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.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A5074C
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.
STATE OF NEW YORK
________________________________________________________________________
5074--C
2015-2016 Regular Sessions
IN ASSEMBLY
February 12, 2015
___________
Introduced by M. of A. McDONALD, LAVINE, MONTESANO, MILLER, GUNTHER,
LIFTON, SIMON, ORTIZ, GOTTFRIED, MOSLEY, TITONE, FAHY, DUPREY, STECK,
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.
LBD06571-05-6
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.