This bill has been amended

Bill S2319-2013

No policy of group accident, group health or group accident and health shall impose copayments in excess of 20 percent of total reimbursement to the provider of care

Provides that no policy of group accident, group health or group accident and health shall impose co-payments in excess of twenty percent of total reimbursement to the provider of care.

Details

Actions

  • Jan 8, 2014: REFERRED TO INSURANCE
  • Jan 15, 2013: REFERRED TO INSURANCE

Memo

BILL NUMBER:S2319

TITLE OF BILL: An act to amend the insurance law, in relation to physical therapy services

PURPOSE: To limit the imposition of co-payments for physical therapy services to no more than twenty percent of the reimbursement to the provider of care.

SUMMARY OF PROVISIONS:

Sections 1 through 5 prohibit payors from imposing costs on insureds for the provision of physical therapy services in excess of 20 percent of the reimbursement to the provider of care.

Section 6. Effective Date.

JUSTIFICATION: This bill will protect consumers by prohibiting plans from inappropriately shifting the cost of physical therapy care to consumers by limiting co-payments to no more than 20 percent of the total reimbursement to the provider of care. Under existing law, health plans must cover physical therapy services. Despite that requirement, health plans have shifted the vast majority of the cost of physical therapy services by imposing increasingly high co-payments on consumers. Under certain health plans, co-payments for physical therapy services have exceeded the reimbursement paid by the plan to the provider of care.

This cost shift has imposed a financial burden on consumers, and it has restricted access to physical therapy services. Consumers frequently cannot afford the cost imposed by these copayments for medically necessary physical therapy care. physical therapy services generally require multiple visits over the healing process. A co-payment of $50 for a physical therapy plan of care of 3 times a week for a month will cost the consumer $600 in out-of-pocket expenses which is beyond the means of many consumers. As a result, New Yorkers are forgoing medically necessary care running the risk of worsening the underlying condition or risking re-injury.

This bill would reestablish the obligation of health plans to cover the expense of physical therapy services by limiting co-payments to no more than twenty percent of the total reimbursement to the provider of care. The 20 percent limitation will allow plans to require co-payments that discourage inappropriate care but will prohibit plans from inappropriately shifting the cost of physical therapy care to consumers.

LEGISLATIVE HISTORY: 2009-2010 A.8171-A Referred to Insurance 2011-2012 S.4870A/A.187A

FISCAL IMPLICATIONS: None

EFFECTIVE DATE: 180 days after it shall have become a law.


Text

STATE OF NEW YORK ________________________________________________________________________ 2319 2013-2014 Regular Sessions IN SENATE January 15, 2013 ___________
Introduced by Sen. DeFRANCISCO -- 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 physical therapy services 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 CO-PAYMENTS IN EXCESS OF TWENTY PERCENT OF THE TOTAL REIMBURSEMENT TO THE PROVIDER OF CARE. S 2. Subparagraph (A) of paragraph 1 of subsection (f) of section 4235 of the insurance law, as amended by chapter 219 of the laws of 2011, 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 physician for the employee or other member of the insured group, the employee's or member's spouse, the employee's or member's child or chil-
dren, or other persons chiefly dependent upon the employee or member for support and maintenance; provided that: (i) a policy of hospital, medical, surgical, or prescription drug expense insurance that provides coverage for children shall provide such coverage to a married or unmarried child until attainment of age twen- ty-six, without regard to financial dependence, residency with the employee or member, student status, or employment, except a policy that is a grandfathered health plan may, for plan years beginning before January first, two thousand fourteen, exclude coverage of an adult child under age twenty-six who is eligible to enroll in an employer-sponsored health plan other than a group health plan of a parent. For purposes of this item, "grandfathered health plan" means coverage provided by an insurer in which an individual was enrolled on March twenty-third, two thousand ten for as long as the coverage maintains grandfathered status in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C. S 18011(e); and (ii) a policy under which coverage 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 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 child remains in such condition, if the insured employee or member has within thirty-one days of such child's attainment of the termination age submitted proof of such child's incapacity as described herein. NO POLICY OF GROUP ACCIDENT, GROUP HEALTH OR GROUP ACCIDENT AND HEALTH INSURANCE SHALL IMPOSE CO-PAYMENTS IN EXCESS OF TWENTY PERCENT OF THE TOTAL REIMBURSEMENT TO THE PROVIDER OF CARE. 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 CO-PAYMENTS IN EXCESS OF TWENTY PERCENT OF THE TOTAL REIMBURSEMENT TO THE PROVIDER OF CARE; 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 RELATED TO REIMBURSEMENT FOR PHYSICAL THERAPY SERVICES SHALL NOT EXCEED TWENTY PERCENT OF THE TOTAL REIMBURSEMENT TO THE PROVIDER OF CARE, 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 RELATED TO REIMBURSEMENT FOR PHYSICAL
THERAPY SERVICES SHALL NOT EXCEED TWENTY PERCENT OF THE TOTAL REIMBURSE- MENT TO THE PROVIDER OF CARE. S 6. This act shall take effect on the one hundred eightieth day after it shall have become a law.

Comments

Open Legislation comments facilitate discussion of New York State legislation. All comments are subject to moderation. Comments deemed off-topic, commercial, campaign-related, self-promotional; or that contain profanity or hate speech; or that link to sites outside of the nysenate.gov domain are not permitted, and will not be published. Comment moderation is generally performed Monday through Friday.

By contributing or voting you agree to the Terms of Participation and verify you are over 13.

Discuss!

blog comments powered by Disqus