A5590-2011 Actions

• Jan 4, 2012: referred to insurance
• Feb 23, 2011: referred to insurance

A5590-2011 Text

 S T A T E   O F   N E W   Y O R K
 
 
                                         5590
 2011-2012 Regular Sessions
 I N  ASSEMBLY
 February 23, 2011
 
 Introduced  by  M.  of A. BRENNAN, SCARBOROUGH, JAFFEE, BARRON -- Multi
 Sponsored by -- M. of A.  PHEFFER -- read once  and  referred  to  the
 Committee on Insurance
 

AN ACT to amend the insurance law and the public health law, in relation
 to physical therapy services and utilization practices
 

THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM
 BLY, DO ENACT AS FOLLOWS:

 

Section 1. Paragraph 23 of subsection  (i)  of  section  3216  of  the
 insurance  law,  as added by chapter 593 of the laws of 2000, is amended
 to read as follows:

 (23) If a policy provides for reimbursement for physical  and  occupa
 tional therapy service which is within the lawful scope of practice of a
 duly  licensed  physical  or occupational therapist, an insured shall be
 entitled to reimbursement for such service whether the said  service  is
 performed  by a physician or through a duly licensed physical or occupa
 tional therapist, provided however, that nothing contained herein  shall
 be  construed  to  impair any terms of such policy including appropriate
 utilization review and the requirement that said  service  be  performed
 pursuant to a medical order, or a similar or related service of a physi
 cian  PROVIDED  THAT  SUCH TERMS SHALL NOT IMPOSE DIFFERENT DEDUCTIBLES,
 CO-PAYMENTS OR CO-INSURANCE AMOUNTS ON THE BASIS OF THE SETTING IN WHICH
 SUCH PHYSICAL THERAPY SERVICES ARE RENDERED OR WHETHER THE SERVICES  ARE
 PERFORMED BY A PHYSICAL THERAPIST OR PHYSICIAN.
 

S 2. Subparagraph (A) of paragraph 1 of subsection (f) of section 4235
 of  the insurance law, as amended by chapter 240 of the laws of 2009, is
 amended to read as follows:

 (A) Any policy of group accident, group health or group  accident  and
 health  insurance  may include provisions for the payment by the insurer
 of benefits for expenses incurred on account  of  hospital,  medical  or
 surgical  care or physical and occupational therapy by licensed physical
 and occupational therapists upon  the  prescription  or  referral  of  a
 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
 [ ] is old law to be omitted.
 LBD08070-01-1
 
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 physician  for  the  employee  or other member of the insured group, his
 spouse, his child or children, or other persons chiefly  dependent  upon
 him  for  support  and  maintenance;  provided that a policy under which
 coverage  of  a  dependent of an employee or other member of the insured
 group terminates at a specified age shall not so terminate with  respect
 to  an unmarried child who is incapable of self-sustaining employment by
 reason of mental illness, developmental disability, mental  retardation,
 as  defined  in  the  mental  hygiene  law, or physical handicap and who
 became so incapable prior to attainment of the age  at  which  dependent
 coverage  would  otherwise  terminate  and who is chiefly dependent upon
 such employee or member for support and maintenance, while the insurance
 of the employee or member remains in force and the dependent remains  in
 such  condition, if the insured employee or member has within thirty-one
 days of such dependent's attainment of  the  termination  age  submitted
 proof  of such dependent's incapacity as described herein.  NO POLICY OF
 GROUP ACCIDENT, GROUP HEALTH OR  GROUP  ACCIDENT  AND  HEALTH  INSURANCE
 SHALL  IMPOSE DIFFERENT DEDUCTIBLES, CO-PAYMENTS OR CO-INSURANCE AMOUNTS
 ON THE BASIS OF THE SETTING IN WHICH SUCH PHYSICAL THERAPY SERVICES  ARE
 RENDERED  OR  WHETHER THE SERVICES ARE PERFORMED BY A PHYSICAL THERAPIST
 OR PHYSICIAN.
 

S 3. Subparagraph (A) of paragraph 4 of subsection (f) of section 4235
 of the insurance law, as amended by chapter 593 of the laws of 2000,  is
 amended to read as follows:

 (A)  any physical and occupational therapy service which is within the
 lawful scope of practice of a licensed physical and occupational  thera
 pist, a subscriber to such policy shall be entitled to reimbursement for
 such  service,  whether  the said service is performed by a physician or
 licensed physical and occupational therapist pursuant to prescription or
 referral by a physician; AND A POLICY OF GROUP ACCIDENT, GROUP HEALTH OR
 GROUP ACCIDENT AND HEALTH INSURANCE SHALL NOT IMPOSE  DIFFERENT  DEDUCT
 IBLES,  CO-PAYMENTS  OR CO-INSURANCE AMOUNTS ON THE BASIS OF THE SETTING
 IN WHICH SUCH PHYSICAL THERAPY SERVICES  ARE  RENDERED  OR  WHETHER  THE
 SERVICES ARE PERFORMED BY A PHYSICAL THERAPIST OR PHYSICIAN.
 

S 4. Subparagraph (G) of paragraph 1 of subsection (b) of section 4301
 of  the insurance law, as amended by chapter 593 of the laws of 2000, is
 amended to read as follows:

 (G) physical and occupational therapy care provided  through  licensed
 physical  and  occupational therapists upon the prescription of a physi
 cian AND ANY CO-PAYMENTS, DEDUCTIBLES, OR CO-INSURANCE  AMOUNTS  RELATED
 TO  REIMBURSEMENT  FOR PHYSICAL THERAPY SERVICES SHALL NOT DIFFER ON THE
 BASIS OF THE  SETTING  IN  WHICH  SUCH  PHYSICAL  THERAPY  SERVICES  ARE
 RENDERED  OR  WHETHER THE SERVICES ARE PERFORMED BY A PHYSICAL THERAPIST
 OR PHYSICIAN,
 

S 5. Paragraph 13 of subsection (b) of section 4322 of  the  insurance
 law,  as added by chapter 504 of the laws of 1995, is amended to read as
 follows:

 (13) Outpatient physical therapy up to ninety visits per condition per
 calendar year AND ANY CO-PAYMENTS, DEDUCTIBLES OR  CO-INSURANCE  AMOUNTS
 RELATED  TO  REIMBURSEMENT OF PHYSICAL THERAPY SERVICES SHALL NOT DIFFER
 ON THE BASIS OF THE SETTING IN WHICH SUCH PHYSICAL THERAPY SERVICES  ARE
 RENDERED  OR  WHETHER THE SERVICES ARE PERFORMED BY A PHYSICAL THERAPIST
 OR PHYSICIAN.
 

S 6. The opening paragraph of subdivision 4 of  section  4905  of  the
 public  health  law,  as  added  by  chapter 705 of the laws of 1996, is
 amended to read as follows:

 
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 A utilization review agent OR THE HEALTH CARE PLAN FOR WHICH THE AGENT
 PROVIDES UTILIZATION REVIEW  shall  not,  with  respect  to  utilization
 review  activities,  permit or provide compensation or anything of value
 to its employees, agents, or contractors based on:

 

S  7.  The  opening paragraph of subsection (d) of section 4905 of the
 insurance law, as added by chapter 705 of the laws of 1996,  is  amended
 to read as follows:

 A utilization review agent OR THE HEALTH CARE PLAN FOR WHICH THE AGENT
 PROVIDES  UTILIZATION  REVIEW  shall  not,  with  respect to utilization
 review activities, permit or provide compensation or anything  of  value
 to its employees, agents, or contractors based on:

 

S  8.  Subdivision  5  of  section 4406-d of the public health law, as
 added by chapter 705 of the laws of 1996, is amended to read as follows:

 5. No health care plan shall terminate, OR  THREATEN  TO  TERMINATE  a
 contract  or  employment,  [or]  refuse to renew, OR THREATEN REFUSAL TO
 RENEW a contract, [solely] because a health care provider has:

 (a) advocated on behalf of an enrollee;
 (b) filed a complaint against the health care plan;
 (c) appealed a decision of the health care plan;
 (d) provided information or filed a report pursuant to section  forty
 four hundred six-c of this article; [or]
 (e) requested a hearing or review pursuant to this section; OR
 (F) ORDERED OR RENDERED MEDICALLY NECESSARY CARE.
 

S  9. Subsection (e) of section 4803 of the insurance law, as added by
 chapter 705 of the laws of 1996, is amended to read as follows:

 (e) No insurer shall terminate [or], THREATEN TO TERMINATE, refuse  to
 renew  OR  THREATEN REFUSAL TO RENEW a contract for participation in the
 in-network benefits portion of an insurer's network for a  managed  care
 product  [solely] because the health care professional has (1) advocated
 on behalf of an insured; (2) has filed a complaint against the  insurer;
 (3)  has appealed a decision of the insurer; (4) provided information or
 filed a report pursuant to  section  forty-four  hundred  six-c  of  the
 public  health  law;  [or] (5) requested a hearing or review pursuant to
 this section; OR (6) ORDERED OR RENDERED MEDICALLY NECESSARY CARE.
 

S 10. Paragraph (d) of subdivision 1 of section  4902  of  the  public
 health  law,  as added by chapter 705 of the laws of 1996, is amended to
 read as follows:

 (d) Establishment of a process for rendering utilization review deter
 minations which shall, at a  minimum,  include:  written  procedures  to
 assure  that utilization reviews and determinations are conducted within
 the timeframes established herein; procedures to notify an enrollee,  an
 enrollee's  designee  [and/or] AND an enrollee's health care provider of
 adverse determinations; and procedures for appeal  of  adverse  determi
 nations  including the establishment of an expedited appeals process for
 denials of continued inpatient care or where there is imminent or  seri
 ous threat to the health of the enrollee;
 

S  11.  Paragraph 4 of subsection (a) of section 4902 of the insurance
 law, as added by chapter 705 of the laws of 1996, is amended to read  as
 follows:

 (4) Establishment of a process for rendering utilization review deter
 minations  which  shall,  at  a  minimum, include: written procedures to
 assure that utilization reviews and determinations are conducted  within
 the  timeframes  established herein; procedures to notify an insured, an
 insured's designee [and/or] AND an insured's  health  care  provider  of
 adverse  determinations;  and  procedures for appeal of adverse determi
 nations including the establishment of an expedited appeals process  for
 
       A. 5590                             4
 denials  of continued inpatient care or where there is imminent or seri
 ous threat to the health of the insured;
 

S  12.  Paragraph  (a)  of subdivision 2 of section 4901 of the public
 health law, as added by chapter 705 of the laws of 1996, is  amended  to
 read as follows:

 (a)  The  utilization  review  plan,  INCLUDING BUT NOT LIMITED TO THE
 CLINICAL REVIEW CRITERIA AND STANDARDS AND THE  DEFINITION/STANDARDS  OF
 MEDICAL  NECESSITY USED UNDER THE UTILIZATION REVIEW PLAN. A UTILIZATION
 REVIEW AGENT SHALL REPORT ANY AMENDMENT OR CHANGES  TO  THE  UTILIZATION
 REVIEW PLAN TO THE COMMISSIONER WITHIN THIRTY DAYS OF MAKING SUCH AMEND
 MENT OR CHANGE;
 

S  13.  Paragraph 1 of subsection (b) of section 4901 of the insurance
 law, as added by chapter 705 of the laws of 1996, is amended to read  as
 follows:

 (1)  The  utilization  review  plan,  INCLUDING BUT NOT LIMITED TO THE
 CLINICAL REVIEW CRITERIA AND STANDARDS AND THE  DEFINITION/STANDARDS  OF
 MEDICAL  NECESSITY USED UNDER THE UTILIZATION REVIEW PLAN. A UTILIZATION
 REVIEW AGENT SHALL REPORT ANY AMENDMENT OR CHANGES  TO  THE  UTILIZATION
 REVIEW  PLAN  TO  THE  SUPERINTENDENT  WITHIN THIRTY DAYS OF MAKING SUCH
 AMENDMENT OR CHANGE;
 

S 14.

Section 4406-d of the public health law is amended by  adding  a
 new subdivision 1-a to read as follows:

 1-A. UPON WRITTEN REQUEST BY A PARTICIPATING HEALTH CARE PROFESSIONAL,
 A HEALTH CARE PLAN SHALL PROVIDE SPECIFIC WRITTEN CLINICAL REVIEW CRITE
 RIA  RELATING  TO  A PARTICULAR CONDITION, DISEASE, SERVICE OR PROCEDURE
 AND, WHERE APPROPRIATE, OTHER CLINICAL INFORMATION WHICH THE HEALTH CARE
 PLAN OR ITS UTILIZATION REVIEW AGENT MIGHT CONSIDER IN  ITS  UTILIZATION
 REVIEW  AND  THE  HEALTH  CARE PLAN SHALL INCLUDE WITH THE INFORMATION A
 DESCRIPTION OF HOW IT WILL BE USED IN THE  UTILIZATION  REVIEW  PROCESS;
 PROVIDED, HOWEVER, THAT TO THE EXTENT SUCH INFORMATION IS PROPRIETARY TO
 THE HEALTH CARE PLAN, THE PARTICIPATING HEALTH CARE PROVIDER OR PROSPEC
 TIVE  HEALTH  CARE  PROVIDER  SHALL  ONLY  USE  THE  INFORMATION FOR THE
 PURPOSES OF ASSISTING THE PARTICIPATING HEALTH CARE PROVIDER IN EVALUAT
 ING COVERED SERVICES PROVIDED BY THE ORGANIZATION, AN  ADVERSE  DETERMI
 NATION OR AN APPEAL OF ADVERSE DETERMINATION.
 

S  15. 

Section  4803  of the insurance law is amended by adding a new
 subsection (a-1) to read as follows:

 (A-1) UPON WRITTEN REQUEST BY  A  PARTICIPATING  HEALTH  CARE  PROFES
 SIONAL,  A  HEALTH  CARE  PLAN  SHALL  PROVIDE SPECIFIC WRITTEN CLINICAL
 REVIEW CRITERIA RELATING TO A PARTICULAR CONDITION, DISEASE, SERVICE  OR
 PROCEDURE  AND,  WHERE APPROPRIATE, OTHER CLINICAL INFORMATION WHICH THE
 HEALTH CARE PLAN OR ITS UTILIZATION REVIEW AGENT MIGHT CONSIDER  IN  ITS
 UTILIZATION  REVIEW  AND  THE  HEALTH  CARE  PLAN SHALL INCLUDE WITH THE
 INFORMATION A DESCRIPTION OF HOW IT WILL  BE  USED  IN  THE  UTILIZATION
 REVIEW  PROCESS;  PROVIDED, HOWEVER, THAT TO THE EXTENT SUCH INFORMATION
 IS PROPRIETARY TO THE HEALTH CARE PLAN, THE  PARTICIPATING  HEALTH  CARE
 PROVIDER OR PROSPECTIVE HEALTH CARE PROVIDER SHALL ONLY USE THE INFORMA
 TION FOR THE PURPOSES OF ASSISTING THE PARTICIPATING HEALTH CARE PROVID
 ER  IN  EVALUATING  COVERED  SERVICES  PROVIDED  BY THE ORGANIZATION, AN
 ADVERSE DETERMINATION OR AN APPEAL OF ADVERSE DETERMINATION.
 

S 16.

Section 4406-c of the public health law is amended by  adding  a
 new subdivision 5-e to read as follows:

 5-E.  NO HEALTH CARE PLAN SHALL BY CONTRACT, WRITTEN POLICY OR WRITTEN
 PROCEDURE REFUSE TO HONOR, PROHIBIT OR IN ANY WAY RESTRICT  THE  ABILITY
 OF  AN  ENROLLEE  TO  ASSIGN  HIS OR HER BENEFITS ALLOWABLE OR OTHERWISE
 PAYABLE TO THE ENROLLEE AS PAYMENT FOR PROFESSIONAL SERVICES RENDERED.
 
       A. 5590                             5
 

S 17. The insurance law is amended by adding a new section  4803-a  to
 read as follows:

 

S  4803-A.  PROHIBITIONS. 1. NO MANAGED CARE HEALTH INSURANCE CONTRACT
 OR MANAGED CARE PRODUCT SHALL BY CONTRACT,  WRITTEN  POLICY  OR  WRITTEN
 PROCEDURE  REFUSE  TO HONOR, PROHIBIT OR IN ANY WAY RESTRICT THE ABILITY
 OF AN ENROLLEE TO ASSIGN HIS OR  HER  BENEFITS  ALLOWABLE  OR  OTHERWISE
 PAYABLE TO THE ENROLLEE AS PAYMENT FOR PROFESSIONAL SERVICES RENDERED.
 2.  ANY  CONTRACT  PROVISION,  WRITTEN  POLICY OR WRITTEN PROCEDURE IN
 VIOLATION OF THIS SECTION SHALL BE DEEMED TO BE VOID AND UNENFORCEABLE.
 

S 18.

Section 4905 of the public health law is amended by adding a new
 subdivision 16 to read as follows:

 16. A HEALTH CARE PLAN SHALL PROVIDE NOTICE TO PARTICIPATING PROVIDERS
 SIXTY DAYS IN ADVANCE OF A CHANGE IN UTILIZATION REVIEW AGENTS.
 

S 19.

Section 4905 of the insurance law is amended  by  adding  a  new
 subsection (p) to read as follows:

 (P) A HEALTH CARE PLAN SHALL PROVIDE NOTICE TO PARTICIPATING PROVIDERS
 SIXTY DAYS IN ADVANCE OF A CHANGE IN UTILIZATION REVIEW AGENTS.
 

S  20.  This  act  shall  take effect on the one hundred eightieth day
 after it shall have become a law.

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