Senate Bill S4321

2009-2010 Legislative Session

Prohibits payors from imposing higher co-pays on consumers for physical therapy services on the basis of provider or setting

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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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Date of Action	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Apr 30, 2010	print number 4321a
Apr 30, 2010	amend and recommit to insurance
Jan 06, 2010	referred to insurance
Apr 22, 2009	referred to insurance

Bill Amendments

Original

A (Active)

co-Sponsors

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2009-S4321 - Details

See Assembly Version of this Bill:: A8171
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3216, 4235, 4301 & 4322, Ins L
Versions Introduced in Other Legislative Sessions:: 2011-2012: S4870, A187
2013-2014: S2319, A1666
2015-2016: S28, A1063
2017-2018: S5764, A569
2019-2020: S3751, A405
2021-2022: S3562, A594
2023-2024: S1470, A6345
2025-2026: S5045, A6484

2009-S4321 - Summary

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.

2009-S4321 - Sponsor Memo

                                 BILL NUMBER:  S4321

 TITLE OF BILL :

An act to amend the insurance law, in relation to physical therapy
services


 PURPOSE OR GENERAL IDEA OF BILL :

To prohibit the imposition of higher co-pays on consumers for physical
therapy services on the basis of provider or setting.

 SUMMARY OF PROVISIONS :

Sections 1 through 5 prohibit payors from imposing higher c-pays on
consumers for physical therapy services on the basis of provider or
setting.

Section 6. Effective Date.

 JUSTIFICATION :

The provisions of the bill will protect consumers of physical therapy
services by prohibiting plans from inappropriately shifting the cost
of care onto consumers by treating independently practicing physical

therapists as "specialists" triggering specialist level co-payments.

The application of specialist co-payments to physical therapy care is
a distortion of the concept of specialized care and has led to
co-payments up to $50 per visit. Specialty co-payments have been
historically limited to specialized medical services such as certain
medical specialties or advanced health care services with commensurate
higher professional fees. However, health payors have extended the
concept to physical therapy services provided outside of a physician's
office such as a physical therapist owned physical therapy clinic. In
so doing, health payors treat therapy services, a routine health care
service, as a specialty service triggering the higher copayment.

In certain situations, specialty co-payments have exceeded the
reimbursement provided by the health payor to the physical therapist.
Physical therapy services generally require multiple visits over the
healing process, leading to significant out of pocket expenses for
consumers when specialty co-payments are applied. For example, it is
not uncommon for physical therapy treatment to require 3 physical
therapy sessions each week for a month. Applying a specialty copayment
of $50 to this example leads to an out-of-pocket expense for the
consumer of $600.  This amount is on top of the cost of health
insurance that the consumer of their employer is paying.

The application of specialty co-payments to physical therapy services
has essentially permitted health payors to shift to consumers all but
a nominal amount of the costs of physical therapy care despite
provisions of the Insurance Law that require coverage of these
services. These specialty co-payments have also led consumers to delay
or forgo treatment since they cannot afford to self-fund their
physical therapy.

This bill would prohibit health payors from imposing a higher
co-payments on the basis of the provider or setting in which physical
therapy services are provided.

 PRIOR LEGISLATIVE HISTORY :

New Bill.

 FISCAL IMPLICATIONS :

None.

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

2009-S4321 - Bill Text download pdf

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

                                  4321

                       2009-2010 Regular Sessions

                            I N  S E N A T E

                             April 22, 2009
                               ___________

Introduced  by  Sen. BRESLIN -- 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 DIFFERENT DEDUCTIBLES,
CO-PAYMENTS OR CO-INSURANCE AMOUNTS ON THE BASIS OF THE SETTING IN WHICH
SUCH PHYSICAL THERAPY SERVICES ARE RENDERED OR WHETHER THE SERVICES  ARE
PERFORMED BY A PHYSICAL THERAPIST OR PHYSICIAN.
  S  2.  Paragraph  1 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:
  (1)  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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD11213-01-9

S. 4321                             2

spouse,  his  child or children, or other persons chiefly dependent upon
him for support and maintenance; provided  that  a  policy  under  which
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 DIFFERENT DEDUCTIBLES, CO-PAYMENTS OR CO-INSURANCE  AMOUNTS
ON  THE BASIS OF THE SETTING IN WHICH SUCH PHYSICAL THERAPY SERVICES ARE
RENDERED OR WHETHER THE SERVICES ARE PERFORMED BY A  PHYSICAL  THERAPIST
OR PHYSICIAN.
  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 DIFFERENT DEDUCT-
IBLES, CO-PAYMENTS OR CO-INSURANCE AMOUNTS ON THE BASIS OF  THE  SETTING
IN  WHICH  SUCH  PHYSICAL  THERAPY  SERVICES ARE RENDERED OR WHETHER THE
SERVICES ARE PERFORMED BY A PHYSICAL THERAPIST OR PHYSICIAN.
  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, DEDUCTIBLES, OR CO-INSURANCE AMOUNTS RELATED
TO REIMBURSEMENT FOR PHYSICAL THERAPY SERVICES SHALL NOT DIFFER  ON  THE
BASIS  OF  THE  SETTING  IN  WHICH  SUCH  PHYSICAL  THERAPY SERVICES ARE
RENDERED OR WHETHER THE SERVICES ARE PERFORMED BY A  PHYSICAL  THERAPIST
OR PHYSICIAN,
  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, DEDUCTIBLES OR CO-INSURANCE AMOUNTS
RELATED TO REIMBURSEMENT OF PHYSICAL THERAPY SERVICES SHALL  NOT  DIFFER
ON  THE BASIS OF THE SETTING IN WHICH SUCH PHYSICAL THERAPY SERVICES ARE
RENDERED OR WHETHER THE SERVICES ARE PERFORMED BY A  PHYSICAL  THERAPIST
OR PHYSICIAN.
  S 6. This act shall take effect on the one hundred eightieth day after
it shall have become a law.

co-Sponsors

View additional co-sponsors

2009-S4321A (ACTIVE) - Details

See Assembly Version of this Bill:: A8171
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3216, 4235, 4301 & 4322, Ins L
Versions Introduced in Other Legislative Sessions:: 2011-2012: S4870, A187
2013-2014: S2319, A1666
2015-2016: S28, A1063
2017-2018: S5764, A569
2019-2020: S3751, A405
2021-2022: S3562, A594
2023-2024: S1470, A6345
2025-2026: S5045, A6484

2009-S4321A (ACTIVE) - Summary

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.

2009-S4321A (ACTIVE) - Sponsor Memo

                                 BILL NUMBER:  S4321A

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


 PURPOSE OR GENERAL IDEA OF BILL :

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 reinjury.

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.

 PRIOR LEGISLATIVE HISTORY :

New Bill.

 FISCAL IMPLICATIONS :

None.

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

2009-S4321A (ACTIVE) - Bill Text download pdf

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

                                 4321--A

                       2009-2010 Regular Sessions

                            I N  S E N A T E

                             April 22, 2009
                               ___________

Introduced  by  Sens.  BRESLIN,  ALESI,  DIAZ,  DILAN,  ESPADA,  GOLDEN,
  HASSELL-THOMPSON, PARKER -- 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 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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD11213-02-0

S. 4321--A                          2

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
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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Senate Bill S4321

Sponsored By

Archive: Last Bill Status - In Senate Committee Insurance Committee

Actions

Bill Amendments

co-Sponsors

2009-S4321 - Details

2009-S4321 - Summary

2009-S4321 - Sponsor Memo

2009-S4321 - Bill Text download pdf

co-Sponsors

2009-S4321A (ACTIVE) - Details

2009-S4321A (ACTIVE) - Summary

2009-S4321A (ACTIVE) - Sponsor Memo

2009-S4321A (ACTIVE) - Bill Text download pdf

Comments

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Sponsored By

Archive: Last Bill Status - In Senate Committee Insurance Committee

Actions

Bill Amendments

co-Sponsors

2009-S4321 - Details

2009-S4321 - Summary

2009-S4321 - Sponsor Memo

2009-S4321 - Bill Text download pdf

co-Sponsors

2009-S4321A (ACTIVE) - Details

2009-S4321A (ACTIVE) - Summary

2009-S4321A (ACTIVE) - Sponsor Memo

2009-S4321A (ACTIVE) - Bill Text download pdf

Comments