S T A T E O F N E W Y O R K
________________________________________________________________________
7877
2009-2010 Regular Sessions
I N A S S E M B L Y
April 28, 2009
___________
Introduced by M. of A. GOTTFRIED, ENGLEBRIGHT, JACOBS, PAULIN, LIFTON,
DelMONTE, TOWNS, EDDINGTON, CHRISTENSEN, KAVANAGH -- Multi-Sponsored
by -- M. of A. BRENNAN, DESTITO, DINOWITZ, FARRELL, GALEF, GLICK,
GUNTHER, HOOPER, JAFFEE, JOHN, KOON, LUPARDO, MAYERSOHN, McENENY,
PHEFFER, REILLY, SWEENEY -- read once and referred to the Committee on
Insurance
AN ACT to amend the public health law and the insurance law, in relation
to nurse practitioner access
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Paragraph (a) of subdivision 5 of section 4403 of the
public health law, as amended by chapter 586 of the laws of 1998, is
amended to read as follows:
(a) The commissioner, at the time of initial licensure, at least every
three years thereafter, and upon application for expansion of service
area, shall ensure that the health maintenance organization maintains a
network of health care providers adequate to meet the comprehensive
health needs of its enrollees and to provide an appropriate choice of
providers sufficient to provide the services covered under its
enrollee's contracts by determining that (i) there are a sufficient
number of geographically accessible participating providers; (ii) there
are opportunities to select from at least three primary care providers
pursuant to travel and distance time standards, providing that such
standards account for the conditions of accessing providers in rural
areas; (iii) there are sufficient providers in each area of specialty
practice to meet the needs of the enrollment population; (iv) there is
no exclusion of any appropriately licensed type of provider as a class;
[and] (v) THERE IS NO EXCLUSION OF APPROPRIATELY LICENSED AND CERTIFIED
NURSE PRACTITIONERS AS A CLASS OF PRIMARY CARE PRACTITIONERS OR AS
PROVIDERS OF SPECIALTY PRACTICE AND (VI) contracts entered into with
health care providers neither transfer financial risk to providers, in a
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD01104-01-9
A. 7877 2
manner inconsistent with the provisions of paragraph (c) of subdivision
one of this section, nor penalize providers for unfavorable case mix so
as to jeopardize the quality of or enrollees' appropriate access to
medically necessary services; provided, however, that payment at less
than prevailing fee for service rates or capitation shall not be deemed
or presumed prima facie to jeopardize quality or access.
S 2. The insurance law is amended by adding a new section 3217-d to
read as follows:
S 3217-D. NURSE PRACTITIONER SERVICE REIMBURSEMENT. NO INSURER SUBJECT
TO THIS ARTICLE THAT PROVIDES COVERAGE FOR PHYSICIAN SERVICES SHALL
EXCLUDE APPROPRIATELY LICENSED AND CERTIFIED NURSE PRACTITIONERS AS A
CLASS OF PRIMARY CARE PRACTITIONERS OR AS PROVIDERS OF SPECIALTY PRAC-
TICE. AN INSURER SHALL PROVIDE REIMBURSEMENT FOR THOSE SERVICES
PRESCRIBED BY THIS SECTION AT RATES NEGOTIATED BETWEEN THE INSURER AND
THE PROVIDER OF SUCH SERVICES. IN THE ABSENCE OF AGREED UPON RATES, AN
INSURER SHALL PAY FOR SUCH SERVICES AT THE USUAL AND CUSTOMARY CHARGE,
WHICH SHALL NOT BE UNREASONABLE.
S 3. Subparagraphs (F), (G) and (H) of paragraph 4 of subsection (f)
of section 4235 of the insurance law, subparagraph (F) as added and
subparagraphs (G) and (H) as relettered by chapter 456 of the laws of
1993, are amended and a new subparagraph (I) is added to read as
follows:
(F) any speech-language pathology or audiology service which is within
the lawful scope of practice of a duly licensed speech-language patholo-
gist or audiologist, a subscriber to such policy shall be entitled to
reimbursement for such service whether the said service is performed by
a physician or duly licensed speech-language pathologist or audiologist,
provided however, that nothing contained herein shall be construed to
impair any terms of such policy which may require said service to be
performed pursuant to a medical order, or a similar or related service
of a physician, in which case coverage need not be provided for any
tests, evaluations or diagnoses if such tests, evaluations or diagnoses
have already been provided by or through a physician within twelve
months of the referral or order from the physician. However, nothing
herein shall be construed as preventing an insurer from covering more
than one test or evaluation provided by a speech-language pathologist or
audiologist within a twelve-month period where such test or evaluation
is ordered by a physician as medically necessary. Nor shall anything
herein be construed as prohibiting the limitation of such services,
where covered, to specified settings other than offices, such as hospi-
tals or to services provided by such professionals as part of a home
care agency's services; and when such policy or any certificate issued
thereunder is delivered or issued for delivery without the state by an
authorized insurer, covered persons residing in this state shall be
entitled to reimbursement for speech-language pathology or audiology
service as herein provided[.];
(G) psychiatric or psychological services or for the diagnosis and
treatment of mental, nervous, or emotional disorders or ailments, howev-
er defined in such policy, a subscriber to such policy shall be entitled
to reimbursement for such psychiatric or psychological services or diag-
nosis or treatment whether performed by a physician, psychiatrist or a
certified and registered psychologist when the services rendered are
within the lawful scope of their practice, and when such policy or any
certificate issued thereunder is delivered or issued for delivery with-
out this state by an authorized insurer, covered persons residing in
this state shall be entitled to reimbursement for such diagnosis and
A. 7877 3
treatment by a physician, psychiatrist or a certified and registered
psychologist as hereinabove provided; [and]
(H) any service which is within the lawful scope of practice of a
licensed chiropractor, a subscriber to such policy shall be entitled to
reimbursement for such service when such service is performed by a
licensed chiropractor[.]; AND
(I) ANY SERVICE WHICH IS WITHIN THE LAWFUL SCOPE OF PRACTICE OF A
CERTIFIED NURSE PRACTITIONER, A SUBSCRIBER TO SUCH POLICY SHALL BE ENTI-
TLED TO REIMBURSEMENT FOR SUCH SERVICE WHEN SAID SERVICE IS PERFORMED BY
A CERTIFIED NURSE PRACTITIONER. AN INSURER SHALL PROVIDE REIMBURSEMENT
FOR THOSE SERVICES PRESCRIBED BY THIS SUBPARAGRAPH AT RATES NEGOTIATED
BETWEEN THE INSURER AND THE PROVIDER OF SUCH SERVICES. IN THE ABSENCE OF
AGREED UPON RATES, AN INSURER SHALL PAY FOR SUCH SERVICES AT THE USUAL
AND CUSTOMARY CHARGE, WHICH SHALL NOT BE UNREASONABLE.
S 4. Subsection (b) of section 4301 of the insurance law, subparagraph
(G) of paragraph 1 and paragraph 3 as amended by chapter 593 of the laws
of 2000 and subparagraph (I) as added and subparagraphs (J) and (K) as
relettered by chapter 456 of the laws of 1993, is amended to read as
follows:
(b) (1) Medical expense indemnity shall consist of reimbursement for:
(A) medical care provided through licensed physicians OR CERTIFIED
NURSE PRACTITIONERS,
(B) dental care provided through licensed dentists,
(C) optometric care provided through licensed optometrists,
(D) podiatrical care provided through licensed podiatrists,
(E) chiropractic care provided through licensed chiropractors,
(F) psychiatric or psychological services provided through physicians,
psychiatrists or certified and registered psychologists,
(G) physical and occupational therapy care provided through licensed
physical and occupational therapists upon the prescription of a physi-
cian,
(H) nursing service,
(I) speech-language pathology or audiology services provided through
licensed speech-language pathologists or audiologists, provided however,
that nothing contained herein shall be construed to prohibit a contract
from requiring said service from being performed pursuant to a medical
order or similar or related service of a physician OR NURSE
PRACTITIONER, in which case coverage need not be provided for any tests,
evaluations or diagnoses if such tests, evaluations or diagnoses have
already been provided by or through a physician within twelve months of
the referral or order from the physician OR NURSE PRACTITIONER. Howev-
er, nothing herein shall be construed as preventing a corporation from
covering more than one test or evaluation provided by a speech-language
pathologist or audiologist within a twelve-month period where such tests
or evaluations is ordered by a physician OR NURSE PRACTITIONER as
medically necessary. Nor shall anything herein be construed as prohibit-
ing the limitation of such services, where covered, to specified
settings other than offices, such as hospitals or to services provided
by such professionals as part of a home care agency's services,
(J) necessary appliances, drugs, medicines and supplies, and
(K) bio-analytical or clinical laboratory examinations and reports
thereof reported to a physician OR NURSE PRACTITIONER, osteopath,
dentist, optometrist, podiatrist, chiropractor or physical therapist
made by any privately operated bioanalytical or clinical laboratory.
(2) It is not mandatory that a contract issued by a medical expense
indemnity corporation provide for and offer all of the services hereina-
A. 7877 4
bove described, but when any service is provided which can be performed
by more than one of the practitioners hereinbefore referred to, benefits
under the contract shall be provided regardless of which practitioner
performed the service, provided that the performance of such service was
within the scope of the license of such practitioner. Unless such
contract shall otherwise provide there shall be no reimbursement for
ophthalmic materials, lenses, spectacles, eyeglasses, and/or appurte-
nances thereto.
(3) Every medical expense indemnity corporation shall be open to the
participation of licensed physicians, podiatrists, chiropractors, opto-
metrists, physical and occupational therapists, speech-language patholo-
gists, audiologists, and dentists, CERTIFIED NURSE PRACTITIONERS, certi-
fied and registered psychologists without discrimination against schools
of medical practice, podiatry practice, chiropractic practice, optome-
tric practice, physical and occupational therapy practice, dental prac-
tice, speech-language pathology practice (subject to the permitted limi-
tations of paragraph one of this subsection), audiology practice
(subject to the permitted limitations of paragraph one of this
subsection), and psychological training as defined in the education law.
S 5. The insurance law is amended by adding a new section 4325-a to
read as follows:
S 4325-A. NURSE PRACTITIONER SERVICE REIMBURSEMENT. NO INSURER SUBJECT
TO THIS ARTICLE THAT PROVIDES COVERAGE FOR PHYSICIAN SERVICES SHALL
EXCLUDE APPROPRIATELY LICENSED AND CERTIFIED NURSE PRACTITIONERS AS A
CLASS OF PRIMARY CARE PRACTITIONERS OR AS PROVIDERS OF SPECIALTY PRAC-
TICE. AN INSURER SHALL PROVIDE REIMBURSEMENT FOR THOSE SERVICES
PRESCRIBED BY THIS SECTION AT RATES NEGOTIATED BETWEEN THE INSURER AND
THE PROVIDER OF SUCH SERVICES. IN THE ABSENCE OF AGREED UPON RATES, AN
INSURER SHALL PAY FOR SUCH SERVICES AT THE USUAL AND CUSTOMARY CHARGE,
WHICH SHALL NOT BE UNREASONABLE.
S 6. This act shall take effect on the sixtieth day after it shall
have become a law and shall apply to all policies and contracts issued,
renewed, modified, altered or amended on or after such date.