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.

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S2319-2013 Actions

• Jan 15, 2013: REFERRED TO INSURANCE

S2319-2013 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.

S2319-2013 Text

                      S T A T E   O F   N E W   Y O R K
  ________________________________________________________________________

                                    2319

                         2013-2014 Regular Sessions

                              I N  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-

   EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                        [ ] is old law to be omitted.
                                                             LBD03730-01-3

 S. 2319                             2

  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

 S. 2319                             3

  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.