S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   8747
 
                             I N  S E N A T E
 
                               March 6, 2024
                                ___________
 
 Introduced  by  Sen. ADDABBO -- read twice and ordered printed, and when
   printed to be committed to the Committee on Insurance
 
 AN ACT to amend the insurance  law,  in  relation  to  health  insurance
   coverage of physical and occupational therapy services
 
   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.
   § 2. 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,
 item  (ii)  as amended by chapter 479 of the laws of 2022, is amended to
 read as follows:
   (A) Any policy of group accident, group health or group  accident  and
 health  insurance  may include provisions for the payment by the insurer
 of benefits for expenses incurred on account  of  hospital,  medical  or
 surgical  care or physical and occupational therapy by licensed physical
 and occupational therapists upon  the  prescription  or  referral  of  a
 physician  for  the  employee  or other member of the insured group, the
 employee's or member's spouse, the employee's or member's child or chil-
 dren, or other persons chiefly dependent upon the employee or member for
 support and maintenance; provided that:
   (i) a policy of hospital,  medical,  surgical,  or  prescription  drug
 expense insurance that provides coverage for children shall provide such
 coverage  to  a married or unmarried child until attainment of age twen-
              

 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD09646-01-3
 S. 8747                             2
 
 ty-six, without regard  to  financial  dependence,  residency  with  the
 employee  or member, student status, or employment, except a policy that
 is a grandfathered health plan may,  for  plan  years  beginning  before
 January first, two thousand fourteen, exclude coverage of an adult child
 under  age twenty-six who is eligible to enroll in an employer-sponsored
 health plan other than a group health plan of a parent. For purposes  of
 this  item,  "grandfathered  health  plan" means coverage provided by an
 insurer in which an individual was enrolled on March  twenty-third,  two
 thousand  ten for as long as the coverage maintains grandfathered status
 in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.
 § 18011(e); [and]
   (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, 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[.]; AND
   (III)  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.
   § 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, PROVIDED HOWEVER, THAT NO POLICY OF GROUP ACCI-
 DENT,  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;
   § 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. CO-PAYMENTS RELATED TO REIMBURSEMENT FOR SUCH SERVICES  SHALL  NOT
 EXCEED  TWENTY  PERCENT  OF  THE  TOTAL REIMBURSEMENT TO THE PROVIDER OF
 CARE,
   § 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. 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.
   § 6. This act shall take effect on the one hundred eightieth day after
 it shall have become a law.