Senate Bill S10315

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   10315
 
                             I N  S E N A T E
 
                               May 12, 2026
                                ___________
 
 Introduced  by  Sen.  WEBER  -- read twice and ordered printed, and when
   printed to be committed to the Committee on Disabilities
 
 AN ACT to amend the mental hygiene law and the  public  health  law,  in
   relation to establishing a mandatory supplemental therapeutic services
   reimbursement  for  individuals  receiving services through the office
   for people with developmental disabilities

   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.  The mental hygiene law is amended by adding a new section
 16.36 to read as follows:
 § 16.36 SUPPLEMENTAL THERAPEUTIC SERVICES REIMBURSEMENT.
   1. NOTWITHSTANDING ANY INCONSISTENT PROVISION OF LAW,  RULE  OR  REGU-
 LATION,  THE  COMMISSIONER SHALL, UPON APPLICATION AND UPON SATISFACTION
 OF THE CRITERIA SET FORTH IN SUBDIVISION THREE OF THIS SECTION,  AUTHOR-
 IZE  SUPPLEMENTAL REIMBURSEMENT FOR THERAPEUTIC SERVICES FOR AN ELIGIBLE
 INDIVIDUAL WHEN SUCH SERVICES: (A) HAVE BEEN DETERMINED TO BE  MEDICALLY
 NECESSARY;  (B)  ARE INCLUDED IN AN APPROVED SERVICE PLAN, PLAN OF CARE,
 OR OTHER AUTHORIZED PLANNING DOCUMENT; AND (C) CANNOT BE SECURED  WITHIN
 TWENTY-ONE  DAYS  DESPITE  DOCUMENTED  REASONABLE EFFORTS TO OBTAIN SUCH
 SERVICES AT STATE-ESTABLISHED REIMBURSEMENT RATES.
   2. FOR PURPOSES OF THIS SECTION,  "THERAPEUTIC  SERVICES"  SHALL  MEAN
 COUNSELING,  PSYCHOTHERAPY,  BEHAVIORAL  THERAPY,  OR  OTHER  CLINICALLY
 APPROPRIATE  THERAPEUTIC  INTERVENTION  PROVIDED  BY  A  PERSON  WHO  IS
 LICENSED,  CERTIFIED,  OR OTHERWISE LEGALLY AUTHORIZED UNDER THE LAWS OF
 THIS STATE TO FURNISH SUCH SERVICE.
   3. SUPPLEMENTAL REIMBURSEMENT UNDER THIS  SECTION  SHALL  BE  APPROVED
 UPON  A  DETERMINATION BY THE COMMISSIONER, OR THE COMMISSIONER'S DESIG-
 NEE, THAT:
   (A) THE SERVICE IS MEDICALLY NECESSARY AND  INCLUDED  IN  AN  APPROVED
 PLANNING DOCUMENT;
   (B)  THE  ELIGIBLE INDIVIDUAL OR THE INDIVIDUAL'S AUTHORIZED REPRESEN-
 TATIVE, IN COORDINATION WITH THE RELEVANT CARE MANAGER, SERVICE  COORDI-
 NATOR,  OR OTHER RESPONSIBLE PLANNING ENTITY, MADE DOCUMENTED REASONABLE
 EFFORTS OVER A PERIOD OF NOT LESS THAN TWENTY-ONE  DAYS  TO  OBTAIN  THE
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD15849-02-6
 S. 10315                            2
 
 SERVICE  FROM  A PROVIDER WILLING TO ACCEPT THE APPLICABLE STATE-ESTABL-
 ISHED REIMBURSEMENT RATE, AND SUCH EFFORTS WERE UNSUCCESSFUL;
   (C) DELAY OR ABSENCE OF SUCH SERVICE WOULD MATERIALLY IMPAIR THE INDI-
 VIDUAL'S HEALTH, BEHAVIORAL STABILITY, COMMUNITY FUNCTIONING, OR MAINTE-
 NANCE  IN THE LEAST RESTRICTIVE SETTING APPROPRIATE TO SUCH INDIVIDUAL'S
 NEEDS; AND
   (D) THE PROVIDER SELECTED TO  FURNISH  THE  SERVICE  IS  APPROPRIATELY
 LICENSED,  CERTIFIED,  OR OTHERWISE LEGALLY AUTHORIZED UNDER THE LAWS OF
 THIS STATE.
   4. UPON APPROVAL UNDER SUBDIVISION THREE OF THIS SECTION, THE  COMMIS-
 SIONER  SHALL AUTHORIZE REIMBURSEMENT IN AN AMOUNT EQUAL TO SEVENTY-FIVE
 PERCENT OF THE PROVIDER'S BILLED CHARGES, SUBJECT TO THE FOLLOWING:
   (A) THE MINIMUM SUPPLEMENTAL REIMBURSEMENT FLOOR SHALL BE ONE  HUNDRED
 TWENTY  DOLLARS PER HOUR FOR INDIVIDUAL THERAPY SESSIONS, NINETY DOLLARS
 PER HOUR FOR GROUP THERAPY SESSIONS, AND ONE HUNDRED FIFTY  DOLLARS  PER
 HOUR  FOR  BEHAVIORAL  INTERVENTION  OR  APPLIED BEHAVIOR ANALYSIS (ABA)
 SERVICES. SUCH REIMBURSEMENT FLOORS SHALL NOT BE REDUCED  BY  REGULATION
 OR ADMINISTRATIVE ACTION.
   (B)  BEGINNING  JANUARY FIRST, TWO THOUSAND TWENTY-EIGHT, AND ANNUALLY
 THEREAFTER, THE MINIMUM REIMBURSEMENT FLOORS SET FORTH IN PARAGRAPH  (A)
 OF  THIS  SUBDIVISION  SHALL  BE INCREASED BY THE SAME PERCENTAGE AS THE
 MEDICAL CARE COMPONENT OF THE CONSUMER PRICE INDEX FOR ALL URBAN CONSUM-
 ERS (CPI-U) FOR THE NEW YORK METROPOLITAN AREA FOR THE PRECEDING  CALEN-
 DAR  YEAR, AS PUBLISHED BY THE UNITED STATES BUREAU OF LABOR STATISTICS.
 SUCH ANNUAL ADJUSTMENT IS MANDATORY.
   (C) THE MAXIMUM REIMBURSEMENT  SHALL  NOT  EXCEED  TWO  HUNDRED  FIFTY
 DOLLARS  PER  HOUR  FOR  INDIVIDUAL  THERAPY,  ONE  HUNDRED SEVENTY-FIVE
 DOLLARS PER HOUR  FOR  GROUP  THERAPY,  AND  THREE  HUNDRED  TWENTY-FIVE
 DOLLARS  PER  HOUR  FOR  ABA  SERVICES, SUBJECT TO THE SAME ANNUAL CPI-U
 ADJUSTMENT DESCRIBED IN PARAGRAPH (B) OF THIS SUBDIVISION.
   5. THE COMMISSIONER SHALL ACT ON A COMPLETE  APPLICATION  FOR  SUPPLE-
 MENTAL  REIMBURSEMENT UNDER THIS SECTION WITHIN FIFTEEN BUSINESS DAYS OF
 RECEIPT.  FAILURE TO ACT WITHIN SUCH PERIOD SHALL CONSTITUTE APPROVAL OF
 THE APPLICATION BY OPERATION OF  LAW.  THE  COMMISSIONER  SHALL  PROVIDE
 WRITTEN  NOTICE TO THE APPLICANT WITHIN FIVE BUSINESS DAYS OF A DETERMI-
 NATION, INCLUDING THE BASIS FOR ANY DENIAL.
   6. TO THE EXTENT ANY THERAPEUTIC SERVICE AUTHORIZED UNDER THIS SECTION
 IS OR MAY BE REIMBURSABLE UNDER THE NEW  YORK  STATE  MEDICAID  PROGRAM,
 INCLUDING ANY APPLICABLE WAIVER OR MANAGED CARE ARRANGEMENT, THE COMMIS-
 SIONER  SHALL COORDINATE IMPLEMENTATION OF THIS SECTION WITH THE DEPART-
 MENT OF HEALTH TO ENSURE COMPLIANCE  WITH  APPLICABLE  FEDERAL  MEDICAID
 REQUIREMENTS.  NO  SUPPLEMENTAL  REIMBURSEMENT  SHALL BE AUTHORIZED IN A
 MANNER THAT WOULD JEOPARDIZE FEDERAL FINANCIAL PARTICIPATION OR  VIOLATE
 ANY APPLICABLE FEDERAL STATUTE, REGULATION, OR WAIVER CONDITION.
   7.  ANY  INDIVIDUAL OR AUTHORIZED REPRESENTATIVE WHO IS DENIED SUPPLE-
 MENTAL REIMBURSEMENT UNDER THIS SECTION,  OR  WHO  DOES  NOT  RECEIVE  A
 DETERMINATION  WITHIN THE TIMEFRAME REQUIRED BY SUBDIVISION FIVE OF THIS
 SECTION, MAY SEEK ADMINISTRATIVE REVIEW PURSUANT  TO  APPLICABLE  PROCE-
 DURES  UNDER  THE  MENTAL  HYGIENE LAW AND MAY FILE A COMPLAINT WITH THE
 OFFICE OF THE MEDICAID INSPECTOR GENERAL. THE COMMISSIONER  SHALL  MAIN-
 TAIN  A  DEDICATED  INTAKE  PROCESS  FOR  COMPLAINTS  ARISING UNDER THIS
 SECTION AND SHALL RESPOND IN WRITING WITHIN TEN BUSINESS DAYS.
   8. THE COMMISSIONER SHALL PROMULGATE REGULATIONS NECESSARY  TO  IMPLE-
 MENT  THIS  SECTION WITHIN NINETY DAYS OF ENACTMENT, INCLUDING STANDARDS
 GOVERNING: (A) DOCUMENTATION OF PROVIDER UNAVAILABILITY AT STATE-ESTABL-
 ISHED REIMBURSEMENT RATES DURING  THE  TWENTY-ONE  DAY  PERIOD  REQUIRED
 S. 10315                            3
 
 UNDER  SUBDIVISION  THREE  OF  THIS SECTION; (B) VERIFICATION OF MEDICAL
 NECESSITY; (C) ALLOWABLE SERVICE CATEGORIES; (D) PRIOR AUTHORIZATION AND
 UTILIZATION REVIEW PROCEDURES; AND (E) AUDIT AND PROGRAM INTEGRITY MEAS-
 URES.
   §  2.  Section  32 of the public health law is amended by adding a new
 subdivision 25-a to read as follows:
   25-A.  PRACTICES  RELATED   TO   SUPPLEMENTAL   THERAPEUTIC   SERVICES
 REIMBURSEMENT AUTHORIZED PURSUANT TO SECTION 16.36 OF THE MENTAL HYGIENE
 LAW  FOR  THE  PURPOSE  OF  DETECTING  FRAUD,  WASTE, ABUSE, OR IMPROPER
 PAYMENT, TO THE SAME EXTENT AS OTHER PAYMENTS MADE WITH STATE  OR  MEDI-
 CAID FUNDS;
   § 3. On or before December first next succeeding the effective date of
 this  act,  and  annually thereafter, the commissioner of the office for
 people with developmental disabilities shall  publish  on  the  office's
 website  and  submit  to the governor, temporary president of the senate
 and speaker of the assembly, a report setting forth, for  the  preceding
 year:   (a) the number of applications received; (b) the number approved
 and denied; (c) the general reasons for denial in  aggregate  form;  (d)
 the  types of services approved; (e) average and aggregate reimbursement
 amounts; (f) the number of applications approved by operation of law due
 to the commissioner's failure to act within fifteen business  days;  and
 (g)  a  summary  of  access-related outcomes. No personally identifiable
 information shall be included in such report.
   § 4. Nothing in this act shall be construed to create  an  entitlement
 to  any  therapeutic  service  beyond  amounts appropriated therefor, to
 alter underlying program eligibility standards, to require the state  to
 revise  any  generally  applicable reimbursement methodology outside the
 limited circumstances set forth herein, or to create any  private  right
 of action.
   §  5.  This  act shall take effect on the ninetieth day after it shall
 have become a law. Effective immediately, the addition, amendment and/or
 repeal of any rule or regulation necessary  for  the  implementation  of
 this  act  on its effective date are authorized to be made and completed
 on or before such effective date.