Assembly Bill A3195

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

                                  3195

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                            January 23, 2009
                               ___________

Introduced by M. of A. BRADLEY, GOTTFRIED, J. RIVERA, MAYERSOHN, COLTON,
  JAFFEE,  SCARBOROUGH,  LATIMER, SCHIMEL -- Multi-Sponsored by -- M. of
  A. BRENNAN, CHRISTENSEN,  CLARK,  ESPAILLAT,  FARRELL,  GREENE,  JOHN,
  PHEFFER,  SWEENEY -- read once and referred to the Committee on Insur-
  ance

AN ACT to amend the insurance law and the public health law, in relation
  to the termination of a health care professional's participation in  a
  managed care plan

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

  Section 1. 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  refuse 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)  HAS  advocated  on  behalf  of  an  insured; (2) has filed a
complaint against the insurer; (3) has appealed a decision of the insur-
er; (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) IS CREDENTIALED  ONLY
AT  A HOSPITAL OR HOSPITALS THAT NO LONGER PARTICIPATE IN THE IN-NETWORK
BENEFITS PORTION OF THE INSURER'S NETWORK FOR THE MANAGED CARE PRODUCT.
  S 2. 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 a contract or employment, or
refuse 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]

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD03286-01-9
              

A. 3195                             2

  (e) requested a hearing or review pursuant to this section; OR
  (F)  IS  CREDENTIALED  ONLY  AT A HOSPITAL OR HOSPITALS THAT NO LONGER
PARTICIPATE IN THE HEALTH CARE PLAN'S NETWORK OF PROVIDERS.
  S 3. Section 4804 of the insurance law is  amended  by  adding  a  new
subsection (g) to read as follows:
  (G)  IF  AN  INSURER TERMINATES A GENERAL HOSPITAL FROM THE IN-NETWORK
BENEFITS PORTION OF ITS NETWORK FOR A  MANAGED  CARE  PRODUCT  OR  IF  A
GENERAL  HOSPITAL  TERMINATES  ITS  IN-NETWORK PROVIDER CONTRACT WITH AN
INSURER FOR A MANAGED CARE  PRODUCT,  SUCH  GENERAL  HOSPITAL  SHALL  BE
ALLOWED  TO  CONTINUE TO PROVIDE SERVICES TO PATIENTS OF ANY HEALTH CARE
PROFESSIONAL WHO PARTICIPATES IN THE IN-NETWORK BENEFITS PORTION OF  THE
INSURER'S  NETWORK  FOR  A MANAGED CARE PRODUCT AND HAS STAFF MEMBERSHIP
AND CLINICAL PRIVILEGES AT SUCH  GENERAL  HOSPITAL  FOR  A  TRANSITIONAL
PERIOD  OF  UP TO ONE   HUNDRED TWENTY DAYS FROM THE DATE OF SUCH TERMI-
NATION; PROVIDED HOWEVER, THE PROVISIONS OF THIS  SUBSECTION  SHALL  NOT
APPLY  IF  A PATIENT'S HEALTH CARE PROFESSIONAL HAS STAFF MEMBERSHIP AND
CLINICAL PRIVILEGES AT ANOTHER GENERAL HOSPITAL WHICH  IS  PART  OF  THE
IN-NETWORK PORTION OF THE INSURER'S NETWORK FOR A  MANAGED CARE PRODUCT.
SUCH  CARE SHALL BE AUTHORIZED BY THE INSURER ONLY IF THE GENERAL HOSPI-
TAL AGREES TO (1) CONTINUE TO ACCEPT REIMBURSEMENT FROM THE  INSURER  AT
THE  RATES  APPLICABLE PRIOR TO THE  START OF THE TRANSITIONAL PERIOD AS
PAYMENT IN FULL; (2) ADHERE TO THE INSURER'S QUALITY ASSURANCE  REQUIRE-
MENTS  AND  PROVIDE TO THE INSURER NECESSARY MEDICAL INFORMATION RELATED
TO SUCH CARE; AND (3) OTHERWISE ADHERE TO  THE  INSURER'S  POLICIES  AND
PROCEDURES,  INCLUDING BUT NOT LIMITED TO PROCEDURES REGARDING REFERRALS
AND OBTAINING PRE-AUTHORIZATION AND A TREATMENT  PLAN  APPROVED  BY  THE
INSURER.
  S  4. Section 4403 of the public health law is amended by adding a new
subdivision 7 to read as follows:
  7.  IF A HEALTH MAINTENANCE ORGANIZATION TERMINATES A GENERAL HOSPITAL
FROM ITS NETWORK OF PROVIDERS OR IF A GENERAL  HOSPITAL  TERMINATES  ITS
NETWORK  PROVIDER CONTRACT WITH A HEALTH  MAINTENANCE ORGANIZATION, SUCH
GENERAL HOSPITAL SHALL BE ALLOWED TO CONTINUE TO PROVIDE  SERVICES    TO
PATIENTS OF ANY HEALTH CARE PROFESSIONAL WHO IS PART OF THE HEALTH MAIN-
TENANCE  ORGANIZATION'S    NETWORK OF PROVIDERS AND HAS STAFF MEMBERSHIP
AND CLINICAL PRIVILEGES AT SUCH GENERAL HOSPITAL    FOR  A  TRANSITIONAL
PERIOD  OF  UP  TO  ONE HUNDRED TWENTY DAYS FROM THE DATE OF SUCH TERMI-
NATION;   PROVIDED HOWEVER,  THIS  SUBDIVISION  SHALL  NOT  APPLY  IF  A
PATIENT'S  HEALTH  CARE  PROFESSIONAL  HAS STAFF MEMBERSHIP AND CLINICAL
PRIVILEGES AT ANOTHER GENERAL HOSPITAL  WHICH  IS  PART  OF  THE  HEALTH
MAINTENANCE  ORGANIZATION'S NETWORK OF PROVIDERS. SUCH SERVICES SHALL BE
AUTHORIZED BY THE  HEALTH MAINTENANCE ORGANIZATION IF THE GENERAL HOSPI-
TAL AGREES TO: (A) CONTINUE TO  ACCEPT  REIMBURSEMENT  FROM  THE  HEALTH
MAINTENANCE  ORGANIZATION  AT THE RATES APPLICABLE PRIOR TO THE START OF
THE TRANSITIONAL PERIOD AS PAYMENT IN FULL; (B)  ADHERE  TO  THE  HEALTH
MAINTENANCE  ORGANIZATION'S   QUALITY ASSURANCE REQUIREMENTS AND PROVIDE
TO THE ORGANIZATION NECESSARY MEDICAL INFORMATION  RELATED TO SUCH CARE;
AND (C) OTHERWISE ADHERE TO THE ORGANIZATION'S POLICIES AND  PROCEDURES,
INCLUDING  BUT NOT LIMITED TO PROCEDURES REGARDING REFERRALS AND OBTAIN-
ING PRE-AUTHORIZATION AND A  TREATMENT PLAN APPROVED BY THE HEALTH MAIN-
TENANCE ORGANIZATION.
  S 5. This act shall take effect on the sixtieth  day  after  it  shall
have become a law.