A05074 Summary:

COSPNSRLavine, Montesano, Miller, Gunther, Lifton, Simon, Ortiz, Gottfried, Mosley, Titone, Fahy, Duprey, Steck, Arroyo, Harris
MLTSPNSRCook, Hooper, McLaughlin, Saladino, Simanowitz
Add §367-j, Soc Serv L; amd §4403, Pub Health L
Establishes the "complex needs patient act" including definitions and reimbursement and billing procedures; preserves access to quality complex rehabilitation technology for patients with complex medical needs.
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A05074 Actions:

02/12/2015referred to health
04/28/2015reported referred to ways and means
04/30/2015amend and recommit to ways and means
04/30/2015print number 5074a
05/28/2015amend (t) and recommit to ways and means
05/28/2015print number 5074b
01/06/2016referred to health
01/21/2016reported referred to ways and means
01/22/2016amend and recommit to ways and means
01/22/2016print number 5074c
06/07/2016reported referred to rules
06/14/2016rules report cal.271
06/14/2016substituted by s3651d
 02/23/2015PRINT NUMBER 3651A
 04/30/2015PRINT NUMBER 3651B
 05/28/2015PRINT NUMBER 3651C
 01/15/2016PRINT NUMBER 3651D
 06/08/2016PASSED SENATE
 06/08/2016referred to ways and means
 06/14/2016substituted for a5074c
 06/14/2016ordered to third reading rules cal.271
 06/14/2016passed assembly
 06/14/2016returned to senate
 11/28/2016VETOED MEMO.270
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A05074 Memo:

submitted in accordance with Assembly Rule III, Sec 1(f)
SPONSOR: McDonald (MS)
  TITLE OF BILL: An act to amend the social services law and the public health law, in relation to preserving access to quality complex rehabilitation technol- ogy for patients with complex medical needs   PURPOSE OR GENERAL IDEA OF BILL: To maintain access to quality complex rehabilitation equipment for patients with specific diagnoses and physical conditions who require individually configured equipment and technology to sustain independence and avoid institutionalization. The bill will also safeguard the config- uration, delivery and repair of customized technology and equipment by establishing qualifications currently sought administratively through prior authorization and administrative review.   SUMMARY OF SPECIFIC PROVISIONS: Section 1 sets forth the title of the Act as the "Complex Needs Patient Act". Section 2 is the legislative intent of maintaining access to complex technology and supportive services. Section 3 amends the social service law by adding a new section which provides definitions for the individual's possible eligible for complex technology equipment, the type of equipment and components of equipment addressed and the qualifications of individuals appropriate to fit and individually configure such equipment. Section 4 amends the public health to require all health maintenance organization to provide adequate access to services and equipment provided by qualified complex rehabilitation technology suppliers. Section 5 provides the effective date.   JUSTIFICATION: The bill distinguishes complex rehabilitation technology and the need for customized, sophisticated technology by a small portion of the general population, who, without access to such equipment could not maintain mobility, quality of life or independence. Much of the popu- lation requiring such complex rehabilitation technology were previously exempt from being enrolled in managed care insurance plans and access to appropriate, high quality equipment was determined through a stringent evaluation and prior authorization process administered by the State Department of Health. The Department required physician authorization, independent evaluation of the individual's needs by licensed therapists in an independent clinic setting, that the supplier complete and submit a request for prior authorization, that the supplier operate a store front in New York State, that the supplier employ licensed and trained professionals who customize and fit patients in person. The bill is intended to preserve as much of that process as determined necessary by the department for specific complex needs patients and for certain complex need technology. The bill does not establish new reimbursement rates, but established the Department's authority to maintain adequate rates. The bill will protect existing prior authorization and approval proce- dures.   PRIOR LEGISLATIVE HISTORY: A7257-A / S7252 laws of 2013-14   FISCAL IMPLICATIONS: None   EFFECTIVE DATE: The first of January next succeeding the date on which it shall have become law with provisions.
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A05074 Text:

                STATE OF NEW YORK
                               2015-2016 Regular Sessions
                   IN ASSEMBLY
                                    February 12, 2015
        Introduced  by  M.  of  A. McDONALD, LAVINE, MONTESANO, MILLER, GUNTHER,
          ARROYO  --  Multi-Sponsored  by  -- M. of A. COOK, HOOPER, McLAUGHLIN,
          SALADINO, SIMANOWITZ -- read once and referred  to  the  Committee  on
          Health  -- reported and referred to the Committee on Ways and Means --
          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 -- recommitted to the Committee on Health in accordance with
          Assembly Rule 3, sec. 2 -- committee discharged, bill amended, ordered
          reprinted as amended and recommitted to said committee -- reported and
          referred to the Committee on Ways and Means
        AN  ACT  to  amend the social services law and the public health law, in
          relation to preserving access to quality complex rehabilitation  tech-
          nology for patients with complex medical needs
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
     1    Section 1. Short title. This act shall be known and may  be  cited  as
     2  the "complex needs patient act".
     3    § 2. Legislative intent. It is the intent of the legislature to:
     4    1.  protect access for complex needs patients to quality complex reha-
     5  bilitation technology;
     6    2. establish and improve standards  and  safeguards  relating  to  the
     7  provision of complex rehabilitation technology; and
     8    3.  provide  quality support for complex needs patients to stay in the
     9  home or community setting,  prevent  institutionalization,  and  prevent
    10  hospitalizations and other costly secondary complications.
    11    §  3. The social services law is amended by adding a new section 367-j
    12  to read as follows:
    13    § 367-j. Complex needs patient act.  1. Definitions. As used  in  this
    14  section:
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.

        A. 5074--C                          2
     1    (a) "Complex needs patient" means an individual with significant phys-
     2  ical  or  functional  impairment  resulting  from a medical condition or
     3  disease including, but not limited to:  spinal  cord  injury,  traumatic
     4  brain  injury,  cerebral palsy, muscular dystrophy, spina bifida, osteo-
     5  genesis   imperfecta,  arthrogryposis,  amyotrophic  lateral  sclerosis,
     6  multiple  sclerosis,  demyelinating   disease,   myelopathy,   myopathy,
     7  progressive  muscular  atrophy,  anterior  horn cell disease, post-polio
     8  syndrome,  cerebellar  degeneration,  dystonia,  huntington's   disease,
     9  spinocerebellar  disease,  and certain types of amputation, paralysis or
    10  paresis.
    11    (b) "Complex rehabilitation technology" means products  classified  as
    12  durable  medical  equipment  within  the  medicare program as of January
    13  first, two thousand fifteen that are individually configured  for  indi-
    14  viduals  to  meet  their specific and unique medical, physical and func-
    15  tional needs and capacities for basic and functional activities of daily
    16  living. Such products include, but  are  not  limited  to:  individually
    17  configured  manual and power wheelchairs and accessories, adaptive seat-
    18  ing and positioning items and accessories, and other specialized  equip-
    19  ment such as standing frames and gait trainers and accessories.
    20    (c)  "Employee" means a person whose taxes are withheld by a qualified
    21  complex rehabilitation technology supplier and reported to the  internal
    22  revenue service.
    23    (d) "Healthcare common procedure coding system", or "HCPCS", means the
    24  billing  codes  used by medicare and overseen by the federal centers for
    25  medicare and medicaid services that are based on the current  procedural
    26  technology codes developed by the American medical association.
    27    (e)  "Individually  configured"  means  a device with a combination of
    28  sizes, features, adjustments or modifications  that  are  configured  or
    29  designed by a qualified complex rehabilitation technology supplier for a
    30  specific  individual  by  measuring,  fitting, programming, adjusting or
    31  adapting the device so that the device is consistent with  the  individ-
    32  ual's medical condition, physical and functional needs and capabilities,
    33  body  size,  period of need and intended use as determined by an assess-
    34  ment or evaluation by a qualified health care professional.
    35    (f) "Mixed HCPCS  codes"  means  Healthcare  Common  Procedure  Coding
    36  System  codes  that  refer to a mix of complex rehabilitation technology
    37  products and standard mobility and accessory products.
    38    (g) "Pure HCPCS codes" means Healthcare Common Procedure Coding System
    39  codes  that  refer  exclusively  to  complex  rehabilitation  technology
    40  products.
    41    (h)  "Qualified  complex rehabilitation technology professional" means
    42  an individual who is certified as an assistive  technology  professional
    43  (ATP) by the Rehabilitation Engineering and Assistive Technology Society
    44  of North America (RESNA).
    45    (i)  "Qualified  complex  rehabilitation  technology supplier" means a
    46  company or entity that:
    47    (i) is accredited by a recognized accrediting organization;
    48    (ii) is an enrolled medicare supplier and meets the supplier and qual-
    49  ity  standards  established  for  durable  medical  equipment  suppliers
    50  including those for complex rehabilitation technology under the medicare
    51  program;
    52    (iii)  has  at least one employee who is a qualified complex rehabili-
    53  tation technology professional available to analyze the needs and capac-
    54  ities of complex needs patients in consultation with a qualified  health
    55  care  professional  and  participate  in  the  selection  of appropriate

        A. 5074--C                          3
     1  complex rehabilitation technology and provide training in the proper use
     2  of the complex rehabilitation technology;
     3    (iv)  requires  a  qualified complex rehabilitation technology profes-
     4  sional be physically present for the  evaluation  and  determination  of
     5  appropriate   complex   rehabilitation   technology  for  complex  needs
     6  patients;
     7    (v) has the capability to provide  service  and  repair  by  qualified
     8  technicians for all complex rehabilitation technology it sells;
     9    (vi) has at least one storefront location within New York state; and
    10    (vii)  provides  written  information regarding how to receive service
    11  and repair of complex rehabilitation technology  to  the  complex  needs
    12  patient prior to the ordering of such technology.
    13    (j)  "Qualified  health care professional" means a health care profes-
    14  sional licensed by the state education department who has  no  financial
    15  relationship  with a qualified complex rehabilitation technology suppli-
    16  er, including but not limited to a physician, physical therapist,  occu-
    17  pational  therapist,  or  other  licensed  health  care professional who
    18  performs specialty evaluations within the professional's scope of  prac-
    19  tice.
    20    2. Reimbursement and billing procedures. (a) To the extent permissible
    21  under  federal  law, the commissioner shall maintain specific reimburse-
    22  ment and billing  procedures  within  the  state  medicaid  program  for
    23  complex  rehabilitation  technology products and services to ensure that
    24  medicaid payments for such products and services permit adequate  access
    25  to  complex  needs  patients  and  takes  into  account  the significant
    26  resources, infrastructure, and staff needed to meet their needs.
    27    (b) Pursuant to paragraph (a) of this  subdivision,  the  commissioner
    28  shall,  not  later than October first, two thousand eighteen: (i) desig-
    29  nate products and services included in  mixed  and  pure  HCPCS  billing
    30  codes  as  complex  rehabilitation technology, and as needed, create new
    31  billing codes or code modifiers for services and  products  covered  for
    32  complex needs patients; (ii) set minimum standards consistent with para-
    33  graph  (i)  of subdivision one of this section in order for suppliers to
    34  be considered  qualified  complex  rehabilitation  technology  suppliers
    35  eligible  for  medicaid reimbursement; (iii) exempt products or services
    36  billed under mixed or pure HCPCS codes from inclusion  in  any  bidding,
    37  selective contracting, request for proposal, or similar initiative; (iv)
    38  require complex needs patients receiving a complex rehabilitation manual
    39  wheelchair,  power wheelchair, or seating component to be evaluated by a
    40  qualified health care professional and  a  qualified  complex  rehabili-
    41  tation technology professional to qualify for reimbursement (such evalu-
    42  ation  shall  be exempt from any health care professional cap); (v) make
    43  other changes as needed to  protect  access  to  complex  rehabilitation
    44  technology  for  complex  needs  patients; and (vi) affirm that with the
    45  exception of those enrollees covered under a  payment  rate  methodology
    46  otherwise  negotiated,  payments  for  complex rehabilitation technology
    47  provided to patients eligible for medical  assistance  by  organizations
    48  operating in accordance with the provisions of article forty-four of the
    49  public  health  law or by health maintenance organizations organized and
    50  operating in accordance with article forty-three of the  insurance  law,
    51  shall be the rates of payment that would be paid for such payments under
    52  the  medical  assistance  program  as determined by the commissioner and
    53  applicable to services at the time such services were provided.
    54    § 4. Section 4403 of the public health law is amended by adding a  new
    55  subdivision 9 to read as follows:

        A. 5074--C                          4
     1    9. Every health maintenance organization shall include adequate access
     2  to  services  and equipment provided by qualified complex rehabilitation
     3  technology suppliers, pursuant to section three hundred sixty-seven-j of
     4  the social services law, and  adopt  the  supplier  standards  contained
     5  therein.
     6    §  5. This act shall take effect on the first of January next succeed-
     7  ing the date on which it shall have become a law,  and  shall  apply  to
     8  contracts  and policies issued, renewed, modified or amended on or after
     9  such effective date.
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