NY State Senate Bill 2015-S5076A

Senate Bill S5076A

2015-2016 Legislative Session

Relates to including certain out of home services such as transition from a hospital, nursing facility or other institutional setting to the home within home care insurance coverage

download bill text pdf

Archive: Last Bill Status - In Senate Committee Insurance Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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Actions

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 11, 2016	print number 5076a
Jan 11, 2016	amend and recommit to insurance
Jan 06, 2016	referred to insurance
Apr 30, 2015	referred to insurance

Bill Amendments

Original

A (Active)

2015-S5076 - Details

See Assembly Version of this Bill:: A7706
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3221 & 4303, Ins L
Versions Introduced in Other Legislative Sessions:: 2017-2018: A54
2019-2020: A408
2021-2022: A380
2023-2024: A7953

2015-S5076 - Summary

Includes certain out of home services such as transition from a hospital, nursing facility or other institutional setting to the home within home care insurance coverage.

2015-S5076 - Sponsor Memo

                                BILL NUMBER:S5076

TITLE OF BILL:  An act to amend the insurance law, in relation to
including certain out of home services such as transition from a
hospital, nursing facility or other institutional setting to the home
within home care insurance coverage

PURPOSE:

To update and align the Insurance Law specifications for home care
coverage with the current system of hospital and medical practice

SUMMARY OF PROVISIONS:

The current State Insurance Law provisions for home care specify
coverage for these services when under the care of a physician,
established and approved in writing by the physician, and provided by
state certified/licensed home care agencies.

The bill maintains these baseline standards for coverage while
updating the 40+ year-old specifications for: a covered individual's
receipt of services, the listed services that certified/licensed
agencies actually provide, and the cost and utilization control
mechanisms now used by insurers.

Specifically, sections one and two of the bill, respectively, amend

3221 and § 4303 of the insurance law to update the following in each
section:

* Consistent with current hospital and medical care practice, the bill
modernizes the specifications for the covered individual to be for an
individual who requires services for: (i)transition from a hospital,
nursing facility or other institutional setting to home;(ii)
rehabilitation, recovery or medical management at home following
hospitalization or institutional care; or (iii) medical management of
a condition predisposing the covered individual to hospitalization or
confinement in a nursing facility or to the need for other out-of-home
services otherwise covered under the contract or policy if home care
is not provided.

*  Updates the reference to a home care agency's authorized list of
services (now specified in § 3221 and § 4303 as nursing, home health
aide, physical therapy, occupational therapy or speech therapy) to
reflect other services the agency actually provides which include
social work, respiratory therapy and nutritional counseling, which are
likewise proven vital to cost-effective and necessary care in the
modern delivery system.

*  Replaces outdated mechanisms for utilization and cost controls
(e.g., replaces the existing law's 40 visit minimum) with contemporary
and more dynamic controls used in insurance and managed care, such as
management or utilization review of home care benefits, or use of
preauthorization and appropriateness criteria as to the level and
intensity of treatment applicable to home care.


Section three of the bill provides for an effective date of January 1,
2006, and applicability to policies and contracts issued, renewed,
modified or amended on or after such date.

JUSTIFICATION:

This bill provides long overdue updates to antiquated sections of the
State Insurance Law that stipulate the coverage for home care
services.

The current home care coverage provisions, adopted in the early 1970s,
were written and set forth for the health care system as it existed at
that time.

In that era:

*  Hospitals were reimbursed per diem and without today's limitations
on length of stay; many of today's complex procedures did not exist,
nor did cases of such brief, even same-day, turnarounds; patients
being discharged were nowhere near today's level of continuing,
intense and complex medical need.

*  Nursing homes were the primary health system option for chronically
ill, unlike today where home care plays a dominant role.

*  Transition of patients from hospitals to home, or from nursing
homes (particularly rehab patients) to home, was not the major,
complex hurdle that it is today, nor the level of priority medical
focus that today is addressed substantially through home
care-hospital-physician partnership.

*  Today's technologies for delivery of services and comprehensive
medical management between physicians and home care agencies (such as
telehealth/telemedicine) did not exist.

*  Home care itself was not the integrated and heavily relied-upon
model evidenced in today's system.

The type of system that framed the now 40+ year-old insurance law
provisions bears little resemblance to the health care system of
today.

This bill's modernization of the law would delineate the conditions of
home care coverage consistent with today's state of the art health and
medical care practices. It would support the operation of the entire
health care system, synchronize coverage to the newest models and
innovations of care, promote cost-savings and efficiency, and most
importantly benefit covered individuals. It would also preserve and
enhance the original statue's intent of utilizing home care to prevent
avoidable hospitalizations, emergency room use and other higher cost
medical services use.

LEGISLATIVE HISTORY:

New Bill

FISCAL IMPLICATIONS:


This bill will promote increased cost-efficiency and savings in the
health care system.

EFFECTIVE DATE:

The bill would take effect January 1, 2016, and apply to policies and
contracts issued, renewed, modified or amended on or after such date.

2015-S5076 - Bill Text download pdf

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

                                  5076

                       2015-2016 Regular Sessions

                            I N  S E N A T E

                             April 30, 2015
                               ___________

Introduced  by  Sen.  SEWARD -- 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 including certain  out
  of  home services such as transition from a hospital, nursing facility
  or other institutional setting to the home within home care  insurance
  coverage

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

  Section 1. Subparagraphs (C), (D) and (E) of paragraph 1 of subsection
(k) of section 3221 of the insurance law, subparagraphs (C) and  (D)  as
amended  by  chapter  557  of  the  laws of 2000, are amended to read as
follows:
  (C) Home care means the care and treatment of a covered person who  is
under  the  care  of  a  physician  [but  only  if] AND WHO REQUIRES THE
SERVICES OF AN AGENCY DESCRIBED IN SUBPARAGRAPH (D)  OF  THIS  PARAGRAPH
FOR: TRANSITION OF THE COVERED PERSON FROM HOSPITAL, NURSING FACILITY OR
OTHER INSTITUTIONAL SETTING TO HOME; REHABILITATION, RECOVERY OR MEDICAL
MANAGEMENT  OF  THE  COVERED PERSON AT HOME FOLLOWING HOSPITALIZATION OR
FOLLOWING CARE IN A NURSING FACILITY OR OTHER INSTITUTIONAL SETTING;  OR
MEDICAL MANAGEMENT OF A CONDITION PREDISPOSING THE COVERED INDIVIDUAL TO
hospitalization  [or],  confinement in a nursing facility [as defined in
subchapter XVIII of the federal Social Security Act, 42 U.S.C.  SS  1395
et  seq,  would  otherwise  have  been  required]  OR THE NEED FOR OTHER
OUT-OF-HOME SERVICES OTHERWISE COVERED UNDER THE CONTRACT if  home  care
[was]  IS not provided, and the plan covering the home health service is
established and approved in writing by such physician.
  (D) Home care shall be  provided  by  an  agency  possessing  a  valid
certificate of approval or license issued pursuant to article thirty-six
of the public health law and shall consist of one or more of the follow-
ing:

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10539-02-5

S. 5076                             2

  (i) Part-time or intermittent home nursing care by or under the super-
vision of a registered professional nurse (R.N.).
  (ii) Part-time or intermittent home health aide services which consist
primarily of caring for the patient.
  (iii)  Physical,  occupational or speech therapy, SOCIAL WORK, RESPIR-
ATORY THERAPY AND NUTRITIONAL COUNSELING, if provided by the home health
service or agency.
  (iv) Medical supplies, drugs and medications prescribed  by  a  physi-
cian, and laboratory services by or on behalf of a certified home health
agency  or  licensed  home care services agency to the extent such items
would have been covered under the contract if  the  covered  person  had
been  hospitalized  or confined in a skilled nursing facility as defined
in subchapter XVIII of the federal Social Security  Act,  42  U.S.C.  SS
1395 et seq.
  (E)  For  the purpose of determining the benefits for home care avail-
able to a covered person, [each visit by a member of a  home  care  team
shall  be  considered as one home care visit; the contract may contain a
limitation on the number of home care visits, but not  less  than  forty
such  visits  in any calendar year or in any continuous period of twelve
months, for each person covered under the contract; four hours  of  home
health  aide service shall be considered as one home care visit] NOTHING
IN THIS PARAGRAPH SHALL BE CONSTRUED TO PREVENT THE MANAGEMENT OR UTILI-
ZATION REVIEW OF HOME CARE BENEFITS, INCLUDING THE  USE  OF  PREAUTHORI-
ZATION  AND  APPROPRIATENESS  CRITERIA  AS TO THE LEVEL AND INTENSITY OF
TREATMENT APPLICABLE TO HOME CARE, PROVIDED HOWEVER THAT ANY SUCH DETER-
MINATIONS MAY BE SUBJECT TO APPEAL  UNDER  ARTICLE  FORTY-NINE  OF  THIS
CHAPTER.
  S  2.  Paragraph  3 of subsection (a) of section 4303 of the insurance
law, subparagraphs (A), (B) and (C) as amended by  chapter  557  of  the
laws  of  2000 and subparagraph (D) as amended by chapter 21 of the laws
of 1990, is amended to read as follows:
  (3) For home care to residents in this state. Such home care  coverage
shall  be  included  at  the  inception  of  all new contracts and, with
respect to all other contracts, added at any  anniversary  date  of  the
contract  subject  to  evidence  of  insurability.  Such coverage may be
subject to an annual deductible of not more than fifty dollars for  each
covered  person  and  may  be  subject  to a coinsurance provision which
provides for coverage of not  less  than  seventy-five  percent  of  the
reasonable  cost  of  services  for  which  payment may be made. No such
corporation need provide such coverage to persons eligible for medicare.
  (A) Home care shall mean the care and treatment of  a  covered  person
who is under the care of a physician [but only if:
  (i)]  AND WHO REQUIRES THE SERVICES OF AN AGENCY DESCRIBED IN SUBPARA-
GRAPH (B) OF THIS PARAGRAPH FOR: TRANSITION OF THE COVERED  PERSON  FROM
HOSPITAL,  NURSING  FACILITY OR OTHER INSTITUTIONAL SETTING TO HOME; FOR
REHABILITATION, RECOVERY OR MEDICAL MANAGEMENT OF THE COVERED PERSON  AT
HOME  FOLLOWING  HOSPITALIZATION OR FOLLOWING CARE IN A NURSING FACILITY
OR OTHER INSTITUTIONAL SETTING; OR MEDICAL  MANAGEMENT  OF  A  CONDITION
PREDISPOSING THE COVERED INDIVIDUAL TO hospitalization [or], confinement
in  a  nursing  facility  [as  defined in subchapter XVIII of the Social
Security Act, 42 U.S.C.  S  1395  et  seq,  would  otherwise  have  been
required]  OR  THE NEED FOR OTHER OUT-OF-HOME SERVICES OTHERWISE COVERED
UNDER THE POLICY, if home care [was] IS not provided, and
  [(ii)] the plan covering the home health service  is  established  and
approved in writing by such physician.

S. 5076                             3

  (B)  Home  care  shall  be  provided  by  an agency possessing a valid
certificate of approval or license issued pursuant to article thirty-six
of the public health law.
  (C) Home care shall consist of one or more of the following:
  (i) part-time or intermittent home nursing care by or under the super-
vision of a registered professional nurse (R.N.),
  (ii) part-time or intermittent home health aide services which consist
primarily of caring for the patient,
  (iii)  physical,  occupational or speech therapy, SOCIAL WORK, RESPIR-
ATORY THERAPY AND NUTRITIONAL COUNSELING, if provided by the home health
service or agency, and
  (iv) medical supplies, drugs and medications prescribed  by  a  physi-
cian, and laboratory services by or on behalf of a certified home health
agency  or  licensed  home care services agency to the extent such items
would have been covered or provided under the contract  if  the  covered
person  had  been hospitalized or confined in a skilled nursing facility
as defined in subchapter XVIII of the Social Security Act, 42  U.S.C.  S
1395 et seq.
  (D)  For  the purpose of determining the benefits for home care avail-
able to a covered person, [each visit by a member of a  home  care  team
shall  be  considered as one home care visit. The contract may contain a
limitation on the number of home care visits, but not  less  than  forty
such  visits  in any calendar year or in any continuous period of twelve
months, for each covered person. Four hours of home health aide  service
shall  be  considered as one home care visit. Every contract issued by a
hospital  service  corporation  or  health  service  corporation   which
provides coverage supplementing part A and part B of subchapter XVIII of
the  Social  Security  Act, 42 U.S.C. S 1395 et seq, must make available
and, if requested by a subscriber holding a direct payment  contract  or
by all subscribers in a group remittance group or by the contract holder
in  the case of group contracts issued pursuant to section four thousand
three hundred five of this article,  provide  coverage  of  supplemental
home  care visits beyond those provided by part A and part B, sufficient
to produce an aggregate coverage of three hundred sixty-five  home  care
visits  per  contract  year. Such coverage shall be provided pursuant to
regulations prescribed by the  superintendent.  Written  notice  of  the
availability  of such coverage shall be delivered to the group remitting
agent or group contract holder prior to inception of such  contract  and
annually thereafter, except that this notice shall not be required where
a  policy  covers  two  hundred  or  more employees or where the benefit
structure was the subject of collective bargaining affecting persons who
are employed in more than one state] NOTHING IN THIS PARAGRAPH SHALL  BE
CONSTRUED  TO  PREVENT THE MANAGEMENT OR UTILIZATION REVIEW OF HOME CARE
BENEFITS, INCLUDING THE  USE  OF  PREAUTHORIZATION  AND  APPROPRIATENESS
CRITERIA  AS  TO THE LEVEL AND INTENSITY OF TREATMENT APPLICABLE TO HOME
CARE, PROVIDED HOWEVER THAT ANY SUCH DETERMINATIONS MAY  BE  SUBJECT  TO
APPEAL UNDER ARTICLE FORTY-NINE OF THIS CHAPTER.
  S 3. This act shall take effect January 1, 2016 and shall apply to all
policies  and contracts issued, renewed, modified, altered or amended on
or after such date.

2015-S5076A (ACTIVE) - Details

See Assembly Version of this Bill:: A7706
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3221 & 4303, Ins L
Versions Introduced in Other Legislative Sessions:: 2017-2018: A54
2019-2020: A408
2021-2022: A380
2023-2024: A7953

2015-S5076A (ACTIVE) - Summary

Includes certain out of home services such as transition from a hospital, nursing facility or other institutional setting to the home within home care insurance coverage.

2015-S5076A (ACTIVE) - Sponsor Memo

                                 BILL NUMBER:  S5076A

 TITLE OF BILL :

An act to amend the insurance law, in relation to including certain
out of home services such as transition from a hospital, nursing
facility or other institutional setting to the home within home care
insurance coverage

 PURPOSE :

To update and align the Insurance Law specifications for home care
coverage with the current system of hospital and medical practice

 SUMMARY OF PROVISIONS :

The current State Insurance Law provisions for home care specify
coverage for these services when under the care of a physician,
established and approved in writing by the physician, and provided by
state certified/licensed home care agencies.

The bill maintains these baseline standards for coverage while
updating the 40+ year-old specifications for: a covered individual's
receipt of services, the listed services that certified/licensed
agencies actually provide, and the cost and utilization control
mechanisms now used by insurers.

Specifically, sections one and two of the bill, respectively, amend

§ 3221 and § 4303 of the insurance law to update the following in each
section:

* Consistent with current hospital and medical care practice, the bill
modernizes the specifications for the covered individual to be for an
individual who requires services for: (i)transition from a hospital,
nursing facility or other institutional setting to home;(ii)
rehabilitation, recovery or medical management at home following
hospitalization or institutional care; or (iii) medical management of
a condition predisposing the covered individual to hospitalization or
confinement in a nursing facility or to the need for other out-of-home
services otherwise covered under the contract or policy if home care
is not provided.

* Updates the reference to a home care agency's authorized list of
services (now specified in § 3221 and § 4303 as nursing, home health
aide, physical therapy, occupational therapy or speech therapy) to
reflect other services the agency actually provides which include
social work, respiratory therapy and nutritional counseling, which are
likewise proven vital to cost-effective and necessary care in the
modem delivery system.

* Replaces outdated mechanisms for utilization and cost controls
(e.g., replaces the existing law's 40 visit minimum) with contemporary
and more dynamic controls used in insurance and managed care, such as
management or utilization review of home care benefits, or use of
preauthorization and appropriateness criteria as to the level and
intensity of treatment applicable to home care.

Section three of the bill provides for an effective date of January 1,
2006, and applicability to policies and contracts issued, renewed,
modified or amended on or after such date.

 JUSTIFICATION :



This bill provides long overdue updates to antiquated sections of the
State Insurance Law that stipulate the coverage for home care
services.

The current home care coverage provisions, adopted in the early 1970s,
were written and set forth for the health care system as it existed at
that time.

In that era:

* Hospitals were reimbursed per diem and without today's limitations
on length of stay; many of today's complex procedures did not exist,
nor did cases of such brief, even same-day, turnarounds; patients
being discharged were nowhere near today's level of continuing,
intense and complex medical need.

* Nursing homes were the primary health system option for chronically
ill, unlike today where home care plays a dominant role.

* Transition of patients from hospitals to home, or from nursing homes
(particularly rehab patients) to home, was not the major, complex
hurdle that it is today, nor the level of priority medical focus that
today is addressed substantially through home care-hospital-physician
partnership.

* Today's technologies for delivery of services and comprehensive
medical management between physicians and home care agencies (such as
telehealth/telemedicine) did not exist.

* Home care itself was not the integrated and heavily relied-upon
model evidenced in today's system.

The type of system that framed the now 40+ year-old insurance law
provisions bears little resemblance to the health care system of
today.

This bill's modernization of the law would delineate the conditions of
home care coverage consistent with today's state of the art health and
medical care practices. It would support the operation of the entire
health care system, synchronize coverage to the newest models and
innovations of care, promote cost-savings and efficiency, and most
importantly benefit covered individuals. It would also preserve and
enhance the original statue's intent of utilizing home care to prevent
avoidable hospitalizations, emergency room use and other higher cost
medical services use.

 LEGISLATIVE HISTORY :

New Bill

 FISCAL IMPLICATIONS :

This bill will promote increased cost-efficiency and savings in the
health care system.

 EFFECTIVE DATE :
The bill would take effect January 1, 2017, and apply to policies and
contracts issued, renewed, modified or amended on or after such date.

2015-S5076A (ACTIVE) - Bill Text download pdf

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

                                 5076--A

                       2015-2016 Regular Sessions

                            I N  S E N A T E

                             April 30, 2015
                               ___________

Introduced  by  Sen.  SEWARD -- read twice and ordered printed, and when
  printed to be committed to the Committee on Insurance  --  recommitted
  to the Committee on Insurance in accordance with Senate Rule 6, sec. 8
  --  committee  discharged,  bill amended, ordered reprinted as amended
  and recommitted to said committee

AN ACT to amend the insurance law, in relation to including certain  out
  of  home services such as transition from a hospital, nursing facility
  or other institutional setting to the home within home care  insurance
  coverage

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

  Section 1. Subparagraphs (C), (D) and (E) of paragraph 1 of subsection
(k) of section 3221 of the insurance law, subparagraphs (C) and  (D)  as
amended  by  chapter  557  of  the  laws of 2000, are amended to read as
follows:
  (C) Home care means the care and treatment of a covered person who  is
under  the  care  of  a  physician  [but  only  if] AND WHO REQUIRES THE
SERVICES OF AN AGENCY DESCRIBED IN SUBPARAGRAPH (D)  OF  THIS  PARAGRAPH
FOR: TRANSITION OF THE COVERED PERSON FROM HOSPITAL, NURSING FACILITY OR
OTHER INSTITUTIONAL SETTING TO HOME; REHABILITATION, RECOVERY OR MEDICAL
MANAGEMENT  OF  THE  COVERED PERSON AT HOME FOLLOWING HOSPITALIZATION OR
FOLLOWING CARE IN A NURSING FACILITY OR OTHER INSTITUTIONAL SETTING;  OR
MEDICAL MANAGEMENT OF A CONDITION PREDISPOSING THE COVERED INDIVIDUAL TO
hospitalization  [or],  confinement in a nursing facility [as defined in
subchapter XVIII of the federal Social Security Act, 42 U.S.C.  SS  1395
et  seq,  would  otherwise  have  been  required]  OR THE NEED FOR OTHER
OUT-OF-HOME SERVICES OTHERWISE COVERED UNDER THE CONTRACT if  home  care
[was]  IS not provided, and the plan covering the home health service is
established and approved in writing by such physician.
  (D) Home care shall be  provided  by  an  agency  possessing  a  valid
certificate of approval or license issued pursuant to article thirty-six

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10539-03-6

S. 5076--A                          2

of the public health law and shall consist of one or more of the follow-
ing:
  (i) Part-time or intermittent home nursing care by or under the super-
vision of a registered professional nurse (R.N.).
  (ii) Part-time or intermittent home health aide services which consist
primarily of caring for the patient.
  (iii)  Physical,  occupational or speech therapy, SOCIAL WORK, RESPIR-
ATORY THERAPY AND NUTRITIONAL COUNSELING, if provided by the home health
service or agency.
  (iv) Medical supplies, drugs and medications prescribed  by  a  physi-
cian, and laboratory services by or on behalf of a certified home health
agency  or  licensed  home care services agency to the extent such items
would have been covered under the contract if  the  covered  person  had
been  hospitalized  or confined in a skilled nursing facility as defined
in subchapter XVIII of the federal Social Security  Act,  42  U.S.C.  SS
1395 et seq.
  (E)  For  the purpose of determining the benefits for home care avail-
able to a covered person, [each visit by a member of a  home  care  team
shall  be  considered as one home care visit; the contract may contain a
limitation on the number of home care visits, but not  less  than  forty
such  visits  in any calendar year or in any continuous period of twelve
months, for each person covered under the contract; four hours  of  home
health  aide service shall be considered as one home care visit] NOTHING
IN THIS PARAGRAPH SHALL BE CONSTRUED TO PREVENT THE MANAGEMENT OR UTILI-
ZATION REVIEW OF HOME CARE BENEFITS, INCLUDING THE  USE  OF  PREAUTHORI-
ZATION  AND  APPROPRIATENESS  CRITERIA  AS TO THE LEVEL AND INTENSITY OF
TREATMENT APPLICABLE TO HOME CARE, PROVIDED HOWEVER THAT ANY SUCH DETER-
MINATIONS MAY BE SUBJECT TO APPEAL  UNDER  ARTICLE  FORTY-NINE  OF  THIS
CHAPTER.
  S  2.  Paragraph  3 of subsection (a) of section 4303 of the insurance
law, subparagraphs (A), (B) and (C) as amended by  chapter  557  of  the
laws  of  2000 and subparagraph (D) as amended by chapter 21 of the laws
of 1990, is amended to read as follows:
  (3) For home care to residents in this state. Such home care  coverage
shall  be  included  at  the  inception  of  all new contracts and, with
respect to all other contracts, added at any  anniversary  date  of  the
contract  subject  to  evidence  of  insurability.  Such coverage may be
subject to an annual deductible of not more than fifty dollars for  each
covered  person  and  may  be  subject  to a coinsurance provision which
provides for coverage of not  less  than  seventy-five  percent  of  the
reasonable  cost  of  services  for  which  payment may be made. No such
corporation need provide such coverage to persons eligible for medicare.
  (A) Home care shall mean the care and treatment of  a  covered  person
who is under the care of a physician [but only if:
  (i)]  AND WHO REQUIRES THE SERVICES OF AN AGENCY DESCRIBED IN SUBPARA-
GRAPH (B) OF THIS PARAGRAPH FOR: TRANSITION OF THE COVERED  PERSON  FROM
HOSPITAL,  NURSING  FACILITY OR OTHER INSTITUTIONAL SETTING TO HOME; FOR
REHABILITATION, RECOVERY OR MEDICAL MANAGEMENT OF THE COVERED PERSON  AT
HOME  FOLLOWING  HOSPITALIZATION OR FOLLOWING CARE IN A NURSING FACILITY
OR OTHER INSTITUTIONAL SETTING; OR MEDICAL  MANAGEMENT  OF  A  CONDITION
PREDISPOSING THE COVERED INDIVIDUAL TO hospitalization [or], confinement
in  a  nursing  facility  [as  defined in subchapter XVIII of the Social
Security Act, 42 U.S.C.  S  1395  et  seq,  would  otherwise  have  been
required]  OR  THE NEED FOR OTHER OUT-OF-HOME SERVICES OTHERWISE COVERED
UNDER THE POLICY, if home care [was] IS not provided, and

S. 5076--A                          3

  [(ii)] the plan covering the home health service  is  established  and
approved in writing by such physician.
  (B)  Home  care  shall  be  provided  by  an agency possessing a valid
certificate of approval or license issued pursuant to article thirty-six
of the public health law.
  (C) Home care shall consist of one or more of the following:
  (i) part-time or intermittent home nursing care by or under the super-
vision of a registered professional nurse (R.N.),
  (ii) part-time or intermittent home health aide services which consist
primarily of caring for the patient,
  (iii) physical, occupational or speech therapy, SOCIAL  WORK,  RESPIR-
ATORY THERAPY AND NUTRITIONAL COUNSELING, if provided by the home health
service or agency, and
  (iv)  medical  supplies,  drugs and medications prescribed by a physi-
cian, and laboratory services by or on behalf of a certified home health
agency or licensed home care services agency to the  extent  such  items
would  have  been  covered or provided under the contract if the covered
person had been hospitalized or confined in a skilled  nursing  facility
as  defined  in subchapter XVIII of the Social Security Act, 42 U.S.C. S
1395 et seq.
  (D) For the purpose of determining the benefits for home  care  avail-
able  to  a  covered person, [each visit by a member of a home care team
shall be considered as one home care visit. The contract may  contain  a
limitation  on  the  number of home care visits, but not less than forty
such visits in any calendar year or in any continuous period  of  twelve
months,  for each covered person. Four hours of home health aide service
shall be considered as one home care visit. Every contract issued  by  a
hospital   service  corporation  or  health  service  corporation  which
provides coverage supplementing part A and part B of subchapter XVIII of
the Social Security Act, 42 U.S.C. S 1395 et seq,  must  make  available
and,  if  requested by a subscriber holding a direct payment contract or
by all subscribers in a group remittance group or by the contract holder
in the case of group contracts issued pursuant to section four  thousand
three  hundred  five  of  this article, provide coverage of supplemental
home care visits beyond those provided by part A and part B,  sufficient
to  produce  an aggregate coverage of three hundred sixty-five home care
visits per contract year. Such coverage shall be  provided  pursuant  to
regulations  prescribed  by  the  superintendent.  Written notice of the
availability of such coverage shall be delivered to the group  remitting
agent  or  group contract holder prior to inception of such contract and
annually thereafter, except that this notice shall not be required where
a policy covers two hundred or  more  employees  or  where  the  benefit
structure was the subject of collective bargaining affecting persons who
are  employed in more than one state] NOTHING IN THIS PARAGRAPH SHALL BE
CONSTRUED TO PREVENT THE MANAGEMENT OR UTILIZATION REVIEW OF  HOME  CARE
BENEFITS,  INCLUDING  THE  USE  OF  PREAUTHORIZATION AND APPROPRIATENESS
CRITERIA AS TO THE LEVEL AND INTENSITY OF TREATMENT APPLICABLE  TO  HOME
CARE,  PROVIDED  HOWEVER  THAT ANY SUCH DETERMINATIONS MAY BE SUBJECT TO
APPEAL UNDER ARTICLE FORTY-NINE OF THIS CHAPTER.
  S 3. This act shall take effect January 1, 2017 and shall apply to all
policies and contracts issued, renewed, modified, altered or amended  on
or after such date.

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