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

                                  9384

                          I N  A S S E M B L Y

                            February 29, 2016
                               ___________

Introduced  by M. of A. GUNTHER -- read once and referred to the Commit-
  tee on Insurance

AN ACT to amend the insurance  law,  in  relation  to  health  insurance
  coverage of physical and occupational therapy services and payment for
  early  intervention  services;  and to amend the insurance law and the
  public health law, in relation to the provision of medically necessary
  care and utilization review

  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, FURTHER, THAT SUCH TERMS SHALL NOT IMPOSE CO-PAYMENTS  IN
EXCESS  OF  TWENTY PERCENT OF THE TOTAL REIMBURSEMENT TO THE PROVIDER OF
CARE. VISIT LIMITS FOR PHYSICAL AND OCCUPATIONAL THERAPY SERVICES  SHALL
BE  SUBJECT  TO  AN EXCEPTIONS PROCESS, THAT SHALL INCLUDE THE INSURED'S
PHYSICIAN CERTIFYING THAT THE CESSATION OF SERVICES  WOULD  MOST  LIKELY
RESULT  IN  FURTHER  DISABILITY  OR  HARM TO THE INSURED. ANY EXCEPTIONS
PROCESS SHALL BE FURTHER DETERMINED BY THE SUPERINTENDENT.
  S 2. Subsection (b) of section 3235-a of the insurance law,  as  added
by  section  3 of part C of chapter 1 of the laws of 2002, is amended to
read as follows:
  (b) Where a policy of  accident  and  health  insurance,  including  a
contract  issued  pursuant  to  article  forty-three  of  this  chapter,
provides coverage for an early intervention program service, such cover-

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

                                                           LBD14350-01-6

A. 9384                             2

age shall not be applied against any maximum annual or lifetime monetary
limits set forth in such policy  or  contract.  Visit  limitations  [and
other  terms  and  conditions  of  the policy] will continue to apply to
early  intervention  services. However, any visits used for early inter-
vention program services shall not reduce the number of visits otherwise
available under the policy or contract for such services.
  S 3. 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
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] IN THIS
CLAUSE.  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. VISIT LIMITS FOR  PHYS-
ICAL  AND  OCCUPATIONAL SERVICES SHALL BE SUBJECT TO AN EXCEPTIONS PROC-
ESS, THAT SHALL INCLUDE  AN  INSURED'S  PHYSICIAN  CERTIFYING  THAT  THE
CESSATION  OF SERVICES WOULD MOST LIKELY RESULT IN FURTHER DISABILITY OR
HARM TO THE INSURED. ANY EXCEPTIONS PROCESS SHALL BE FURTHER  DETERMINED
BY THE SUPERINTENDENT.
  S 4. 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. 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.
VISIT LIMITS FOR PHYSICAL AND OCCUPATIONAL  THERAPY  SERVICES  SHALL  BE
SUBJECT TO AN EXCEPTIONS PROCESS, THAT SHALL INCLUDE AN INSURED'S PHYSI-
CIAN  CERTIFYING THAT THE CESSATION OF SERVICES WOULD MOST LIKELY RESULT
IN FURTHER DISABILITY OR HARM TO THE  INSURED.  ANY  EXCEPTIONS  PROCESS
SHALL BE FURTHER DETERMINED BY THE SUPERINTENDENT;
  S 5. 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. CO-PAYMENTS RELATED TO REIMBURSEMENT FOR SUCH SERVICES  SHALL  NOT
EXCEED  TWENTY  PERCENT  OF  THE  TOTAL REIMBURSEMENT TO THE PROVIDER OF
CARE. VISIT LIMITS FOR PHYSICAL AND OCCUPATIONAL THERAPY SERVICES  SHALL
BE  SUBJECT  TO  AN  EXCEPTIONS  PROCESS, THAT SHALL INCLUDE THE COVERED
PERSON'S PHYSICIAN CERTIFYING THAT THE CESSATION OF SERVICES WOULD  MOST
LIKELY  RESULT  IN FURTHER DISABILITY OR HARM TO THE COVERED PERSON. ANY
EXCEPTIONS PROCESS SHALL BE FURTHER DETERMINED BY THE SUPERINTENDENT,

A. 9384                             3

  S 6. Paragraph 13 of subsection (b) of section 4322 of  the  insurance
law,  as  added by chapter 504 of the laws of 1995, is amended and a new
paragraph 13-a is added to read as follows:
  (13) Outpatient physical therapy up to ninety visits per condition per
calendar  year.  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. VISIT LIMITS FOR PHYSICAL THERAPY SERVICES
SHALL BE SUBJECT TO  AN  EXCEPTIONS  PROCESS,  THAT  SHALL  INCLUDE  THE
COVERED  PERSON'S  PHYSICIAN  CERTIFYING  THAT THE CESSATION OF SERVICES
WOULD MOST LIKELY RESULT IN FURTHER DISABILITY OR HARM  TO  THE  COVERED
PERSON.    ANY  EXCEPTIONS  PROCESS  SHALL  BE FURTHER DETERMINED BY THE
SUPERINTENDENT.
  (13-A) OUTPATIENT OCCUPATIONAL THERAPY UP TO NINETY VISITS PER  CONDI-
TION  PER  CALENDAR  YEAR.  ANY CO-PAYMENTS RELATED TO REIMBURSEMENT FOR
OCCUPATIONAL THERAPY SERVICES SHALL NOT EXCEED  TWENTY  PERCENT  OF  THE
TOTAL  REIMBURSEMENT  TO  THE PROVIDER OF CARE. VISIT LIMITS FOR OCCUPA-
TIONAL THERAPY SERVICES SHALL BE SUBJECT TO AN EXCEPTIONS PROCESS,  THAT
SHALL INCLUDE THE COVERED PERSON'S PHYSICIAN CERTIFYING THAT SUCH CESSA-
TION  OF SERVICES WOULD MOST LIKELY RESULT IN FURTHER DISABILITY OR HARM
TO THE COVERED PERSON.  ANY EXCEPTIONS PROCESS SHALL BE  FURTHER  DETER-
MINED BY THE SUPERINTENDENT.
  S  7. Subsection (e) of section 4803 of the insurance law, as added by
chapter 705 of the laws of 1996, is amended and a new  subsection  (a-1)
is added 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.
  (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  8.  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;

A. 9384                             4

  S 9. 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 10. 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:
  S 11. Subdivision 5 of section 4406-d of the  public  health  law,  as
added  by chapter 705 of the laws of 1996, is amended and a new subdivi-
sion 1-a is added 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.
  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  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;

A. 9384                             5

  S  13.  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 14. 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 15. This act shall take effect on  the  one  hundred  eightieth  day
after it shall have become a law.