BILL NUMBER: S2541

SPONSOR: COMRIE
 
TITLE OF BILL:

An act to amend the social services law, in relation to providing
extended speech, physical or occupational therapy under Medicaid

 
PURPOSE:

This bill enables patients to receive coverage of medically necessary
speech, physical, and occupational therapy services under Medicaid
beyond the 20-visit annual limit.

 
SUMMARY OF PROVISIONS:

Section one amends the Social Services Law to allow exceeding the Medi-
caid limit of 20 therapy visits a year for speech, physical, or occupa-
tional therapy for a patient, if the physician or nurse practitioner who
ordered the therapy attests to the medical necessity of more sessions.

              

 
JUSTIFICATION:

The 20-visit limit on Medicaid coverage for speech, physical, and occu-
pational therapy has resulted in countless denials of medically neces-
sary treatment. For many individuals, reaching the twenty-visit cap
means forgoing crucial therapy until the next calendar year, which may
be months away. Without regular therapy, many individuals lose the
progress they had made and even deteriorate. It has left Medicaid recip-
ients with disabilities unable to maintain a level of functioning they
once had, forced victims of accidents into lifelong pain without the
means to regain full functioning, prevented individuals from fully
recovering after surgery, and kept people from being able to return to
work.

New York Medicaid's speech, physical, and occupational therapy cap is
completely out of step with what is happening in commercial insurance
and in Medicare. Medicare places an annual dollar limit on coverage of
the three therapies but, critically, provides for an exception process
allowing coverage beyond the dollar limit where additional therapies are
medically necessary.

As part of the required essential health benefits in New York, small
group and individual health insurance plans, including qualified health
plans and the Essential Plan, currently have a sixty-visit limit on
rehabilitative speech, physical, and occupational therapies, and an
additional sixty visits per year in a habilitative services benefit for
the three therapies.

Managed care plans, through their Medicare Advantage products, are
already familiar with exceptions processes sought for these same thera-
pies in Medicare. By establishing an exception to the limit, New York
will give Medicaid recipients the ability to maintain and improve their
functioning so that they, can participate to their maximum capacity in
daily life. The Medicaid program should no longer seek savings at the
expense of individuals ability to avoid pain, recover from surgery,
prevent physical decline, and return to work.

 
LEGISLATIVE HISTORY:
S8300 COMRIE No Same as

 
FISCAL IMPLICATIONS:

To be determined. The cost of additional therapy will be offset by the
improved health of patients and increased ability to return to taxpaying
employment.

 
EFFECTIVE DATE:
180 days.