Amd §§3216, 3235-a, 4235, 4301, 4322, 4803, 4901, 4902 & 4905, Ins L; amd §§4406-d, 4901, 4902 & 4905, Pub
Health L
 
Expands health insurance coverage of physical and occupational therapy services by limiting co-payments and regulating visit limitations; expands coverage of early intervention services; expands utilization review of health insurance coverage for medically necessary care.
STATE OF NEW YORK
________________________________________________________________________
5760
2019-2020 Regular Sessions
IN SENATE
May 14, 2019
___________
Introduced by Sens. BRESLIN, ADDABBO, KAMINSKY, KENNEDY -- read twice
and ordered printed, and when printed to be committed to the Committee
on Insurance
AN ACT to amend the insurance law, in relation to health insurance
coverage of physical and occupational therapy services and payment for
early intervention services; and to amend the insurance law and the
public health law, in relation to the provision of medically necessary
care and utilization review
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. Visit limits for physical and occupational therapy services shall
16 be subject to an exceptions process, that shall include the insured's
17 physician certifying that the cessation of services would most likely
18 result in further disability or harm to the insured. Any exceptions
19 process shall be further determined by the superintendent.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD00572-01-9
S. 5760 2
1 § 2. Subsection (b) of section 3235-a of the insurance law, as added
2 by section 3 of part C of chapter 1 of the laws of 2002, is amended to
3 read as follows:
4 (b) Where a policy of accident and health insurance, including a
5 contract issued pursuant to article forty-three of this chapter,
6 provides coverage for an early intervention program service, such cover-
7 age shall not be applied against any maximum annual or lifetime monetary
8 limits set forth in such policy or contract. Visit limitations [and
9 other terms and conditions of the policy] will continue to apply to
10 early intervention services. However, any visits used for early inter-
11 vention program services shall not reduce the number of visits otherwise
12 available under the policy or contract for such services.
13 § 3. Clause (ii) of subparagraph (A) of paragraph 1 of subsection f of
14 section 4235 of the insurance law, as amended by chapter 219 of the laws
15 of 2011, is amended to read as follows:
16 (ii) a policy under which coverage terminates at a specified age shall
17 not so terminate with respect to an unmarried child who is incapable of
18 self-sustaining employment by reason of mental illness, developmental
19 disability, mental retardation, as defined in the mental hygiene law, or
20 physical handicap and who became so incapable prior to attainment of the
21 age at which coverage would otherwise terminate and who is chiefly
22 dependent upon such employee or member for support and maintenance,
23 while the insurance of the employee or member remains in force and the
24 child remains in such condition, if the insured employee or member has
25 within thirty-one days of such child's attainment of the termination age
26 submitted proof of such child's incapacity as described [herein] in this
27 clause. No policy of group accident, group health or group accident and
28 health insurance shall impose co-payments in excess of twenty percent of
29 the total reimbursement to the provider of care. Visit limits for phys-
30 ical and occupational services shall be subject to an exceptions proc-
31 ess, that shall include an insured's physician certifying that the
32 cessation of services would most likely result in further disability or
33 harm to the insured. Any exceptions process shall be further determined
34 by the superintendent.
35 § 4. Subparagraph (A) of paragraph 4 of subsection (f) of section 4235
36 of the insurance law, as amended by chapter 593 of the laws of 2000, is
37 amended to read as follows:
38 (A) any physical and occupational therapy service which is within the
39 lawful scope of practice of a licensed physical and occupational thera-
40 pist, a subscriber to such policy shall be entitled to reimbursement for
41 such service, whether the said service is performed by a physician or
42 licensed physical and occupational therapist pursuant to prescription or
43 referral by a physician. No policy of group accident, group health or
44 group accident and health insurance shall impose co-payments in excess
45 of twenty percent of the total reimbursement to the provider of care.
46 Visit limits for physical and occupational therapy services shall be
47 subject to an exceptions process, that shall include an insured's physi-
48 cian certifying that the cessation of services would most likely result
49 in further disability or harm to the insured. Any exceptions process
50 shall be further determined by the superintendent;
51 § 5. Subparagraph (G) of paragraph 1 of subsection (b) of section 4301
52 of the insurance law, as amended by chapter 593 of the laws of 2000, is
53 amended to read as follows:
54 (G) physical and occupational therapy care provided through licensed
55 physical and occupational therapists upon the prescription of a physi-
56 cian. Co-payments related to reimbursement for such services shall not
S. 5760 3
1 exceed twenty percent of the total reimbursement to the provider of
2 care. Visit limits for physical and occupational therapy services shall
3 be subject to an exceptions process, that shall include the covered
4 person's physician certifying that the cessation of services would most
5 likely result in further disability or harm to the covered person. Any
6 exceptions process shall be further determined by the superintendent,
7 § 6. Paragraph 13 of subsection (b) of section 4322 of the insurance
8 law, as added by chapter 504 of the laws of 1995, is amended and a new
9 paragraph 13-a is added to read as follows:
10 (13) Outpatient physical therapy up to ninety visits per condition per
11 calendar year. Any co-payments related to reimbursement for physical
12 therapy services shall not exceed twenty percent of the total reimburse-
13 ment to the provider of care. Visit limits for physical therapy services
14 shall be subject to an exceptions process, that shall include the
15 covered person's physician certifying that the cessation of services
16 would most likely result in further disability or harm to the covered
17 person. Any exceptions process shall be further determined by the
18 superintendent.
19 (13-a) Outpatient occupational therapy up to ninety visits per condi-
20 tion per calendar year. Any co-payments related to reimbursement for
21 occupational therapy services shall not exceed twenty percent of the
22 total reimbursement to the provider of care. Visit limits for occupa-
23 tional therapy services shall be subject to an exceptions process, that
24 shall include the covered person's physician certifying that such cessa-
25 tion of services would most likely result in further disability or harm
26 to the covered person. Any exceptions process shall be further deter-
27 mined by the superintendent.
28 § 7. Subsection (e) of section 4803 of the insurance law, as added by
29 chapter 705 of the laws of 1996, is amended and a new subsection (a-1)
30 is added to read as follows:
31 (a-1) Upon written request by a participating health care profes-
32 sional, a health care plan shall provide specific written clinical
33 review criteria relating to a particular condition, disease, service or
34 procedure and, where appropriate, other clinical information which the
35 health care plan or its utilization review agent might consider in its
36 utilization review and the health care plan shall include with the
37 information a description of how it will be used in the utilization
38 review process; provided, however, that to the extent such information
39 is proprietary to the health care plan, the participating health care
40 provider or prospective health care provider shall only use the informa-
41 tion for the purposes of assisting the participating health care provid-
42 er in evaluating covered services provided by the organization, an
43 adverse determination or an appeal of adverse determination.
44 (e) No insurer shall terminate [or], threaten to terminate, refuse to
45 renew or threaten refusal to renew a contract for participation in the
46 in-network benefits portion of an insurer's network for a managed care
47 product [solely] because the health care professional has (1) advocated
48 on behalf of an insured; (2) has filed a complaint against the insurer;
49 (3) has appealed a decision of the insurer; (4) provided information or
50 filed a report pursuant to section forty-four hundred six-c of the
51 public health law; [or] (5) requested a hearing or review pursuant to
52 this section; or (6) ordered or rendered medically necessary care.
53 § 8. Paragraph 1 of subsection (b) of section 4901 of the insurance
54 law, as added by chapter 705 of the laws of 1996, is amended to read as
55 follows:
S. 5760 4
1 (1) The utilization review plan, including but not limited to the
2 clinical review criteria and standards and the definition/standards of
3 medical necessity used under the utilization review plan. A utilization
4 review agent shall report any amendment or changes to the utilization
5 review plan to the superintendent within thirty days of making such
6 amendment or change;
7 § 9. Paragraph 4 of subsection (a) of section 4902 of the insurance
8 law, as added by chapter 705 of the laws of 1996, is amended to read as
9 follows:
10 (4) Establishment of a process for rendering utilization review deter-
11 minations which shall, at a minimum, include: written procedures to
12 assure that utilization reviews and determinations are conducted within
13 the timeframes established herein; procedures to notify an insured, an
14 insured's designee [and/or] and an insured's health care provider of
15 adverse determinations; and procedures for appeal of adverse determi-
16 nations including the establishment of an expedited appeals process for
17 denials of continued inpatient care or where there is imminent or seri-
18 ous threat to the health of the insured;
19 § 10. The opening paragraph of subsection (d) of section 4905 of the
20 insurance law, as added by chapter 705 of the laws of 1996, is amended
21 to read as follows:
22 A utilization review agent or the health care plan for which the agent
23 provides utilization review shall not, with respect to utilization
24 review activities, permit or provide compensation or anything of value
25 to its employees, agents, or contractors based on:
26 § 11. Subdivision 5 of section 4406-d of the public health law, as
27 added by chapter 705 of the laws of 1996, is amended and a new subdivi-
28 sion 1-a is added to read as follows:
29 1-a. Upon written request by a participating health care professional,
30 a health care plan shall provide specific written clinical review crite-
31 ria relating to a particular condition, disease, service or procedure
32 and, where appropriate, other clinical information which the health care
33 plan or its utilization review agent might consider in its utilization
34 review and the health care plan shall include with the information a
35 description of how it will be used in the utilization review process;
36 provided, however, that to the extent such information is proprietary to
37 the health care plan, the participating health care provider or prospec-
38 tive health care provider shall only use the information for the
39 purposes of assisting the participating health care provider in evaluat-
40 ing covered services provided by the organization, an adverse determi-
41 nation or an appeal of adverse determination.
42 5. No health care plan shall terminate, or threaten to terminate a
43 contract or employment, [or] refuse to renew, or threaten refusal to
44 renew a contract, [solely] because a health care provider has:
45 (a) advocated on behalf of an enrollee;
46 (b) filed a complaint against the health care plan;
47 (c) appealed a decision of the health care plan;
48 (d) provided information or filed a report pursuant to section forty-
49 four hundred six-c of this article; [or]
50 (e) requested a hearing or review pursuant to this section; or
51 (f) ordered or rendered medically necessary care.
52 § 12. Paragraph (a) of subdivision 2 of section 4901 of the public
53 health law, as added by chapter 705 of the laws of 1996, is amended to
54 read as follows:
55 (a) The utilization review plan, including but not limited to the
56 clinical review criteria and standards and the definition/standards of
S. 5760 5
1 medical necessity used under the utilization review plan. A utilization
2 review agent shall report any amendment or changes to the utilization
3 review plan to the commissioner within thirty days of making such amend-
4 ment or change;
5 § 13. Paragraph (d) of subdivision 1 of section 4902 of the public
6 health law, as added by chapter 705 of the laws of 1996, is amended to
7 read as follows:
8 (d) Establishment of a process for rendering utilization review deter-
9 minations which shall, at a minimum, include: written procedures to
10 assure that utilization reviews and determinations are conducted within
11 the timeframes established herein; procedures to notify an enrollee, an
12 enrollee's designee [and/or] and an enrollee's health care provider of
13 adverse determinations; and procedures for appeal of adverse determi-
14 nations including the establishment of an expedited appeals process for
15 denials of continued inpatient care or where there is imminent or seri-
16 ous threat to the health of the enrollee;
17 § 14. The opening paragraph of subdivision 4 of section 4905 of the
18 public health law, as added by chapter 705 of the laws of 1996, is
19 amended to read as follows:
20 A utilization review agent or the health care plan for which the agent
21 provides utilization review shall not, with respect to utilization
22 review activities, permit or provide compensation or anything of value
23 to its employees, agents, or contractors based on:
24 § 15. This act shall take effect on the one hundred eightieth day
25 after it shall have become a law.