STATE OF NEW YORK
________________________________________________________________________
2573
2015-2016 Regular Sessions
IN ASSEMBLY
January 20, 2015
___________
Introduced by M. of A. BRENNAN, SCARBOROUGH, JAFFEE -- read once and
referred to the Committee on Insurance
AN ACT to amend the insurance law and the public health law, in relation
to physical therapy services and utilization practices
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 different deductibles,
14 co-payments or co-insurance amounts on the basis of the setting in which
15 such physical therapy services are rendered or whether the services are
16 performed by a physical therapist or physician.
17 § 2. Clause (ii) of subparagraph (A) of paragraph 1 of subsection (f)
18 of section 4235 of the insurance law, as amended by chapter 219 of the
19 laws of 2011, is amended to read as follows:
20 (ii) a policy under which coverage terminates at a specified age shall
21 not so terminate with respect to an unmarried child who is incapable of
22 self-sustaining employment by reason of mental illness, developmental
23 disability, mental retardation, as defined in the mental hygiene law, or
24 physical handicap and who became so incapable prior to attainment of the
25 age at which coverage would otherwise terminate and who is chiefly
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD02452-01-5
A. 2573 2
1 dependent upon such employee or member for support and maintenance,
2 while the insurance of the employee or member remains in force and the
3 child remains in such condition, if the insured employee or member has
4 within thirty-one days of such child's attainment of the termination age
5 submitted proof of such child's incapacity as described herein. No
6 policy of group accident, group health or group accident and health
7 insurance shall impose different deductibles, co-payments or co-insu-
8 rance amounts on the basis of the setting in which such physical therapy
9 services are rendered or whether the services are performed by a phys-
10 ical therapist or physician.
11 § 3. Subparagraph (A) of paragraph 4 of subsection (f) of section 4235
12 of the insurance law, as amended by chapter 593 of the laws of 2000, is
13 amended to read as follows:
14 (A) any physical and occupational therapy service which is within the
15 lawful scope of practice of a licensed physical and occupational thera-
16 pist, a subscriber to such policy shall be entitled to reimbursement for
17 such service, whether the said service is performed by a physician or
18 licensed physical and occupational therapist pursuant to prescription or
19 referral by a physician; and a policy of group accident, group health or
20 group accident and health insurance shall not impose different deduct-
21 ibles, co-payments or co-insurance amounts on the basis of the setting
22 in which such physical therapy services are rendered or whether the
23 services are performed by a physical therapist or physician.
24 § 4. Subparagraph (G) of paragraph 1 of subsection (b) of section 4301
25 of the insurance law, as amended by chapter 593 of the laws of 2000, is
26 amended to read as follows:
27 (G) physical and occupational therapy care provided through licensed
28 physical and occupational therapists upon the prescription of a physi-
29 cian and any co-payments, deductibles, or co-insurance amounts related
30 to reimbursement for physical therapy services shall not differ on the
31 basis of the setting in which such physical therapy services are
32 rendered or whether the services are performed by a physical therapist
33 or physician,
34 § 5. Paragraph 13 of subsection (b) of section 4322 of the insurance
35 law, as added by chapter 504 of the laws of 1995, is amended to read as
36 follows:
37 (13) Outpatient physical therapy up to ninety visits per condition per
38 calendar year and any co-payments, deductibles or co-insurance amounts
39 related to reimbursement of physical therapy services shall not differ
40 on the basis of the setting in which such physical therapy services are
41 rendered or whether the services are performed by a physical therapist
42 or physician.
43 § 6. The opening paragraph of subdivision 4 of section 4905 of the
44 public health law, as added by chapter 705 of the laws of 1996, is
45 amended to read as follows:
46 A utilization review agent or the health care plan for which the agent
47 provides utilization review shall not, with respect to utilization
48 review activities, permit or provide compensation or anything of value
49 to its employees, agents, or contractors based on:
50 § 7. The opening paragraph of subsection (d) of section 4905 of the
51 insurance law, as added by chapter 705 of the laws of 1996, is amended
52 to read as follows:
53 A utilization review agent or the health care plan for which the agent
54 provides utilization review shall not, with respect to utilization
55 review activities, permit or provide compensation or anything of value
56 to its employees, agents, or contractors based on:
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1 § 8. Subdivision 5 of section 4406-d of the public health law, as
2 added by chapter 705 of the laws of 1996, is amended to read as follows:
3 5. No health care plan shall terminate, or threaten to terminate a
4 contract or employment, [or] refuse to renew, or threaten refusal to
5 renew a contract, [solely] because a health care provider has:
6 (a) advocated on behalf of an enrollee;
7 (b) filed a complaint against the health care plan;
8 (c) appealed a decision of the health care plan;
9 (d) provided information or filed a report pursuant to section forty-
10 four hundred six-c of this article; [or]
11 (e) requested a hearing or review pursuant to this section; or
12 (f) ordered or rendered medically necessary care.
13 § 9. Subsection (e) of section 4803 of the insurance law, as added by
14 chapter 705 of the laws of 1996, is amended to read as follows:
15 (e) No insurer shall terminate [or], threaten to terminate, refuse to
16 renew or threaten refusal to renew a contract for participation in the
17 in-network benefits portion of an insurer's network for a managed care
18 product [solely] because the health care professional has (1) advocated
19 on behalf of an insured; (2) has filed a complaint against the insurer;
20 (3) has appealed a decision of the insurer; (4) provided information or
21 filed a report pursuant to section forty-four hundred six-c of the
22 public health law; [or] (5) requested a hearing or review pursuant to
23 this section; or (6) ordered or rendered medically necessary care.
24 § 10. Paragraph (d) of subdivision 1 of section 4902 of the public
25 health law, as added by chapter 705 of the laws of 1996, is amended to
26 read as follows:
27 (d) Establishment of a process for rendering utilization review deter-
28 minations which shall, at a minimum, include: written procedures to
29 assure that utilization reviews and determinations are conducted within
30 the timeframes established herein; procedures to notify an enrollee, an
31 enrollee's designee [and/or] and an enrollee's health care provider of
32 adverse determinations; and procedures for appeal of adverse determi-
33 nations including the establishment of an expedited appeals process for
34 denials of continued inpatient care or where there is imminent or seri-
35 ous threat to the health of the enrollee;
36 § 11. Paragraph 4 of subsection (a) of section 4902 of the insurance
37 law, as added by chapter 705 of the laws of 1996, is amended to read as
38 follows:
39 (4) Establishment of a process for rendering utilization review deter-
40 minations which shall, at a minimum, include: written procedures to
41 assure that utilization reviews and determinations are conducted within
42 the timeframes established herein; procedures to notify an insured, an
43 insured's designee [and/or] and an insured's health care provider of
44 adverse determinations; and procedures for appeal of adverse determi-
45 nations including the establishment of an expedited appeals process for
46 denials of continued inpatient care or where there is imminent or seri-
47 ous threat to the health of the insured;
48 § 12. Paragraph (a) of subdivision 2 of section 4901 of the public
49 health law, as added by chapter 705 of the laws of 1996, is amended to
50 read as follows:
51 (a) The utilization review plan, including but not limited to the
52 clinical review criteria and standards and the definition/standards of
53 medical necessity used under the utilization review plan. A utilization
54 review agent shall report any amendment or changes to the utilization
55 review plan to the commissioner within thirty days of making such amend-
56 ment or change;
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1 § 13. Paragraph 1 of subsection (b) of section 4901 of the insurance
2 law, as added by chapter 705 of the laws of 1996, is amended to read as
3 follows:
4 (1) The utilization review plan, including but not limited to the
5 clinical review criteria and standards and the definition/standards of
6 medical necessity used under the utilization review plan. A utilization
7 review agent shall report any amendment or changes to the utilization
8 review plan to the superintendent within thirty days of making such
9 amendment or change;
10 § 14. Section 4406-d of the public health law is amended by adding a
11 new subdivision 1-a to read as follows:
12 1-a. Upon written request by a participating health care professional,
13 a health care plan shall provide specific written clinical review crite-
14 ria relating to a particular condition, disease, service or procedure
15 and, where appropriate, other clinical information which the health care
16 plan or its utilization review agent might consider in its utilization
17 review and the health care plan shall include with the information a
18 description of how it will be used in the utilization review process;
19 provided, however, that to the extent such information is proprietary to
20 the health care plan, the participating health care provider or prospec-
21 tive health care provider shall only use the information for the
22 purposes of assisting the participating health care provider in evaluat-
23 ing covered services provided by the organization, an adverse determi-
24 nation or an appeal of adverse determination.
25 § 15. Section 4803 of the insurance law is amended by adding a new
26 subsection (a-1) to read as follows:
27 (a-1) Upon written request by a participating health care profes-
28 sional, a health care plan shall provide specific written clinical
29 review criteria relating to a particular condition, disease, service or
30 procedure and, where appropriate, other clinical information which the
31 health care plan or its utilization review agent might consider in its
32 utilization review and the health care plan shall include with the
33 information a description of how it will be used in the utilization
34 review process; provided, however, that to the extent such information
35 is proprietary to the health care plan, the participating health care
36 provider or prospective health care provider shall only use the informa-
37 tion for the purposes of assisting the participating health care provid-
38 er in evaluating covered services provided by the organization, an
39 adverse determination or an appeal of adverse determination.
40 § 16. Section 4406-c of the public health law is amended by adding a
41 new subdivision 5-e to read as follows:
42 5-e. No health care plan shall by contract, written policy or written
43 procedure refuse to honor, prohibit or in any way restrict the ability
44 of an enrollee to assign his or her benefits allowable or otherwise
45 payable to the enrollee as payment for professional services rendered.
46 § 17. The insurance law is amended by adding a new section 4803-a to
47 read as follows:
48 § 4803-a. Prohibitions. 1. No managed care health insurance contract
49 or managed care product shall by contract, written policy or written
50 procedure refuse to honor, prohibit or in any way restrict the ability
51 of an enrollee to assign his or her benefits allowable or otherwise
52 payable to the enrollee as payment for professional services rendered.
53 2. Any contract provision, written policy or written procedure in
54 violation of this section shall be deemed to be void and unenforceable.
55 § 18. Section 4905 of the public health law is amended by adding a new
56 subdivision 16 to read as follows:
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1 16. A health care plan shall provide notice to participating providers
2 sixty days in advance of a change in utilization review agents.
3 § 19. Section 4905 of the insurance law is amended by adding a new
4 subsection (p) to read as follows:
5 (p) A health care plan shall provide notice to participating providers
6 sixty days in advance of a change in utilization review agents.
7 § 20. This act shall take effect on the one hundred eightieth day
8 after it shall have become a law.
