A08513 Summary:

BILL NOA08513
 
SAME ASNo Same As
 
SPONSOROrtiz
 
COSPNSR
 
MLTSPNSRCrespo
 
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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A08513 Memo:

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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A08513 Text:



 
                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.
                                                                   LBD04339-01-5

        A. 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.
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