termination  of  the  health  care  professional. Such decision shall be
    20  provided in writing to the health care professional.
    21    (e) A decision by the hearing panel to terminate or not renew a health
    22  care professional shall be effective not less than thirty days after the
    23  receipt by the health care professional of the hearing panel's decision;
    24  provided, however, that the provisions of paragraph (e)  of  subdivision
    25  six  of  section  [four  thousand four] forty-four hundred three of this
    26  article shall apply to such termination or non-renewal.
    27    (f) In no event shall termination be effective earlier than sixty days
    28  from the receipt of the notice of termination.
    29    3. [Either party to a contract may exercise a right of non-renewal  at
    30  the  expiration  of  the  contract  period  set  forth therein or, for a
    31  contract without a specific  expiration  date,  on  each  January  first
    32  occurring  after  the contract has been in effect for at least one year,
    33  upon sixty days notice to the other party; provided, however,  that  any
    34  non-renewal  shall  not  constitute  a  termination for purposes of this
    35  section.
    36    4.] A health care plan shall develop and implement policies and proce-
    37  dures to ensure that health care professionals are regularly informed of
    38  information maintained by the health care plan to evaluate the  perform-
    39  ance  or  practice of the health care professional. The health care plan
    40  shall consult with health care professionals in developing methodologies
    41  to collect and analyze health care professional profiling  data.  Health
    42  care  plans  shall  provide  any such information and profiling data and
    43  analysis to health care professionals. Such information, data or  analy-
    44  sis  shall be provided on a periodic basis appropriate to the nature and
    45  amount of data and the volume and  scope  of  services  provided.    Any
    46  profiling  data used to evaluate the performance or practice of a health
    47  care professional shall be  measured  against  stated  criteria  and  an
    48  appropriate  group  of health care professionals using similar treatment
    49  modalities serving a comparable patient population. Upon presentation of
    50  such information or data, each health care professional shall  be  given
    51  the  opportunity to discuss the unique nature of the health care profes-
    52  sional's patient population which may have a bearing on the health  care
    53  professional's  profile  and  to work cooperatively with the health care
    54  plan to improve performance.

        A. 1212                             4
 
     1    [5.] 4. No health care plan shall terminate a contract or  employment,
     2  or  refuse  to  renew  a contract, solely because a health care provider
     3  has:
     4    (a) advocated on behalf of an enrollee;
     5    (b) filed a complaint against the health care plan;
     6    (c) appealed a decision of the health care plan;
     7    (d)  provided information or filed a report pursuant to section forty-
     8  four hundred six-c of this article; or
     9    (e) requested a hearing or review pursuant to this section.
    10    [6.] 5. Except as provided herein, no contract or agreement between  a
    11  health  care  plan  and  a  health  care  professional shall contain any
    12  provision which shall supersede or impair a health  care  professional's
    13  right to notice of reasons for termination or non-renewal and the oppor-
    14  tunity  for a hearing or review concerning such termination or non-rene-
    15  wal.
    16    [7.] 6. Any contract provision in violation of this section  shall  be
    17  deemed to be void and unenforceable.
    18    [8.]  7. For purposes of this section, "health care plan" shall mean a
    19  health maintenance organization licensed pursuant to article forty-three
    20  of the insurance law or certified pursuant to this article or  an  inde-
    21  pendent  practice  association  certified or recognized pursuant to this
    22  article.
    23    [9.] 8. For purposes of this section, "health care professional" shall
    24  mean a health care professional licensed, registered or certified pursu-
    25  ant to title eight of the education law.
    26    § 2. Section 4803 of the insurance law, as added by chapter 705 of the
    27  laws of 1996, subsection (a) as amended by chapter 237 of  the  laws  of
    28  2009, is amended to read as follows:
    29    §  4803.  Health care professional applications and terminations.  (a)
    30  (1) An insurer which offers a managed care product shall, upon  request,
    31  make  available and disclose to health care professionals written appli-
    32  cation procedures and minimum qualification requirements which a  health
    33  care professional must meet in order to be considered by the insurer for
    34  participation  in  the  in-network  benefits  portion  of  the insurer's
    35  network for the managed care product. The  insurer  shall  consult  with
    36  appropriately  qualified  health  care  professionals  in developing its
    37  qualification requirements for participation in the in-network  benefits
    38  portion of the insurer's network for the managed care product. An insur-
    39  er  shall  complete review of the health care professional's application
    40  to participate in the in-network portion of the insurer's  network  and,
    41  within  ninety  days of receiving a health care professional's completed
    42  application to participate in the insurer's  network,  will  notify  the
    43  health  care  professional as to: (A) whether he or she is credentialed;
    44  or (B) whether additional time is necessary to make a  determination  in
    45  spite  of  the insurer's best efforts or because of a failure of a third
    46  party to provide necessary  documentation,  or  non-routine  or  unusual
    47  circumstances  require  additional  time for review.   In such instances
    48  where additional time is  necessary  because  of  a  lack  of  necessary
    49  documentation,  an insurer shall make every effort to obtain such infor-
    50  mation as soon as possible.
    51    (2) If the completed  application  of  a  newly-licensed  health  care
    52  professional or a health care professional who has recently relocated to
    53  this  state  from another state and has not previously practiced in this
    54  state, who joins a group practice of health care professionals  each  of
    55  whom  participates in the in-network portion of an insurer's network, is
    56  neither approved nor declined within ninety days pursuant  to  paragraph

        A. 1212                             5
 
     1  one  of  this  subsection, such health care professional shall be deemed
     2  "provisionally credentialed"  and  may  participate  in  the  in-network
     3  portion of an insurer's network; provided, however, that a provisionally
     4  credentialed  physician  may  not  be designated as an insured's primary
     5  care physician until such time as the physician has been  fully  creden-
     6  tialed.  The  network  participation  for  a  provisionally credentialed
     7  health care professional shall begin on the day following the  ninetieth
     8  day  of  receipt  of  the completed application and shall last until the
     9  final credentialing determination is made by the insurer. A health  care
    10  professional shall only be eligible for provisional credentialing if the
    11  group  practice  of  health  care  professionals notifies the insurer in
    12  writing that, should the application ultimately be  denied,  the  health
    13  care  professional  or the group practice: (A) shall refund any payments
    14  made by the insurer for  in-network  services  provided  by  the  provi-
    15  sionally  credentialed  health care professional that exceed any out-of-
    16  network benefits payable under the insured's contract with the  insurer;
    17  and  (B)  shall  not  pursue  reimbursement  from the insured, except to
    18  collect the copayment or coinsurance  that  otherwise  would  have  been
    19  payable  had  the  insured  received services from a health care profes-
    20  sional participating in the in-network portion of an insurer's  network.
    21  Interest  and  penalties  pursuant to section three thousand two hundred
    22  twenty-four-a of this chapter shall not be assessed based on the  denial
    23  of a claim submitted during the period when the health care professional
    24  was  provisionally  credentialed; provided, however, that nothing herein
    25  shall prevent an insurer from paying a claim from a health care  profes-
    26  sional  who is provisionally credentialed upon submission of such claim.
    27  An insurer shall not deny, after appeal, a claim for  services  provided
    28  by  a  provisionally credentialed health care professional solely on the
    29  ground that the claim was not timely filed.
    30    (b) (1) An insurer shall not terminate or not renew a contract with  a
    31  health  care  professional  for participation in the in-network benefits
    32  portion of the insurer's network for a managed care product  unless  the
    33  insurer  provides  to the health care professional a written explanation
    34  of the reasons for the proposed contract termination and an  opportunity
    35  for  a review or hearing as hereinafter provided. This section shall not
    36  apply in cases involving imminent harm to patient care, a  determination
    37  of  fraud,  or a final disciplinary action by a state licensing board or
    38  other governmental agency that impairs the  health  care  professional's
    39  ability to practice.
    40    (2)  The  notice  of  the proposed contract termination or non-renewal
    41  provided by the insurer to the health care professional shall include:
    42    (i) the reasons for the proposed action;
    43    (ii) notice that the health care professional has the right to request
    44  a hearing or review, at the professional's discretion,  before  a  panel
    45  [appointed  by the insurer] comprised of no fewer than three health care
    46  professionals licensed to practice by the state of New York;
    47    (iii) a time limit of not less than thirty days within which a  health
    48  care professional may request a hearing or review; and
    49    (iv)  a  time  limit  for a hearing date which must be held within not
    50  less than thirty days after the date of receipt of a request for a hear-
    51  ing.
    52    (3) The hearing panel shall be comprised of three  [persons  appointed
    53  by  the  insurer]  health care professionals licensed to practice by the
    54  state of New York in the same profession as the subject of  the  review,
    55  one of whom is appointed by the insurer, one of whom is appointed by the
    56  health  care professional who is the subject of the hearing. The remain-

        A. 1212                             6
 
     1  ing member of the panel shall be chosen by the other two panel  members.
     2  At  least  one person on such panel shall be a clinical peer in the same
     3  discipline and the same or similar specialty as the health care  profes-
     4  sional  under  review.  The hearing panel may consist of more than three
     5  persons, provided however that the number  of  clinical  peers  on  such
     6  panel  shall constitute one-third or more of the total membership of the
     7  panel and provided further that the ratio of the number of  health  care
     8  professionals  appointed by the health care plan to the number of health
     9  care professionals appointed by the subject of the hearing to the number
    10  of health care professionals chosen  by  the  two  other  panel  members
    11  remains one to one to one.
    12    (4)  The  hearing panel shall render a decision on the proposed action
    13  in a timely manner. Such decision shall  include  reinstatement  of  the
    14  health  care  professional  by  the  insurer,  provisional reinstatement
    15  subject to conditions set forth by the insurer  or  termination  of  the
    16  health  care professional. Such decision shall be provided in writing to
    17  the health care professional.
    18    (5) A decision by the hearing panel to terminate or not renew a health
    19  care professional shall be effective not less than thirty days after the
    20  receipt by the health care professional of the hearing panel's decision;
    21  provided, however, that the provisions of subsection (e) of section four
    22  thousand eight hundred four of this article shall apply to  such  termi-
    23  nation.
    24    (6)  In no event shall termination or non-renewal be effective earlier
    25  than sixty days from the receipt of the notice of termination or non-re-
    26  newal.
    27    (c) [Either party to a contract for participation  in  the  in-network
    28  benefits  portion of an insurer's network for a managed care product may
    29  exercise a right of non-renewal at the expiration of the contract period
    30  set forth therein or, for a contract without a specific expiration date,
    31  on each January first occurring after the contract has  been  in  effect
    32  for  at  least  one  year,  upon  sixty  days notice to the other party;
    33  provided, however, that any non-renewal shall not  constitute  a  termi-
    34  nation for purposes of this section.
    35    (d)] An insurer shall develop and implement policies and procedures to
    36  ensure  that  health  care providers participating in the the in-network
    37  benefits portion of an insurer's network for a managed care product  are
    38  regularly  informed of information maintained by the insurer to evaluate
    39  the performance or practice of the health care professional. The insurer
    40  shall consult with health care professionals in developing methodologies
    41  to collect and analyze provider profiling data. Insurers  shall  provide
    42  any  such  information  and  profiling data and analysis to these health
    43  care professionals. Such information, data or analysis shall be provided
    44  on a periodic basis appropriate to the nature and amount of data and the
    45  volume and scope of services provided. Any profiling data used to evalu-
    46  ate the performance or practice of such a health care professional shall
    47  be measured against stated criteria and an appropriate group  of  health
    48  care professionals using similar treatment modalities serving a compara-
    49  ble  patient  population. Upon presentation of such information or data,
    50  each such health care professional shall be  given  the  opportunity  to
    51  discuss  the  unique  nature  of  the health care professional's patient
    52  population which may have a bearing on the professional's profile and to
    53  work cooperatively with the insurer to improve performance.
    54    [(e)] (d) No insurer shall terminate or refuse to renew a contract for
    55  participation in the in-network benefits portion of an insurer's network
    56  for a managed care product solely because the health  care  professional

        A. 1212                             7
 
     1  has  (1)  advocated  on  behalf of an insured; (2) has filed a complaint
     2  against the insurer; (3) has appealed a decision  of  the  insurer;  (4)
     3  provided  information  or  filed a report pursuant to section forty-four
     4  hundred  six-c  of  the public health law; or (5) requested a hearing or
     5  review pursuant to this section.
     6    [(f)] (e) Except as provided herein, no contract or agreement  between
     7  an  insurer  and  a  health  care  professional for participation in the
     8  in-network benefits portion of an insurer's network for a  managed  care
     9  product  shall  contain  any provision which shall supersede or impair a
    10  health care professional's right to notice of reasons for termination or
    11  non-renewal and the opportunity for a  hearing  concerning  such  termi-
    12  nation or non-renewal.
    13    [(g)] (f) Any contract provision in violation of this section shall be
    14  deemed to be void and unenforceable.
    15    [(h)]  (g)  For  purposes  of this section, "health care professional"
    16  shall mean a health care professional licensed, registered or  certified
    17  pursuant to title eight of the education law.
    18    § 3. This act shall take effect immediately.
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