STATE OF NEW YORK
________________________________________________________________________
5278
2023-2024 Regular Sessions
IN ASSEMBLY
March 7, 2023
___________
Introduced by M. of A. GUNTHER -- read once and referred to the Commit-
tee on Insurance
AN ACT to amend the insurance law, in relation to health insurance
coverage of physical and occupational 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, further, that such terms shall not impose co-payments in
14 excess of twenty percent of the total reimbursement to the provider of
15 care.
16 § 2. Subparagraph (A) of paragraph 1 of subsection (f) of section 4235
17 of the insurance law, as amended by chapter 219 of the laws of 2011,
18 item (ii) as amended by chapter 479 of the laws of 2022, is amended to
19 read as follows:
20 (A) Any policy of group accident, group health or group accident and
21 health insurance may include provisions for the payment by the insurer
22 of benefits for expenses incurred on account of hospital, medical or
23 surgical care or physical and occupational therapy by licensed physical
24 and occupational therapists upon the prescription or referral of a
25 physician for the employee or other member of the insured group, the
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD09646-01-3
A. 5278 2
1 employee's or member's spouse, the employee's or member's child or chil-
2 dren, or other persons chiefly dependent upon the employee or member for
3 support and maintenance; provided that:
4 (i) a policy of hospital, medical, surgical, or prescription drug
5 expense insurance that provides coverage for children shall provide such
6 coverage to a married or unmarried child until attainment of age twen-
7 ty-six, without regard to financial dependence, residency with the
8 employee or member, student status, or employment, except a policy that
9 is a grandfathered health plan may, for plan years beginning before
10 January first, two thousand fourteen, exclude coverage of an adult child
11 under age twenty-six who is eligible to enroll in an employer-sponsored
12 health plan other than a group health plan of a parent. For purposes of
13 this item, "grandfathered health plan" means coverage provided by an
14 insurer in which an individual was enrolled on March twenty-third, two
15 thousand ten for as long as the coverage maintains grandfathered status
16 in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.
17 § 18011(e); [and]
18 (ii) a policy under which coverage terminates at a specified age shall
19 not so terminate with respect to an unmarried child who is incapable of
20 self-sustaining employment by reason of mental illness, developmental
21 disability, as defined in the mental hygiene law, or physical handicap
22 and who became so incapable prior to attainment of the age at which
23 coverage would otherwise terminate and who is chiefly dependent upon
24 such employee or member for support and maintenance, while the insurance
25 of the employee or member remains in force and the child remains in such
26 condition, if the insured employee or member has within thirty-one days
27 of such child's attainment of the termination age submitted proof of
28 such child's incapacity as described herein[.]; and
29 (iii) no policy of group accident, group health or group accident and
30 health insurance shall impose co-payments in excess of twenty
31 percent of the total reimbursement to the provider of care.
32 § 3. Subparagraph (A) of paragraph 4 of subsection (f) of section 4235
33 of the insurance law, as amended by chapter 593 of the laws of 2000, is
34 amended to read as follows:
35 (A) any physical and occupational therapy service which is within the
36 lawful scope of practice of a licensed physical and occupational thera-
37 pist, a subscriber to such policy shall be entitled to reimbursement for
38 such service, whether the said service is performed by a physician or
39 licensed physical and occupational therapist pursuant to prescription or
40 referral by a physician, provided however, that no policy of group acci-
41 dent, group health or group accident and health insurance shall impose
42 co-payments in excess of twenty percent of the total reimbursement to
43 the provider of care;
44 § 4. Subparagraph (G) of paragraph 1 of subsection (b) of section 4301
45 of the insurance law, as amended by chapter 593 of the laws of 2000, is
46 amended to read as follows:
47 (G) physical and occupational therapy care provided through licensed
48 physical and occupational therapists upon the prescription of a physi-
49 cian. Co-payments related to reimbursement for such services shall not
50 exceed twenty percent of the total reimbursement to the provider of
51 care,
52 § 5. Paragraph 13 of subsection (b) of section 4322 of the insurance
53 law, as added by chapter 504 of the laws of 1995, is amended to read as
54 follows:
55 (13) Outpatient physical therapy up to ninety visits per condition per
56 calendar year. Any co-payments related to reimbursement for physical
A. 5278 3
1 therapy services shall not exceed twenty percent of the total reimburse-
2 ment to the provider of care.
3 § 6. This act shall take effect on the one hundred eightieth day after
4 it shall have become a law.
