Senate Bill S4870A

2011-2012 Legislative Session

No policy of group accident, group health or group accident and health shall impose copayments in excess of 20 percent of total reimbursement to the provider of care

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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
Jan 05, 2012	print number 4870a
Jan 05, 2012	amend and recommit to insurance
Jan 04, 2012	referred to insurance
Apr 27, 2011	referred to insurance

Bill Amendments

Original

A (Active)

co-Sponsors

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2011-S4870 - Details

See Assembly Version of this Bill:: A187
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3216, 4235, 4301 & 4322, Ins L
Versions Introduced in Other Legislative Sessions:: 2009-2010: S4321, A8171
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

2011-S4870 - 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.

2011-S4870 - Sponsor 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.

2011-S4870 - Bill Text download pdf

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

                                  4870

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                             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.

co-Sponsors

View additional co-sponsors

2011-S4870A (ACTIVE) - Details

See Assembly Version of this Bill:: A187
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3216, 4235, 4301 & 4322, Ins L
Versions Introduced in Other Legislative Sessions:: 2009-2010: S4321, A8171
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

2011-S4870A (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.

2011-S4870A (ACTIVE) - Sponsor Memo

                                BILL NUMBER:S4870A

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
copayment 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.

2011-S4870A (ACTIVE) - Bill Text download pdf

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

                                 4870--A

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                             April 27, 2011
                               ___________

Introduced  by  Sens.  DeFRANCISCO,  AVELLA,  BRESLIN,  GOLDEN, HUNTLEY,
  LANZA, MAZIARZ -- 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 219 of the laws of 2011,  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.
                                                           LBD00680-02-2

S. 4870--A                          2

and  occupational  therapists  upon  the  prescription  or referral of a
physician for the employee or other member of  the  insured  group,  the
employee's or member's spouse, the employee's or member's child or chil-
dren, or other persons chiefly dependent upon the employee or member for
support and maintenance; provided that:
  (i)  a  policy  of  hospital,  medical, surgical, or prescription drug
expense insurance that provides coverage for children shall provide such
coverage to a married or unmarried child until attainment of  age  twen-
ty-six,  without  regard  to  financial  dependence,  residency with the
employee or member, student status, or employment, except a policy  that
is  a  grandfathered  health  plan  may, for plan years beginning before
January first, two thousand fourteen, exclude coverage of an adult child
under age twenty-six who is eligible to enroll in an  employer-sponsored
health  plan other than a group health plan of a parent. For purposes of
this item, "grandfathered health plan" means  coverage  provided  by  an
insurer  in  which an individual was enrolled on March twenty-third, two
thousand ten for as long as the coverage maintains grandfathered  status
in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.
S 18011(e); and
  (ii) a policy under which coverage 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  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
child remains in such condition, if the insured employee or  member  has
within thirty-one days of such child's attainment of the termination age
submitted  proof  of  such  child'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:

S. 4870--A                          3

  (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 S4870A

Sponsored By

Archive: Last Bill Status - In Senate Committee Insurance Committee

Actions

Bill Amendments

co-Sponsors

2011-S4870 - Details

2011-S4870 - Summary

2011-S4870 - Sponsor Memo

2011-S4870 - Bill Text download pdf

co-Sponsors

2011-S4870A (ACTIVE) - Details

2011-S4870A (ACTIVE) - Summary

2011-S4870A (ACTIVE) - Sponsor Memo

2011-S4870A (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

2011-S4870 - Details

2011-S4870 - Summary

2011-S4870 - Sponsor Memo

2011-S4870 - Bill Text download pdf

co-Sponsors

2011-S4870A (ACTIVE) - Details

2011-S4870A (ACTIVE) - Summary

2011-S4870A (ACTIVE) - Sponsor Memo

2011-S4870A (ACTIVE) - Bill Text download pdf

Comments