Assembly Bill A7527A

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

                                 7527--A

                       2013-2014 Regular Sessions

                          I N  A S S E M B L Y

                              May 23, 2013
                               ___________

Introduced  by  M. of A. McDONALD, LAVINE, MONTESANO, MILLER, GUNTHER --
  Multi-Sponsored by -- M. of A. DUPREY,  HOOPER,  ROSA,  SIMANOWITZ  --
  read  once  and  referred to the Committee on Health -- recommitted to
  the Committee on Health in accordance with Assembly Rule 3, sec. 2  --
  committee  discharged,  bill amended, ordered reprinted as amended and
  recommitted to said committee

AN ACT to amend the social services  law,  the  insurance  law  and  the
  public health law, in relation to preserving access to quality complex
  rehabilitation technology for patients with complex medical needs

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

  Section 1. Short title. This act shall be known and may  be  cited  as
the "complex needs patient act".
  S 2. Legislative intent. It is the intent of the legislature to:
  1.  protect access for complex needs patients to quality complex reha-
bilitation technology;
  2. establish and improve standards  and  safeguards  relating  to  the
provision of complex rehabilitation technology; and
  3.  provide  quality support for complex needs patients to stay in the
home or community setting,  prevent  institutionalization,  and  prevent
hospitalizations and other costly secondary complications.
  S  3. The social services law is amended by adding a new section 367-j
to read as follows:
  S 367-J. COMPLEX NEEDS PATIENT ACT.  1. DEFINITIONS. AS USED  IN  THIS
SECTION:
  (A) "COMPLEX NEEDS PATIENT" MEANS AN INDIVIDUAL WITH SIGNIFICANT PHYS-
ICAL  OR  FUNCTIONAL  IMPAIRMENT  RESULTING  FROM A MEDICAL CONDITION OR
DISEASE INCLUDING, BUT NOT LIMITED TO:  SPINAL  CORD  INJURY,  TRAUMATIC
BRAIN  INJURY,  CEREBRAL PALSY, MUSCULAR DYSTROPHY, SPINA BIFIDA, OSTEO-
GENESIS  IMPERFECTA,  ARTHROGRYPOSIS,  AMYOTROPHIC  LATERAL   SCLEROSIS,
MULTIPLE   SCLEROSIS,   DEMYELINATING   DISEASE,  MYELOPATHY,  MYOPATHY,

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10590-03-4
              

A. 7527--A                          2

PROGRESSIVE MUSCULAR ATROPHY, ANTERIOR  HORN  CELL  DISEASE,  POST-POLIO
SYNDROME,   CEREBELLAR  DEGENERATION,  DYSTONIA,  HUNTINGTON'S  DISEASE,
SPINOCEREBELLAR DISEASE, AND CERTAIN TYPES OF AMPUTATION,  PARALYSIS  OR
PARESIS.
  (B)  "COMPLEX  REHABILITATION TECHNOLOGY" MEANS PRODUCTS CLASSIFIED AS
DURABLE MEDICAL EQUIPMENT WITHIN THE  MEDICARE  PROGRAM  AS  OF  JANUARY
FIRST,  TWO THOUSAND THIRTEEN THAT ARE INDIVIDUALLY CONFIGURED FOR INDI-
VIDUALS TO MEET THEIR SPECIFIC AND UNIQUE MEDICAL,  PHYSICAL  AND  FUNC-
TIONAL NEEDS AND CAPACITIES FOR BASIC AND FUNCTIONAL ACTIVITIES OF DAILY
LIVING.  SUCH PRODUCTS INCLUDE, BUT ARE NOT LIMITED TO: MANUAL AND POWER
WHEELCHAIRS AND ACCESSORIES, ADAPTIVE SEATING AND POSITIONING ITEMS  AND
ACCESSORIES, AND OTHER SPECIALIZED EQUIPMENT SUCH AS STANDING FRAMES AND
GAIT TRAINERS AND ACCESSORIES.
  (C)  "EMPLOYEE" MEANS A PERSON WHOSE TAXES ARE WITHHELD BY A QUALIFIED
COMPLEX REHABILITATION TECHNOLOGY SUPPLIER AND REPORTED TO THE  INTERNAL
REVENUE SERVICE.
  (D) "HEALTHCARE COMMON PROCEDURE CODING SYSTEM", OR "HCPCS", MEANS THE
BILLING  CODES  USED BY MEDICARE AND OVERSEEN BY THE FEDERAL CENTERS FOR
MEDICARE AND MEDICAID SERVICES THAT ARE BASED ON THE CURRENT  PROCEDURAL
TECHNOLOGY CODES DEVELOPED BY THE AMERICAN MEDICAL ASSOCIATION.
  (E)  "INDIVIDUALLY  CONFIGURED"  MEANS  A DEVICE WITH A COMBINATION OF
SIZES, FEATURES, ADJUSTMENTS OR MODIFICATIONS THAT IS  CUSTOMIZED  BY  A
QUALIFIED  COMPLEX  REHABILITATION  TECHNOLOGY  SUPPLIER  FOR A SPECIFIC
INDIVIDUAL BY MEASURING, FITTING, PROGRAMMING, ADJUSTING OR ADAPTING THE
DEVICE SO THAT THE DEVICE IS CONSISTENT WITH  THE  INDIVIDUAL'S  MEDICAL
CONDITION,  PHYSICAL  AND  FUNCTIONAL NEEDS AND CAPABILITIES, BODY SIZE,
PERIOD OF NEED AND INTENDED USE AS DETERMINED BY AN ASSESSMENT OR EVALU-
ATION BY A QUALIFIED HEALTH CARE PROFESSIONAL.
  (F) "MIXED HCPCS CODES" MEANS CODES THAT REFER TO  A  MIX  OF  COMPLEX
REHABILITATION  TECHNOLOGY  PRODUCTS AND STANDARD MOBILITY AND ACCESSORY
PRODUCTS.
  (G) "PURE HCPCS CODES" MEANS CODES THAT REFER EXCLUSIVELY  TO  COMPLEX
REHABILITATION TECHNOLOGY PRODUCTS.
  (H)  "QUALIFIED  COMPLEX REHABILITATION TECHNOLOGY PROFESSIONAL" MEANS
AN INDIVIDUAL WHO IS CERTIFIED AS AN ASSISTIVE  TECHNOLOGY  PROFESSIONAL
(ATP) BY THE REHABILITATION ENGINEERING AND ASSISTIVE TECHNOLOGY SOCIETY
OF NORTH AMERICA.
  (I)  "QUALIFIED  COMPLEX  REHABILITATION  TECHNOLOGY SUPPLIER" MEANS A
COMPANY OR ENTITY THAT:
  (I) IS ACCREDITED BY A RECOGNIZED ACCREDITING ORGANIZATION;
  (II) IS AN ENROLLED MEDICARE SUPPLIER AND MEETS THE SUPPLIER AND QUAL-
ITY  STANDARDS  ESTABLISHED  FOR  DURABLE  MEDICAL  EQUIPMENT  SUPPLIERS
INCLUDING THOSE FOR COMPLEX REHABILITATION TECHNOLOGY UNDER THE MEDICARE
PROGRAM;
  (III)  HAS  AT LEAST ONE EMPLOYEE WHO IS A QUALIFIED COMPLEX REHABILI-
TATION TECHNOLOGY PROFESSIONAL AVAILABLE TO ANALYZE THE NEEDS AND CAPAC-
ITIES OF COMPLEX NEEDS PATIENTS IN CONSULTATION WITH A QUALIFIED  HEALTH
CARE  PROFESSIONAL  AND  PARTICIPATE  IN  THE  SELECTION  OF APPROPRIATE
COMPLEX REHABILITATION TECHNOLOGY AND PROVIDE TRAINING IN THE PROPER USE
OF THE COMPLEX REHABILITATION TECHNOLOGY;
  (IV) REQUIRES A QUALIFIED COMPLEX  REHABILITATION  TECHNOLOGY  PROFES-
SIONAL  BE  PHYSICALLY  PRESENT  FOR THE EVALUATION AND DETERMINATION OF
APPROPRIATE  COMPLEX  REHABILITATION  TECHNOLOGY   FOR   COMPLEX   NEEDS
PATIENTS;
  (V)  HAS  THE  CAPABILITY  TO  PROVIDE SERVICE AND REPAIR BY QUALIFIED
TECHNICIANS FOR ALL COMPLEX REHABILITATION TECHNOLOGY IT SELLS;

A. 7527--A                          3

  (VI) HAS AT LEAST ONE STOREFRONT LOCATION WITHIN NEW YORK STATE; AND
  (VII)  PROVIDES  WRITTEN  INFORMATION REGARDING HOW TO RECEIVE SERVICE
AND REPAIR OF COMPLEX REHABILITATION TECHNOLOGY  TO  THE  COMPLEX  NEEDS
PATIENT AT THE TIME SUCH TECHNOLOGY IS DELIVERED.
  (J)  "QUALIFIED  HEALTH CARE PROFESSIONAL" MEANS A HEALTH CARE PROFES-
SIONAL LICENSED BY THE STATE EDUCATION DEPARTMENT WHO HAS  NO  FINANCIAL
RELATIONSHIP  WITH A QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLI-
ER, INCLUDING BUT NOT LIMITED TO A PHYSICIAN, PHYSICAL THERAPIST,  OCCU-
PATIONAL  THERAPIST,  OR  OTHER  LICENSED  HEALTH  CARE PROFESSIONAL WHO
PERFORMS SPECIALTY EVALUATIONS WITHIN THE PROFESSIONAL'S SCOPE OF  PRAC-
TICE.
  2. REIMBURSEMENT AND BILLING PROCEDURES. (A) TO THE EXTENT PERMISSIBLE
UNDER  FEDERAL LAW, THE COMMISSIONER SHALL ESTABLISH SPECIFIC REIMBURSE-
MENT AND BILLING  PROCEDURES  WITHIN  THE  STATE  MEDICAID  PROGRAM  FOR
COMPLEX  REHABILITATION  TECHNOLOGY PRODUCTS AND SERVICES TO ENSURE THAT
MEDICAID PAYMENTS FOR SUCH PRODUCTS AND SERVICES PERMIT ADEQUATE  ACCESS
TO  COMPLEX  NEEDS  PATIENTS  AND  TAKES  INTO  ACCOUNT  THE SIGNIFICANT
RESOURCES, INFRASTRUCTURE, AND STAFF NEEDED TO MEET THEIR NEEDS.
  (B) WHEN ESTABLISHING REIMBURSEMENT AND BILLING PROCEDURES PURSUANT TO
PARAGRAPH (A) OF THIS SUBDIVISION, THE  COMMISSIONER  SHALL,  NOT  LATER
THAN  OCTOBER  FIRST,  TWO  THOUSAND FIFTEEN: (I) DESIGNATE PRODUCTS AND
SERVICES INCLUDED IN MIXED AND PURE HCPCS BILLING CODES AS COMPLEX REHA-
BILITATION TECHNOLOGY, AND AS NEEDED, CREATE NEW BILLING CODES  OR  CODE
MODIFIERS  FOR SERVICES AND PRODUCTS COVERED FOR COMPLEX NEEDS PATIENTS;
(II) SET MINIMUM STANDARDS CONSISTENT WITH PARAGRAPH (I) OF  SUBDIVISION
ONE  OF  THIS  SECTION IN ORDER FOR SUPPLIERS TO BE CONSIDERED QUALIFIED
COMPLEX  REHABILITATION  TECHNOLOGY  SUPPLIERS  ELIGIBLE  FOR   MEDICAID
REIMBURSEMENT;  (III)  EXEMPT PRODUCTS OR SERVICES BILLED UNDER MIXED OR
PURE HCPCS CODES FROM INCLUSION IN ANY BIDDING,  SELECTIVE  CONTRACTING,
REQUEST  FOR PROPOSAL, OR SIMILAR INITIATIVE; (IV) REQUIRE COMPLEX NEEDS
PATIENTS RECEIVING A COMPLEX  REHABILITATION  MANUAL  WHEELCHAIR,  POWER
WHEELCHAIR,  OR  SEATING COMPONENT TO BE EVALUATED BY A QUALIFIED HEALTH
CARE PROFESSIONAL AND  A  QUALIFIED  COMPLEX  REHABILITATION  TECHNOLOGY
PROFESSIONAL  TO  QUALIFY  FOR  REIMBURSEMENT; (V) MAKE OTHER CHANGES AS
NEEDED TO  PROTECT  ACCESS  TO  COMPLEX  REHABILITATION  TECHNOLOGY  FOR
COMPLEX NEEDS PATIENTS; AND (VI) AFFIRM THAT WITH THE EXCEPTION OF THOSE
ENROLLEES COVERED UNDER A PAYMENT RATE METHODOLOGY OTHERWISE NEGOTIATED,
PAYMENTS  FOR  COMPLEX  REHABILITATION  TECHNOLOGY  PROVIDED TO PATIENTS
ELIGIBLE FOR MEDICAL ASSISTANCE BY ORGANIZATIONS OPERATING IN ACCORDANCE
WITH THE PROVISIONS OF ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW OR BY
HEALTH MAINTENANCE ORGANIZATIONS ORGANIZED AND OPERATING  IN  ACCORDANCE
WITH  ARTICLE  FORTY-THREE  OF  THE INSURANCE LAW, SHALL BE THE RATES OF
PAYMENT THAT WOULD BE PAID FOR SUCH PAYMENTS UNDER THE  MEDICAL  ASSIST-
ANCE  PROGRAM  AS  DETERMINED  BY  THE  COMMISSIONER  AND  APPLICABLE TO
SERVICES AT THE TIME SUCH SERVICES WERE PROVIDED.
  S 4. Section 3217-e of the insurance law, as added by chapter  219  of
the laws of 2011, is amended to read as follows:
  S  3217-e.  Choice of health care provider. An insurer that is subject
to this article and requires or provides for designation by  an  insured
of  a  participating  primary  care provider shall permit the insured to
designate any participating primary care provider who  is  available  to
accept  such  individual,  and  in the case of a child, shall permit the
insured  to  designate  a  physician  (allopathic  or  osteopathic)  who
specializes  in  pediatrics as the child's primary care provider if such
provider participates in the network of the insurer.  EVERY POLICY WHICH
PROVIDES MEDICAL, MAJOR MEDICAL, OR SIMILAR COMPREHENSIVE TYPE  COVERAGE

A. 7527--A                          4

SHALL  INCLUDE  ADEQUATE  ACCESS  TO  SERVICES AND EQUIPMENT PROVIDED BY
QUALIFIED  COMPLEX  REHABILITATION  TECHNOLOGY  SUPPLIERS,  PURSUANT  TO
SECTION  THREE  HUNDRED  SIXTY-SEVEN-J  OF  THE SOCIAL SERVICES LAW, AND
ADOPT THE SUPPLIER STANDARDS CONTAINED THEREIN.
  S  5.  Section 4306-d of the insurance law, as added by chapter 219 of
the laws of 2011, is amended to read as follows:
  S 4306-d. Choice of  health  care  provider.  A  corporation  that  is
subject  to  the provisions of this article and requires or provides for
designation by a subscriber of a  participating  primary  care  provider
shall  permit the subscriber to designate any participating primary care
provider who is available to accept such individual, and in the case  of
a child, shall permit the subscriber to designate a physician (allopath-
ic  or osteopathic) who specializes in pediatrics as the child's primary
care provider if such provider participates in the network of the corpo-
ration. EVERY POLICY WHICH PROVIDES MEDICAL, MAJOR MEDICAL,  OR  SIMILAR
COMPREHENSIVE  TYPE  COVERAGE  SHALL INCLUDE ADEQUATE ACCESS TO SERVICES
AND EQUIPMENT PROVIDED BY QUALIFIED  COMPLEX  REHABILITATION  TECHNOLOGY
SUPPLIERS, PURSUANT TO SECTION THREE HUNDRED SIXTY-SEVEN-J OF THE SOCIAL
SERVICES LAW, AND ADOPT THE SUPPLIER STANDARDS CONTAINED THEREIN.
  S  6. Section 4403 of the public health law is amended by adding a new
subdivision 9 to read as follows:
  9. EVERY HEALTH MAINTENANCE ORGANIZATION SHALL INCLUDE ADEQUATE ACCESS
TO SERVICES AND EQUIPMENT PROVIDED BY QUALIFIED  COMPLEX  REHABILITATION
TECHNOLOGY SUPPLIERS, PURSUANT TO SECTION THREE HUNDRED SIXTY-SEVEN-J OF
THE  SOCIAL  SERVICES  LAW,  AND  ADOPT THE SUPPLIER STANDARDS CONTAINED
THEREIN.
  S 7. This act shall take effect on the first of January next  succeed-
ing  the  date  on  which it shall have become a law, and shall apply to
contracts and policies issued, renewed, modified or amended on or  after
such effective date.