Senate Bill S7960

                                 BILL NUMBER:  S7960

 TITLE OF BILL :

An act directing the superintendent of financial services to conduct
an analysis of standards and enforcement provisions for prompt and
equitable settlement of claims for payment of home care services

 PURPOSE :

To review current practices in the authorization and payment of claims
for home care services under the state's prompt, fair and equitable
settlement of claims law, and to determine the need for change in or
enforcement of such standards.

 SUMMARY OF PROVISIONS :

Section 1 directs the Superintendent of the State Department of
Financial Services, in conjunction with the State Commissioner of
Health, to conduct an analysis of the standards for prompt, fair and
equitable settlement of claims and payments for home care services as
required under section 3224-a of the insurance law, New York's prompt,
fair and equitable claims settlement law.

Section 2 is the effective date.

              

 JUSTIFICATION :

Priority state health care reform policies are requiring a major shift
in services from hospitals and other institutional settings into
community based care. Most notably, state policies and models are
specifically seeking a 25% reduction in avoidable hospital admissions
and readmissions and emergency room use over the next several years,
and billions in federal funding to the state is contingent on
achieving this goal. These policies, along with policies requiring
provision of long term care in "least restrictive and most integrated
settings for individuals," are directly dependent on a viable,
accessible and well-operating home care system.

Concurrent with the shift in settings, has been the state's and other
payors' shift of coverage models into managed care and other payor
arrangements distinct from the prior longstanding fee-for-service
system.

Data from studies of the home care field, along with steady and
statewide anecdotal reports, indicate significant impacts from
delayed, denied or "settled" payments of home care services claims.
Such payment issues jeopardize services as well as state policies.

While New York State has a broad statute intended to ensure prompt,
fair and equitable settlement of claims, indications and reports of
compliance concerns or other gaps continue, and necessitate
examination and resolution, particularly with the growing population
need for, and emphasis on, home care services and the dependence of
the state's policies on these services.

To further, and more precisely, narrow and determine the exact nature,
root causes and solutions in terms of either a revision in standards
or in enforcement of such, this legislation would require the State
Department of Financial Services and State Department of Health
jointly conduct an analysis and report on authorization, claims and
settlement practices between payors and providers for home care
services, with the participation and input of the relevant service
coverage and provider representatives.

 LEGISLATIVE HISTORY :
New bill.

 FISCAL IMPLICATIONS :

None.

 EFFECTIVE DATE :
Immediately.