S T A T E O F N E W Y O R K
________________________________________________________________________
6498
2013-2014 Regular Sessions
I N A S S E M B L Y
April 4, 2013
___________
Introduced by M. of A. LAVINE -- read once and referred to the Committee
on Health
AN ACT to amend the public health law and the insurance law, in relation
to health care professional applications and terminations
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Section 4406-d of the public health law, as added by chap-
ter 705 of the laws of 1996, subdivision 1 as amended by chapter 237 of
the laws of 2009, is amended to read as follows;
S 4406-d. Health care professional applications and terminations. 1.
(a) A health care plan shall, upon request, make available and disclose
to health care professionals written application procedures and minimum
qualification requirements which a health care professional must meet in
order to be considered by the health care plan. The plan shall consult
with appropriately qualified health care professionals in developing its
qualification requirements. A health care plan shall complete review of
the health care professional's application to participate in the in-net-
work portion of the health care plan's network and shall, within ninety
days of receiving a health care professional's completed application to
participate in the health care plan's network, notify the health care
professional as to: (i) whether he or she is credentialed; or (ii)
whether additional time is necessary to make a determination in spite of
the health care plan's best efforts or because of a failure of a third
party to provide necessary documentation, or non-routine or unusual
circumstances require additional time for review. In such instances
where additional time is necessary because of a lack of necessary
documentation, a health plan shall make every effort to obtain such
information as soon as possible.
(b) If the completed application of a newly-licensed health care
professional or a health care professional who has recently relocated to
this state from another state and has not previously practiced in this
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD10089-01-3
A. 6498 2
state, who joins a group practice of health care professionals each of
whom participates in the in-network portion of a health care plan's
network, is neither approved nor declined within ninety days pursuant to
paragraph (a) of this subdivision, the health care professional shall be
deemed "provisionally credentialed" and may participate in the in-net-
work portion of the health care plan's network; provided, however, that
a provisionally credentialed physician may not be designated as an
enrollee's primary care physician until such time as the physician has
been fully credentialed. The network participation for a provisionally
credentialed health care professional shall begin on the day following
the ninetieth day of receipt of the completed application and shall last
until the final credentialing determination is made by the health care
plan. A health care professional shall only be eligible for provisional
credentialing if the group practice of health care professionals noti-
fies the health care plan in writing that, should the application ulti-
mately be denied, the health care professional or the group practice:
(i) shall refund any payments made by the health care plan for in-net-
work services provided by the provisionally credentialed health care
professional that exceed any out-of-network benefits payable under the
enrollee's contract with the health care plan; and (ii) shall not pursue
reimbursement from the enrollee, except to collect the copayment that
otherwise would have been payable had the enrollee received services
from a health care professional participating in the in-network portion
of a health care plan's network. Interest and penalties pursuant to
section three thousand two hundred twenty-four-a of the insurance law
shall not be assessed based on the denial of a claim submitted during
the period when the health care professional was provisionally creden-
tialed; provided, however, that nothing herein shall prevent a health
care plan from paying a claim from a health care professional who is
provisionally credentialed upon submission of such claim. A health care
plan shall not deny, after appeal, a claim for services provided by a
provisionally credentialed health care professional solely on the ground
that the claim was not timely filed.
2. (a) A health care plan shall not terminate OR NOT RENEW a contract
with a health care professional unless the health care plan provides to
the health care professional a written explanation of the reasons for
the proposed contract termination and an opportunity for a review or
hearing as hereinafter provided. This section shall not apply in cases
involving imminent harm to patient care, a determination of fraud, or a
final disciplinary action by a state licensing board or other govern-
mental agency that impairs the health care professional's ability to
practice.
(b) The notice of the proposed contract termination OR NON-RENEWAL
provided by the health care plan to the health care professional shall
include:
(i) the reasons for the proposed action;
(ii) notice that the health care professional has the right to request
a hearing or review, at the professional's discretion, before a panel
[appointed by the health care plan] COMPRISED OF NO FEWER THAN THREE
HEALTH CARE PROFESSIONALS LICENSED TO PRACTICE IN THE STATE OF NEW YORK;
(iii) a time limit of not less than thirty days within which a health
care professional may request a hearing; and
(iv) a time limit for a hearing date which must be held within thirty
days after the date of receipt of a request for a hearing.
(c) The hearing panel shall be comprised of three [persons appointed
by the health care plan] HEALTH CARE PROFESSIONALS LICENSED TO PRACTICE
A. 6498 3
BY THE STATE OF NEW YORK IN THE SAME PROFESSION AS THE SUBJECT OF THE
REVIEW, ONE OF WHOM IS APPOINTED BY THE HEALTH CARE PLAN, ONE OF WHOM IS
APPOINTED BY THE HEALTH CARE PROFESSIONAL WHO IS THE SUBJECT OF THE
HEARING. THE REMAINING MEMBER OF THE PANEL SHALL BE CHOSEN BY THE OTHER
TWO PANEL MEMBERS. At least one person on such panel shall be a clinical
peer in the same discipline and the same or similar specialty as the
health care professional under review. The hearing panel may consist of
more than three persons, provided however that the number of clinical
peers on such panel shall constitute one-third or more of the total
membership of the panel AND PROVIDED FURTHER THAT THE RATIO OF THE
NUMBER OF HEALTH CARE PROFESSIONALS APPOINTED BY THE HEALTH CARE PLAN TO
THE NUMBER OF HEALTH CARE PROFESSIONALS APPOINTED BY THE SUBJECT OF THE
HEARING TO THE NUMBER OF HEALTH CARE PROFESSIONALS CHOSEN BY THE OTHER
PANEL MEMBERS REMAINS ONE TO ONE TO ONE.
(d) The hearing panel shall render a decision on the proposed action
in a timely manner. Such decision shall include reinstatement of the
health care professional by the health care plan, provisional rein-
statement subject to conditions set forth by the health care plan or
termination of the health care professional. Such decision shall be
provided in writing to the health care professional.
(e) A decision by the hearing panel to terminate OR NOT RENEW a health
care professional shall be effective not less than thirty days after the
receipt by the health care professional of the hearing panel's decision;
provided, however, that the provisions of paragraph (e) of subdivision
six of section [four thousand four] FORTY-FOUR hundred three of this
article shall apply to such termination OR NON-RENEWAL.
(f) In no event shall termination be effective earlier than sixty days
from the receipt of the notice of termination.
3. [Either party to a contract may exercise a right of non-renewal at
the expiration of the contract period set forth therein or, for a
contract without a specific expiration date, on each January first
occurring after the contract has been in effect for at least one year,
upon sixty days notice to the other party; provided, however, that any
non-renewal shall not constitute a termination for purposes of this
section.
4.] A health care plan shall develop and implement policies and proce-
dures to ensure that health care professionals are regularly informed of
information maintained by the health care plan to evaluate the perform-
ance or practice of the health care professional. The health care plan
shall consult with health care professionals in developing methodologies
to collect and analyze health care professional profiling data. Health
care plans shall provide any such information and profiling data and
analysis to health care professionals. Such information, data or analy-
sis shall be provided on a periodic basis appropriate to the nature and
amount of data and the volume and scope of services provided. Any
profiling data used to evaluate the performance or practice of a health
care professional shall be measured against stated criteria and an
appropriate group of health care professionals using similar treatment
modalities serving a comparable patient population. Upon presentation of
such information or data, each health care professional shall be given
the opportunity to discuss the unique nature of the health care profes-
sional's patient population which may have a bearing on the health care
professional's profile and to work cooperatively with the health care
plan to improve performance.
A. 6498 4
[5.] 4. 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
(e) requested a hearing or review pursuant to this section.
[6.] 5. Except as provided herein, no contract or agreement between a
health care plan and a health care professional shall contain any
provision which shall supersede or impair a health care professional's
right to notice of reasons for termination OR NON-RENEWAL and the oppor-
tunity for a hearing or review concerning such termination OR NON-RENE-
WAL.
[7.] 6. Any contract provision in violation of this section shall be
deemed to be void and unenforceable.
[8.] 7. For purposes of this section, "health care plan" shall mean a
health maintenance organization licensed pursuant to article forty-three
of the insurance law or certified pursuant to this article or an inde-
pendent practice association certified or recognized pursuant to this
article.
[9.] 8. For purposes of this section, "health care professional" shall
mean a health care professional licensed, registered or certified pursu-
ant to title eight of the education law.
S 2. Section 4803 of the insurance law, as added by chapter 705 of the
laws of 1996, subsection (a) as amended by chapter 237 of the laws of
2009, is amended to read as follows:
S 4803. Health care professional applications and terminations. (a)
(1) An insurer which offers a managed care product shall, upon request,
make available and disclose to health care professionals written appli-
cation procedures and minimum qualification requirements which a health
care professional must meet in order to be considered by the insurer for
participation in the in-network benefits portion of the insurer's
network for the managed care product. The insurer shall consult with
appropriately qualified health care professionals in developing its
qualification requirements for participation in the in-network benefits
portion of the insurer's network for the managed care product. An insur-
er shall complete review of the health care professional's application
to participate in the in-network portion of the insurer's network and,
within ninety days of receiving a health care professional's completed
application to participate in the insurer's network, will notify the
health care professional as to: (A) whether he or she is credentialed;
or (B) whether additional time is necessary to make a determination in
spite of the insurer's best efforts or because of a failure of a third
party to provide necessary documentation, or non-routine or unusual
circumstances require additional time for review. In such instances
where additional time is necessary because of a lack of necessary
documentation, an insurer shall make every effort to obtain such infor-
mation as soon as possible.
(2) If the completed application of a newly-licensed health care
professional or a health care professional who has recently relocated to
this state from another state and has not previously practiced in this
state, who joins a group practice of health care professionals each of
whom participates in the in-network portion of an insurer's network, is
neither approved nor declined within ninety days pursuant to paragraph
A. 6498 5
one of this subsection, such health care professional shall be deemed
"provisionally credentialed" and may participate in the in-network
portion of an insurer's network; provided, however, that a provisionally
credentialed physician may not be designated as an insured's primary
care physician until such time as the physician has been fully creden-
tialed. The network participation for a provisionally credentialed
health care professional shall begin on the day following the ninetieth
day of receipt of the completed application and shall last until the
final credentialing determination is made by the insurer. A health care
professional shall only be eligible for provisional credentialing if the
group practice of health care professionals notifies the insurer in
writing that, should the application ultimately be denied, the health
care professional or the group practice: (A) shall refund any payments
made by the insurer for in-network services provided by the provi-
sionally credentialed health care professional that exceed any out-of-
network benefits payable under the insured's contract with the insurer;
and (B) shall not pursue reimbursement from the insured, except to
collect the copayment or coinsurance that otherwise would have been
payable had the insured received services from a health care profes-
sional participating in the in-network portion of an insurer's network.
Interest and penalties pursuant to section three thousand two hundred
twenty-four-a of this chapter shall not be assessed based on the denial
of a claim submitted during the period when the health care professional
was provisionally credentialed; provided, however, that nothing herein
shall prevent an insurer from paying a claim from a health care profes-
sional who is provisionally credentialed upon submission of such claim.
An insurer shall not deny, after appeal, a claim for services provided
by a provisionally credentialed health care professional solely on the
ground that the claim was not timely filed.
(b) (1) An insurer shall not terminate OR NOT RENEW a contract with a
health care professional for participation in the in-network benefits
portion of the insurer's network for a managed care product unless the
insurer provides to the health care professional a written explanation
of the reasons for the proposed contract termination and an opportunity
for a review or hearing as hereinafter provided. This section shall not
apply in cases involving imminent harm to patient care, a determination
of fraud, or a final disciplinary action by a state licensing board or
other governmental agency that impairs the health care professional's
ability to practice.
(2) The notice of the proposed contract termination OR NON-RENEWAL
provided by the insurer to the health care professional shall include:
(i) the reasons for the proposed action;
(ii) notice that the health care professional has the right to request
a hearing or review, at the professional's discretion, before a panel
[appointed by the insurer] COMPRISED OF NO FEWER THAN THREE HEALTH CARE
PROFESSIONALS LICENSED TO PRACTICE BY THE STATE OF NEW YORK;
(iii) a time limit of not less than thirty days within which a health
care professional may request a hearing or review; and
(iv) a time limit for a hearing date which must be held within not
less than thirty days after the date of receipt of a request for a hear-
ing.
(3) The hearing panel shall be comprised of three [persons appointed
by the insurer] HEALTH CARE PROFESSIONALS LICENSED TO PRACTICE BY THE
STATE OF NEW YORK IN THE SAME PROFESSION AS THE SUBJECT OF THE REVIEW,
ONE OF WHOM IS APPOINTED BY THE INSURER, ONE OF WHOM IS APPOINTED BY THE
HEALTH CARE PROFESSIONAL WHO IS THE SUBJECT OF THE HEARING. THE REMAIN-
A. 6498 6
ING MEMBER OF THE PANEL SHALL BE CHOSEN BY THE OTHER TWO PANEL MEMBERS.
At least one person on such panel shall be a clinical peer in the same
discipline and the same or similar specialty as the health care profes-
sional under review. The hearing panel may consist of more than three
persons, provided however that the number of clinical peers on such
panel shall constitute one-third or more of the total membership of the
panel AND PROVIDED FURTHER THAT THE RATIO OF THE NUMBER OF HEALTH CARE
PROFESSIONALS APPOINTED BY THE HEALTH CARE PLAN TO THE NUMBER OF HEALTH
CARE PROFESSIONALS APPOINTED BY THE SUBJECT OF THE HEARING TO THE NUMBER
OF HEALTH CARE PROFESSIONALS CHOSEN BY THE TWO OTHER PANEL MEMBERS
REMAINS ONE TO ONE TO ONE.
(4) The hearing panel shall render a decision on the proposed action
in a timely manner. Such decision shall include reinstatement of the
health care professional by the insurer, provisional reinstatement
subject to conditions set forth by the insurer or termination of the
health care professional. Such decision shall be provided in writing to
the health care professional.
(5) A decision by the hearing panel to terminate OR NOT RENEW a health
care professional shall be effective not less than thirty days after the
receipt by the health care professional of the hearing panel's decision;
provided, however, that the provisions of subsection (e) of section four
thousand eight hundred four OF THIS ARTICLE shall apply to such termi-
nation.
(6) In no event shall termination OR NON-RENEWAL be effective earlier
than sixty days from the receipt of the notice of termination OR NON-RE-
NEWAL.
(c) [Either party to a contract for participation in the in-network
benefits portion of an insurer's network for a managed care product may
exercise a right of non-renewal at the expiration of the contract period
set forth therein or, for a contract without a specific expiration date,
on each January first occurring after the contract has been in effect
for at least one year, upon sixty days notice to the other party;
provided, however, that any non-renewal shall not constitute a termi-
nation for purposes of this section.
(d)] An insurer shall develop and implement policies and procedures to
ensure that health care providers participating in the the in-network
benefits portion of an insurer's network for a managed care product are
regularly informed of information maintained by the insurer to evaluate
the performance or practice of the health care professional. The insurer
shall consult with health care professionals in developing methodologies
to collect and analyze provider profiling data. Insurers shall provide
any such information and profiling data and analysis to these health
care professionals. Such information, data or analysis shall be provided
on a periodic basis appropriate to the nature and amount of data and the
volume and scope of services provided. Any profiling data used to evalu-
ate the performance or practice of such a health care professional shall
be measured against stated criteria and an appropriate group of health
care professionals using similar treatment modalities serving a compara-
ble patient population. Upon presentation of such information or data,
each such health care professional shall be given the opportunity to
discuss the unique nature of the health care professional's patient
population which may have a bearing on the professional's profile and to
work cooperatively with the insurer to improve performance.
[(e)] (D) 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
A. 6498 7
has (1) advocated on behalf of an insured; (2) has filed a complaint
against the insurer; (3) has appealed a decision of the insurer; (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.
[(f)] (E) Except as provided herein, no contract or agreement between
an insurer and a health care professional for participation in the
in-network benefits portion of an insurer's network for a managed care
product shall contain any provision which shall supersede or impair a
health care professional's right to notice of reasons for termination OR
NON-RENEWAL and the opportunity for a hearing concerning such termi-
nation OR NON-RENEWAL.
[(g)] (F) Any contract provision in violation of this section shall be
deemed to be void and unenforceable.
[(h)] (G) For purposes of this section, "health care professional"
shall mean a health care professional licensed, registered or certified
pursuant to title eight of the education law.
S 3. This act shall take effect immediately.