S4870-2011 Actions

• Jan 5, 2012: PRINT NUMBER 4870A
• Jan 5, 2012: AMEND AND RECOMMIT TO INSURANCE
• Jan 4, 2012: REFERRED TO INSURANCE
• Apr 27, 2011: REFERRED TO INSURANCE

S4870-2011 Memo

BILL NUMBER:S4870

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


FISCAL IMPLICATIONS:
None.

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

S4870-2011 Text

 S T A T E   O F   N E W   Y O R K
 
 
                                         4870
 2011-2012 Regular Sessions
 I N  SENATE
 April 27, 2011
 
 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 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
 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
 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
 [ ] is old law to be omitted.
 LBD00680-01-1
 
       S. 4870                             2
 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 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.

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