S T A T E   O F   N E W   Y O R K
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                                  2573

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                            January 20, 2015
                               ___________

Introduced  by  M.  of  A. BRENNAN, SCARBOROUGH, JAFFEE -- read once and
  referred to the Committee on Insurance

AN ACT to amend the insurance law and the public health law, in relation
  to physical therapy services and utilization practices

  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. Clause (ii) of 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:
  (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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD02452-01-5
              

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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  DIFFERENT DEDUCTIBLES, CO-PAYMENTS OR CO-INSU-
RANCE AMOUNTS ON THE BASIS OF THE SETTING IN WHICH SUCH PHYSICAL THERAPY
SERVICES ARE RENDERED OR WHETHER THE SERVICES ARE PERFORMED BY  A  PHYS-
ICAL 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.  The  opening  paragraph of subdivision 4 of section 4905 of the
public health law, as added by chapter 705  of  the  laws  of  1996,  is
amended to read as follows:
  A utilization review agent OR THE HEALTH CARE PLAN FOR WHICH THE AGENT
PROVIDES  UTILIZATION  REVIEW  shall  not,  with  respect to utilization
review activities, permit or provide compensation or anything  of  value
to its employees, agents, or contractors based on:
  S  7.  The  opening paragraph of subsection (d) of section 4905 of the
insurance law, as added by chapter 705 of the laws of 1996,  is  amended
to read as follows:
  A utilization review agent OR THE HEALTH CARE PLAN FOR WHICH THE AGENT
PROVIDES  UTILIZATION  REVIEW  shall  not,  with  respect to utilization
review activities, permit or provide compensation or anything  of  value
to its employees, agents, or contractors based on:

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  S  8.  Subdivision  5  of  section 4406-d of the public health law, as
added by chapter 705 of the laws of 1996, is amended to read as follows:
  5.  No  health  care  plan shall terminate, OR THREATEN TO TERMINATE a
contract or employment, [or] refuse to renew,  OR  THREATEN  REFUSAL  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; OR
  (F) ORDERED OR RENDERED MEDICALLY NECESSARY CARE.
  S 9. Subsection (e) of section 4803 of the insurance law, as added  by
chapter 705 of the laws of 1996, is amended to read as follows:
  (e)  No insurer shall terminate [or], THREATEN TO TERMINATE, refuse to
renew OR THREATEN REFUSAL 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 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; OR (6) ORDERED OR RENDERED MEDICALLY NECESSARY CARE.
  S  10.  Paragraph  (d)  of subdivision 1 of section 4902 of the public
health law, as added by chapter 705 of the laws of 1996, is  amended  to
read as follows:
  (d) Establishment of a process for rendering utilization review deter-
minations  which  shall,  at  a  minimum, include: written procedures to
assure that utilization reviews and determinations are conducted  within
the  timeframes established herein; procedures to notify an enrollee, an
enrollee's designee [and/or] AND an enrollee's health care  provider  of
adverse  determinations;  and  procedures for appeal of adverse determi-
nations including the establishment of an expedited appeals process  for
denials  of continued inpatient care or where there is imminent or seri-
ous threat to the health of the enrollee;
  S 11. Paragraph 4 of subsection (a) of section 4902 of  the  insurance
law,  as added by chapter 705 of the laws of 1996, is amended to read as
follows:
  (4) Establishment of a process for rendering utilization review deter-
minations which shall, at a  minimum,  include:  written  procedures  to
assure  that utilization reviews and determinations are conducted within
the timeframes established herein; procedures to notify an  insured,  an
insured's  designee  [and/or]  AND  an insured's health care provider of
adverse determinations; and procedures for appeal  of  adverse  determi-
nations  including the establishment of an expedited appeals process for
denials of continued inpatient care or where there is imminent or  seri-
ous threat to the health of the insured;
  S  12.  Paragraph  (a)  of subdivision 2 of section 4901 of the public
health law, as added by chapter 705 of the laws of 1996, is  amended  to
read as follows:
  (a)  The  utilization  review  plan,  INCLUDING BUT NOT LIMITED TO THE
CLINICAL REVIEW CRITERIA AND STANDARDS AND THE  DEFINITION/STANDARDS  OF
MEDICAL  NECESSITY USED UNDER THE UTILIZATION REVIEW PLAN. A UTILIZATION
REVIEW AGENT SHALL REPORT ANY AMENDMENT OR CHANGES  TO  THE  UTILIZATION
REVIEW PLAN TO THE COMMISSIONER WITHIN THIRTY DAYS OF MAKING SUCH AMEND-
MENT OR CHANGE;

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  S  13.  Paragraph 1 of subsection (b) of section 4901 of the insurance
law, as added by chapter 705 of the laws of 1996, is amended to read  as
follows:
  (1)  The  utilization  review  plan,  INCLUDING BUT NOT LIMITED TO THE
CLINICAL REVIEW CRITERIA AND STANDARDS AND THE  DEFINITION/STANDARDS  OF
MEDICAL  NECESSITY USED UNDER THE UTILIZATION REVIEW PLAN. A UTILIZATION
REVIEW AGENT SHALL REPORT ANY AMENDMENT OR CHANGES  TO  THE  UTILIZATION
REVIEW  PLAN  TO  THE  SUPERINTENDENT  WITHIN THIRTY DAYS OF MAKING SUCH
AMENDMENT OR CHANGE;
  S 14. Section 4406-d of the public health law is amended by  adding  a
new subdivision 1-a to read as follows:
  1-A. UPON WRITTEN REQUEST BY A PARTICIPATING HEALTH CARE PROFESSIONAL,
A HEALTH CARE PLAN SHALL PROVIDE SPECIFIC WRITTEN CLINICAL REVIEW CRITE-
RIA  RELATING  TO  A PARTICULAR CONDITION, DISEASE, SERVICE OR PROCEDURE
AND, WHERE APPROPRIATE, OTHER CLINICAL INFORMATION WHICH THE HEALTH CARE
PLAN OR ITS UTILIZATION REVIEW AGENT MIGHT CONSIDER IN  ITS  UTILIZATION
REVIEW  AND  THE  HEALTH  CARE PLAN SHALL INCLUDE WITH THE INFORMATION A
DESCRIPTION OF HOW IT WILL BE USED IN THE  UTILIZATION  REVIEW  PROCESS;
PROVIDED, HOWEVER, THAT TO THE EXTENT SUCH INFORMATION IS PROPRIETARY TO
THE HEALTH CARE PLAN, THE PARTICIPATING HEALTH CARE PROVIDER OR PROSPEC-
TIVE  HEALTH  CARE  PROVIDER  SHALL  ONLY  USE  THE  INFORMATION FOR THE
PURPOSES OF ASSISTING THE PARTICIPATING HEALTH CARE PROVIDER IN EVALUAT-
ING COVERED SERVICES PROVIDED BY THE ORGANIZATION, AN  ADVERSE  DETERMI-
NATION OR AN APPEAL OF ADVERSE DETERMINATION.
  S  15.  Section  4803  of the insurance law is amended by adding a new
subsection (a-1) to read as follows:
  (A-1) UPON WRITTEN REQUEST BY  A  PARTICIPATING  HEALTH  CARE  PROFES-
SIONAL,  A  HEALTH  CARE  PLAN  SHALL  PROVIDE SPECIFIC WRITTEN CLINICAL
REVIEW CRITERIA RELATING TO A PARTICULAR CONDITION, DISEASE, SERVICE  OR
PROCEDURE  AND,  WHERE APPROPRIATE, OTHER CLINICAL INFORMATION WHICH THE
HEALTH CARE PLAN OR ITS UTILIZATION REVIEW AGENT MIGHT CONSIDER  IN  ITS
UTILIZATION  REVIEW  AND  THE  HEALTH  CARE  PLAN SHALL INCLUDE WITH THE
INFORMATION A DESCRIPTION OF HOW IT WILL  BE  USED  IN  THE  UTILIZATION
REVIEW  PROCESS;  PROVIDED, HOWEVER, THAT TO THE EXTENT SUCH INFORMATION
IS PROPRIETARY TO THE HEALTH CARE PLAN, THE  PARTICIPATING  HEALTH  CARE
PROVIDER OR PROSPECTIVE HEALTH CARE PROVIDER SHALL ONLY USE THE INFORMA-
TION FOR THE PURPOSES OF ASSISTING THE PARTICIPATING HEALTH CARE PROVID-
ER  IN  EVALUATING  COVERED  SERVICES  PROVIDED  BY THE ORGANIZATION, AN
ADVERSE DETERMINATION OR AN APPEAL OF ADVERSE DETERMINATION.
  S 16. Section 4406-c of the public health law is amended by  adding  a
new subdivision 5-e to read as follows:
  5-E.  NO HEALTH CARE PLAN SHALL BY CONTRACT, WRITTEN POLICY OR WRITTEN
PROCEDURE REFUSE TO HONOR, PROHIBIT OR IN ANY WAY RESTRICT  THE  ABILITY
OF  AN  ENROLLEE  TO  ASSIGN  HIS OR HER BENEFITS ALLOWABLE OR OTHERWISE
PAYABLE TO THE ENROLLEE AS PAYMENT FOR PROFESSIONAL SERVICES RENDERED.
  S 17. The insurance law is amended by adding a new section  4803-a  to
read as follows:
  S  4803-A.  PROHIBITIONS. 1. NO MANAGED CARE HEALTH INSURANCE CONTRACT
OR MANAGED CARE PRODUCT SHALL BY CONTRACT,  WRITTEN  POLICY  OR  WRITTEN
PROCEDURE  REFUSE  TO HONOR, PROHIBIT OR IN ANY WAY RESTRICT THE ABILITY
OF AN ENROLLEE TO ASSIGN HIS OR  HER  BENEFITS  ALLOWABLE  OR  OTHERWISE
PAYABLE TO THE ENROLLEE AS PAYMENT FOR PROFESSIONAL SERVICES RENDERED.
  2.  ANY  CONTRACT  PROVISION,  WRITTEN  POLICY OR WRITTEN PROCEDURE IN
VIOLATION OF THIS SECTION SHALL BE DEEMED TO BE VOID AND UNENFORCEABLE.
  S 18. Section 4905 of the public health law is amended by adding a new
subdivision 16 to read as follows:

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  16. A HEALTH CARE PLAN SHALL PROVIDE NOTICE TO PARTICIPATING PROVIDERS
SIXTY DAYS IN ADVANCE OF A CHANGE IN UTILIZATION REVIEW AGENTS.
  S  19.  Section  4905  of the insurance law is amended by adding a new
subsection (p) to read as follows:
  (P) A HEALTH CARE PLAN SHALL PROVIDE NOTICE TO PARTICIPATING PROVIDERS
SIXTY DAYS IN ADVANCE OF A CHANGE IN UTILIZATION REVIEW AGENTS.
  S 20. This act shall take effect on  the  one  hundred  eightieth  day
after it shall have become a law.