Provides that no policy of group accident, group health or group accident and health shall impose co-payments in excess of twenty percent of total reimbursement to the provider of care.
STATE OF NEW YORK
________________________________________________________________________
28--A
2015-2016 Regular Sessions
IN SENATE(Prefiled)
January 7, 2015
___________
Introduced by Sens. DeFRANCISCO, AVELLA, BOYLE, MARCHIONE, MARTINS,
PANEPINTO, YOUNG -- read twice and ordered printed, and when printed
to be committed to the Committee on Insurance -- committee discharged,
bill amended, ordered reprinted as amended and recommitted to said
committee
AN ACT to amend the insurance law, in relation to physical therapy
services
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Paragraph 23 of subsection (i) of section 3216 of the
2 insurance law, as added by chapter 593 of the laws of 2000, is amended
3 to read as follows:
4 (23) If a policy provides for reimbursement for physical and occupa-
5 tional therapy service which is within the lawful scope of practice of a
6 duly licensed physical or occupational therapist, an insured shall be
7 entitled to reimbursement for such service whether the said service is
8 performed by a physician or through a duly licensed physical or occupa-
9 tional therapist, provided however, that nothing contained herein shall
10 be construed to impair any terms of such policy including appropriate
11 utilization review and the requirement that said service be performed
12 pursuant to a medical order, or a similar or related service of a physi-
13 cian provided that such terms shall not impose co-payments in excess of
14 twenty percent of the total reimbursement to the provider of care or
15 different deductibles, co-payments or co-insurance amounts on the basis
16 of the setting in which such physical therapy services are rendered or
17 whether the services are performed by a physical therapist or physician.
18 § 2. Subparagraph (A) of paragraph 1 of subsection (f) of section 4235
19 of the insurance law, as amended by chapter 219 of the laws of 2011, is
20 amended to read as follows:
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD01104-02-5
S. 28--A 2
1 (A) Any policy of group accident, group health or group accident and
2 health insurance may include provisions for the payment by the insurer
3 of benefits for expenses incurred on account of hospital, medical or
4 surgical care or physical and occupational therapy by licensed physical
5 and occupational therapists upon the prescription or referral of a
6 physician for the employee or other member of the insured group, the
7 employee's or member's spouse, the employee's or member's child or chil-
8 dren, or other persons chiefly dependent upon the employee or member for
9 support and maintenance; provided that:
10 (i) a policy of hospital, medical, surgical, or prescription drug
11 expense insurance that provides coverage for children shall provide such
12 coverage to a married or unmarried child until attainment of age twen-
13 ty-six, without regard to financial dependence, residency with the
14 employee or member, student status, or employment, except a policy that
15 is a grandfathered health plan may, for plan years beginning before
16 January first, two thousand fourteen, exclude coverage of an adult child
17 under age twenty-six who is eligible to enroll in an employer-sponsored
18 health plan other than a group health plan of a parent. For purposes of
19 this item, "grandfathered health plan" means coverage provided by an
20 insurer in which an individual was enrolled on March twenty-third, two
21 thousand ten for as long as the coverage maintains grandfathered status
22 in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.
23 § 18011(e); and
24 (ii) a policy under which coverage terminates at a specified age shall
25 not so terminate with respect to an unmarried child who is incapable of
26 self-sustaining employment by reason of mental illness, developmental
27 disability, mental retardation, as defined in the mental hygiene law, or
28 physical handicap and who became so incapable prior to attainment of the
29 age at which coverage would otherwise terminate and who is chiefly
30 dependent upon such employee or member for support and maintenance,
31 while the insurance of the employee or member remains in force and the
32 child remains in such condition, if the insured employee or member has
33 within thirty-one days of such child's attainment of the termination age
34 submitted proof of such child's incapacity as described herein. No
35 policy of group accident, group health or group accident and health
36 insurance shall impose co-payments in excess of twenty percent of the
37 total reimbursement to the provider of care or different deductibles,
38 co-payments or co-insurance amounts on the basis of the setting in which
39 such physical therapy services are rendered or whether the services are
40 performed by a physical therapist or physician.
41 § 3. Subparagraph (A) of paragraph 4 of subsection (f) of section 4235
42 of the insurance law, as amended by chapter 593 of the laws of 2000, is
43 amended to read as follows:
44 (A) any physical and occupational therapy service which is within the
45 lawful scope of practice of a licensed physical and occupational thera-
46 pist, a subscriber to such policy shall be entitled to reimbursement for
47 such service, whether the said service is performed by a physician or
48 licensed physical and occupational therapist pursuant to prescription or
49 referral by a physician; and a policy of group accident, group health or
50 group accident and health insurance shall not impose co-payments in
51 excess of twenty percent of the total reimbursement to the provider of
52 care or different deductibles, co-payments or co-insurance amounts on
53 the basis of the setting in which such physical therapy services are
54 rendered or whether the services are performed by a physical therapist
55 or physician;
S. 28--A 3
1 § 4. Subparagraph (G) of paragraph 1 of subsection (b) of section 4301
2 of the insurance law, as amended by chapter 593 of the laws of 2000, is
3 amended to read as follows:
4 (G) physical and occupational therapy care provided through licensed
5 physical and occupational therapists upon the prescription of a physi-
6 cian and any co-payments related to reimbursement for physical therapy
7 services shall not exceed twenty percent of the total reimbursement to
8 the provider of care or different deductibles, co-payments or co-insu-
9 rance amounts on the basis of the setting in which such physical therapy
10 services are rendered or whether the services are performed by a phys-
11 ical therapist or physician,
12 § 5. Paragraph 13 of subsection (b) of section 4322 of the insurance
13 law, as added by chapter 504 of the laws of 1995, is amended to read as
14 follows:
15 (13) Outpatient physical therapy up to ninety visits per condition per
16 calendar year and any co-payments related to reimbursement for such
17 services shall not exceed twenty percent of the total reimbursement to
18 the provider of care or different deductibles, co-payments or co-insu-
19 rance amounts on the basis of the setting in which such physical therapy
20 services are rendered or whether the services are performed by a phys-
21 ical therapist or physician.
22 § 6. This act shall take effect on the one hundred eightieth day after
23 it shall have become a law.
