|SAME AS||No Same As|
|Amd SS4406 & 4406-c, Pub Health L; amd S4804, Ins L|
|Provides that health maintenance organizations shall provide market access to diagnostic laboratories.|
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NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A8513 SPONSOR: Ortiz (MS)
TITLE OF BILL: An act to amend the public health law and the insur- ance law, in relation to providing access to diagnostic laboratories by patients in health maintenance organizations   PURPOSE: This bill provides for market access to all diagnostic laboratories which meet the specific criteria in managed health care networks in order to provide for greater transparency in the managed care network environment. The bill will also provide for vacating exclusive control, possession or sale source agreements by managed care networks with a diagnostic laboratory, thereby increasing competition, lowering rates and, most importantly, increasing quality of care. These amendments collectively provide that charges from non-participating laboratory providers be paid for by an enrollee's health maintenance organization plan (the "plan"). The bill also ensures that no health care plan excludes or assigns preferential status to any licensed provider of clinical lab services.   SUMMARY OF PROVISIONS: Section 4406 of the public health law is amended by adding a new subdi- vision 6. Section 4406-c of the public health law is amended by adding two new subdivisions 4-a and 4-b. Section 4804 of the insurance law is amended by adding a new subsection (g).   JUSTIFICATION: Healthcare providers, physicians, patients and including, but not limit- ed to, Federally Qualified Health Centers (FQHC) have had to adjust to the diminishing choices of diagnostic laboratories. This reduction in access has likely been caused by market consolidations and exclusivity agreements that run contrary to the antitrust provisions of the Donnelly Act. Many of the exclusivity agreements by and between managed care network providers and a select few diagnostic laboratories has increased with the advent of not-for-profit managed care providers seeking public trading status. This is to the detriment, disadvantage and inconven- ience of managed care networks such as these healthcare providers, physicians, patients and including, but not limited to, Federally Quali- fied Health Centers' (FQHC) and competitive market participation. This legislation would ensure that managed care networks will not engage in any perceived or actual restraint of trade, interference with free competition in business and commercial transactions, affect prices, restrict production, or otherwise control the market by exclusivity agreements.   LEGISLATIVE HISTORY: 2009/10: A8836 Referred to Health 2011/12: A1691 Referred to Health 2013/14: A5910 Referred to Health   FISCAL IMPLICATIONS: None   EFFECTIVE DATE: Immediately.
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STATE OF NEW YORK ________________________________________________________________________ 8513 2015-2016 Regular Sessions IN ASSEMBLY October 9, 2015 ___________ Introduced by M. of A. ORTIZ -- Multi-Sponsored by -- M. of A. CRESPO -- read once and referred to the Committee on Health AN ACT to amend the public health law and the insurance law, in relation to providing access to diagnostic laboratories by patients in health maintenance organizations The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Section 4406 of the public health law is amended by adding 2 a new subdivision 6 to read as follows: 3 6. Notwithstanding any other provision of law, if an enrollee is 4 referred by an in-plan provider to a provider of clinical laboratory 5 services not participating in the plan (a "non-participating provider"), 6 any service provided by a non-participating provider that would other- 7 wise be paid for by the plan to other non-participating providers shall 8 be paid for by the plan, and the plan shall be responsible for payment 9 directly to the non-participating provider for that service in accord- 10 ance with the time frame for such payments set forth in section three 11 thousand two hundred twenty-four-a of the insurance law; provided, 12 however, that the enrollee shall be responsible for any applicable 13 copay, coinsurance or deductible for such services. Clinical laborato- 14 ries seeking reimbursement pursuant to this article for services 15 rendered shall directly bill the plan whose enrollee received the 16 services. Any payment made by a plan directly to the enrollee rather 17 than to the clinical laboratory seeking reimbursement shall not satisfy 18 the plan's payment obligation to the clinical laboratory. 19 § 2. Section 4406-c of the public health law is amended by adding two 20 new subdivisions 4-a and 4-b to read as follows: 21 4-a. No health care plan, not-for-profit or for-profit health mainte- 22 nance organization, preferred provider organization, point of service 23 plan, government subsidized health care plan or self insured plan 24 (collectively, "plan") shall exclude from participating within its EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD04339-01-5A. 8513 2 1 network any provider of clinical laboratory services that meets the 2 following requirements: (a) such provider is licensed as a Medicare 3 provider by the United States department of health and human services; 4 (b) such provider is either accredited by the college of American 5 pathologists, or licensed by the New York state department of health; 6 and (c) such provider submits electronic claims to the plan for the 7 payment of clinical laboratory services rendered to enrollees. Each plan 8 shall directly pay for clinical laboratory services rendered to enrol- 9 lees by any provider of clinical laboratory services practicing within 10 its network in accordance with the time frame for such payments set 11 forth in section three thousand two hundred twenty-four-a of the insur- 12 ance law; provided, however, that the enrollee shall be responsible for 13 any applicable copay, coinsurance or deductible for such services. 14 4-b. Notwithstanding any other provision of law, in no event shall any 15 plan: (a) reimburse any in-plan provider of clinical laboratory services 16 for a particular laboratory test but not reimburse another in-plan 17 provider of clinical laboratory services for that laboratory test; (b) 18 assign preferential status nor provide preferential treatment to a 19 provider of clinical laboratory services practicing within its network. 20 Such prohibited preferential treatment shall include, but is not limited 21 to, maintaining a substantially different rate of payment or fees for 22 similar products and services provided by one in-plan provider over 23 those of other in-plan providers, or establishing a payment procedure 24 with one in-plan provider as opposed to other in-plan providers known to 25 likely result in the loss of payment for such in-plan providers; (c) 26 establish different performance measures or requirements for one in-plan 27 provider over those of other in-plan providers of clinical laboratory 28 services, including but not limited to, the number of patient service 29 centers required to be operated in a covered area or fluctuating report- 30 ing guidelines and requirements; (d) subcontract the management of the 31 network to an in-plan laboratory that collects a management fee for such 32 management services; or (e) treat any enrollee utilizing the services of 33 any provider of clinical laboratory services practicing within its 34 network in a manner which is not the same as or similar in all material 35 respects to the manner in which all other enrollees utilizing the 36 services of any provider of clinical laboratory services practicing 37 within its network are treated. 38 § 3. Section 4804 of the insurance law is amended by adding a new 39 subsection (g) to read as follows: 40 (g) Notwithstanding any other provision of law, if an insured is 41 referred by an in-plan provider to a provider of clinical laboratory 42 services not participating in the plan (a "non-participating provider"), 43 any service that would otherwise be covered as an in-plan service under 44 the plan that is provided by the non-participating provider shall be 45 covered, and the organization shall be responsible for payment directly 46 to the non-participating provider for those services in accordance with 47 the time frame for such payments set forth in section three thousand two 48 hundred twenty-four-a of this chapter; provided, however, that the 49 insured shall be responsible for any applicable copay, coinsurance or 50 deductible for such services. Clinical laboratories seeking reimburse- 51 ment pursuant to this article for services rendered shall directly bill 52 the organization whose insured received the services. Any payment made 53 by an organization directly to the insured rather than to the clinical 54 laboratory seeking reimbursement shall not satisfy the organization's 55 payment obligation to the clinical laboratory. 56 § 4. This act shall take effect immediately.