STATE OF NEW YORK
________________________________________________________________________
9835--B
IN ASSEMBLY
April 12, 2016
___________
Introduced by M. of A. ABINANTI -- read once and referred to the Commit-
tee on Health -- committee discharged, bill amended, ordered reprinted
as amended and recommitted to said committee -- again reported from
said committee with amendments, ordered reprinted as amended and
recommitted to said committee
AN ACT to amend the public health law, in relation to payments from the
New York state medical indemnity fund
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Section 2999-j of the public health law is amended by
2 adding two new subdivisions 2-a and 7-a to read as follows:
3 2-a. A request for review of a denial of a claim or a denial of a
4 request for prior authorization for the payment or reimbursement from
5 the fund for qualifying health care costs must be made by the claimant
6 no later than sixty days from receipt of the denial and, at a claimant's
7 option, by either (a) making application to the court wherein the judge-
8 ment was awarded or the case was settled, or (b) following the process
9 established by regulations of the commissioner for the administrative
10 review of a denial of a claim or request for prior authorization.
11 7-a. A request for a review of a determination by the fund administra-
12 tor that the relevant provisions of subdivision six of this section have
13 not been met and/or that the plaintiff or claimant is not a qualified
14 plaintiff may be made by any of the parties, no later than sixty days
15 from receipt of the denial, by making application to the court wherein
16 the judgment was awarded or the case was settled.
17 § 2. Subdivisions 2 and 4 of section 2999-j of the public health law,
18 as added by section 52 of part H of chapter 59 of the laws of 2011, are
19 amended to read as follows:
20 2. The provision of qualifying health care costs to qualified plain-
21 tiffs shall not be subject to prior authorization, except as described
22 by the commissioner in regulation; provided, however[, that]:
23 (a) such regulation shall not prevent qualified plaintiffs from
24 receiving care or assistance that would, at a minimum, be authorized
25 under the medicaid program; [and provided, further, that]
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD14645-13-6
A. 9835--B 2
1 (b) if any prior authorization is required by such regulation, the
2 regulation shall require that requests for prior authorization be proc-
3 essed within a reasonably prompt period of time and, subject to the
4 provisions of subdivision two-a of this section, shall identify a proc-
5 ess for prompt administrative review of any denial of a request for
6 prior authorization[.]; and
7 (c) such regulations shall not prohibit qualifying health care costs
8 on the grounds that the qualifying health care cost is not limited to
9 the direct need of the patient and may benefit other members of the
10 household.
11 4. The amount of qualifying health care costs to be paid from the fund
12 shall be calculated[: (a) with respect to services provided in private
13 physician practices on the basis of one hundred percent of the usual and
14 customary rates,] on the basis of one hundred percent of the usual and
15 customary cost. For the purposes of this section, "usual and customary
16 costs" shall mean the eightieth percentile of all charges for the
17 particular health care service performed by a provider in the same or
18 similar specialty and provided in the same geographical area as reported
19 in a benchmarking database maintained by a nonprofit organization speci-
20 fied by the superintendent of financial services. If no such rates are
21 available qualifying health care costs shall be calculated on the basis
22 of no less than one hundred thirty percent of Medicaid or Medicare rates
23 of reimbursement, whichever is higher. If no such rate exists, costs
24 shall be reimbursed as defined by the commissioner in regulation[; or
25 (b) with respect to all other services, on the basis of Medicaid rates
26 of reimbursement or, where no such rates are available, as defined by
27 the commissioner in regulation].
28 § 3. Subdivisions 1 and 3 of section 2999-h of the public health law,
29 as added by section 52 of part H of chapter 59 of the laws of 2011, are
30 amended to read as follows:
31 1. "Birth-related neurological injury" means an injury to the brain or
32 spinal cord of a live infant caused by the deprivation of oxygen or
33 mechanical injury occurring in the course of labor, delivery or resusci-
34 tation, or by other medical services provided or not provided during
35 delivery admission, that rendered the infant with a permanent and
36 substantial motor impairment or with a developmental disability as that
37 term is defined by section 1.03 of the mental hygiene law, or both. This
38 definition shall apply to live births only.
39 3. "Qualifying health care costs" means the future medical, hospital,
40 surgical, nursing, dental, rehabilitation, habilitation, respite, custo-
41 dial, durable medical equipment, home modifications, assistive technolo-
42 gy, vehicle modifications, transportation for purposes of health care
43 related appointments, prescription and non-prescription medications, and
44 other health care costs actually incurred for services rendered to and
45 supplies utilized by qualified plaintiffs, which are necessary to meet
46 their health care needs, including providing therapeutic benefit, as
47 determined by their treating physicians, physician assistants, or nurse
48 practitioners and as otherwise defined by the commissioner in regu-
49 lation.
50 § 4. The public health law is amended by adding a new section 2999-k
51 to read as follows:
52 § 2999-k. Consumer and stakeholder workgroup. The department shall
53 convene a workgroup comprised of qualified plaintiffs or representatives
54 of qualified plaintiffs, physicians, advocates and other interested
55 parties. Such workgroup shall be co-chaired by the commissioner and the
56 superintendent of financial services, and shall be composed of not less
A. 9835--B 3
1 than nine members appointed by the governor, of which two shall be
2 appointed upon recommendation of the temporary president of the senate
3 and two shall be appointed upon the recommendation of the speaker of the
4 assembly. If the commissioner seeks to make any regulations under this
5 title, he or she shall submit the proposed regulations to the workgroup
6 for its input and comments. The commissioner shall consider the input
7 and comments of the workgroup prior to the adoption of any proposed
8 regulation, and if he or she shall act in a manner inconsistent with the
9 workgroup's input and comments, the commissioner shall provide the
10 reasons therefor in writing.
11 § 5. This act shall take effect on the forty-fifth day after it shall
12 have become a law.
