NY State Senate Bill 2025-S5045A

Senate Bill S5045A

2025-2026 Legislative Session

Relates to copayment and coinsurance charged for physical and occupational therapy services

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Current Bill Status - On Floor Calendar

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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Actions

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
May 19, 2025	amended on third reading (t) 5045a
Mar 26, 2025	advanced to third reading
Mar 25, 2025	2nd report cal.
Mar 24, 2025	1st report cal.584
Feb 18, 2025	referred to insurance

Votes

- Mar 24, 2025 - Insurance Committee Vote
  S5045A
  
  11
  
  Aye
  
  0
  
  Nay
  
  0
  
  Aye with Reservations
  
  0
  
  Absent
  
  0
  
  Excused
  
  0
  
  Abstained
  - - Insurance Committee Vote: Mar 24, 2025
      
      aye (11)
      
      Addabbo Jr.
      
      Ashby
      
      Bailey
      
      Cooney
      
      Fernandez
      
      Gounardes
      
      Harckham
      
      Helming
      
      O'Mara
      
      Sanders Jr.
      
      Skoufis

Bill Amendments

Original

A (Active)

co-Sponsors

View additional co-sponsors

2025-S5045 - Details

See Assembly Version of this Bill:: A6484
Law Section:: Insurance Law
Laws Affected:: Amd §§3216, 4235, 4301 & 4322, Ins L
Versions Introduced in Other Legislative Sessions:: 2009-2010: S4321, A8171
2011-2012: S4870, A187
2013-2014: S2319, A1666
2015-2016: S28, A1063
2017-2018: S5764, A569
2019-2020: S3751, A405
2021-2022: S3562, A594
2023-2024: S1470, A6345

2025-S5045 - Summary

Provides that any copayment or coinsurance amount charged by an insurer to the insured for services rendered by a physical therapist or an occupational therapist shall not be more than twenty-five percent greater than the copayment or coinsurance amount imposed for an office visit to a licensed primary care physician or osteopath for the same or a similar diagnosed condition.

2025-S5045 - Sponsor Memo

                                 
BILL NUMBER: S5045

SPONSOR: BAILEY
 
TITLE OF BILL:

An act to amend the insurance law, in relation to physical therapy
services

 
PURPOSE:

To limit the imposition of co-payments for physical therapy services to
no more than twenty percent of the reimbursement to the provider of
care.

 
SUMMARY OF PROVISIONS:

Sections 1 through 5 prohibit payors from imposing costs on insureds for
the provision of physical therapy services in excess of 20 percent of
the reimbursement to the provider of care.

 
JUSTIFICATION:

This bill will protect consumers by prohibiting plans from inappropri-
ately shifting the cost of physical therapy care to consumers by limit-
ing copayments to no more than 20 percent of the total reimbursement to
the provider of care. Under existing law, health plans must cover phys-
ical therapy services. Despite that requirement, health plans have
shifted the vast majority of the cost of physical therapy services by
imposing increasingly high co-payments on consumers. Under certain
health plans, co-payments for physical therapy services have exceeded
the reimbursement paid by the plan to the provider of care. This cost
shift has imposed a financial burden on consumers, and it has restricted
access to physical therapy services. Consumers frequently cannot afford
the cost imposed by these copayments for medically necessary physical
therapy care.  physical therapy services generally require multiple
visits over the healing process. A co-payment of $50 for a physical
therapy plan of care of 3 times a week for a month will cost the consum-
er $600 in out-of-pocket expenses which is beyond the means of many
consumers.

As a result, New Yorkers are forgoing medically necessary care running
the risk of worsening the underlying condition or risking re-injury.

This bill would reestablish the obligation of health plans to cover the
expense of physical therapy services by limiting co-payments to no more
than 20 percent of the total reimbursement to the provider of care.

The 20 percent limitation will allow plans to require co-payments that
discourage inappropriate care but will prohibit plans from inappropri-
ately splitting the cost of physical therapy care to consumers.

 
LEGISLATIVE HISTORY:

2009-10: S4321A - Referred to Insurance

2011-12: S4870A

2013-14: S2319A

2015-16: S2SA

2017-13: S5764A

2019-20: 53751

2021-22: 53562

2023-24: 51470 - Vetoed

 
FISCAL IMPLICATIONS:

None.

 
EFFECTIVE DATE:
180 days after it shall have become a law.

2025-S5045 - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   5045
 
                        2025-2026 Regular Sessions
 
                             I N  S E N A T E
 
                             February 18, 2025
                                ___________
 
 Introduced  by  Sens.  BAILEY,  COMRIE,  GALLIVAN, HELMING, MAY, PARKER,
   SEPULVEDA, STEC -- 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  physical  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.    AN  INSURER  SHALL NOT IMPOSE A COPAYMENT OR COINSURANCE AMOUNT
 CHARGED TO THE INSURED FOR SERVICES RENDERED FOR EACH DATE OF SERVICE BY
 A PHYSICAL THERAPIST LICENSED UNDER ARTICLE ONE  HUNDRED  THIRTY-SIX  OF
 THE  EDUCATION  LAW  OR AN OCCUPATIONAL THERAPIST LICENSED UNDER ARTICLE
 ONE HUNDRED FIFTY-SIX OF THE EDUCATION LAW  THAT  IS  GREATER  THAN  THE
 COPAYMENT  OR  COINSURANCE  AMOUNT  IMPOSED  ON THE INSURED FOR SERVICES
 PROVIDED TO THE INSURED FOR  AN  OFFICE  VISIT  FOR  THE  SERVICE  OF  A
 LICENSED  PRIMARY  CARE PHYSICIAN OR OSTEOPATH FOR THE SAME OR A SIMILAR
 DIAGNOSED CONDITION EVEN IF A DIFFERENT NOMENCLATURE IS USED TO DESCRIBE
 THE CONDITION FOR WHICH THE SERVICES ARE PROVIDED.
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD09380-01-5
 S. 5045                             2

   § 2. Subparagraph (A) of paragraph 1 of subsection (f) of section 4235
 of the insurance law is amended by adding a new clause (iii) to read  as
 follows:
   (III)  A  POLICY  SHALL  NOT  IMPOSE A COPAYMENT OR COINSURANCE AMOUNT
 CHARGED TO THE INSURED FOR SERVICES RENDERED FOR EACH DATE OF SERVICE BY
 A PHYSICAL THERAPIST LICENSED UNDER ARTICLE ONE  HUNDRED  THIRTY-SIX  OF
 THE  EDUCATION  LAW  OR AN OCCUPATIONAL THERAPIST LICENSED UNDER ARTICLE
 ONE HUNDRED FIFTY-SIX OF THE EDUCATION LAW  THAT  IS  GREATER  THAN  THE
 COPAYMENT  OR  COINSURANCE  AMOUNT  IMPOSED  ON THE INSURED FOR SERVICES
 PROVIDED TO THE INSURED FOR  AN  OFFICE  VISIT  FOR  THE  SERVICE  OF  A
 LICENSED  PRIMARY  CARE PHYSICIAN OR OSTEOPATH FOR THE SAME OR A SIMILAR
 DIAGNOSED CONDITION EVEN IF A DIFFERENT NOMENCLATURE IS USED TO DESCRIBE
 THE CONDITION FOR WHICH THE SERVICES ARE PROVIDED.
   § 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.  A POLICY SHALL NOT IMPOSE A COPAYMENT OR COIN-
 SURANCE AMOUNT CHARGED TO THE INSURED FOR  SERVICES  RENDERED  FOR  EACH
 DATE  OF  SERVICE  BY  A  PHYSICAL  THERAPIST LICENSED UNDER ARTICLE ONE
 HUNDRED THIRTY-SIX OF THE EDUCATION LAW  OR  AN  OCCUPATIONAL  THERAPIST
 LICENSED  UNDER  ARTICLE ONE HUNDRED FIFTY-SIX OF THE EDUCATION LAW THAT
 IS GREATER THAN THE COPAYMENT  OR  COINSURANCE  AMOUNT  IMPOSED  ON  THE
 INSURED FOR SERVICES PROVIDED TO THE INSURED FOR AN OFFICE VISIT FOR THE
 SERVICE  OF  A LICENSED PRIMARY CARE PHYSICIAN OR OSTEOPATH FOR THE SAME
 OR A SIMILAR DIAGNOSED CONDITION EVEN IF  A  DIFFERENT  NOMENCLATURE  IS
 USED TO DESCRIBE THE CONDITION FOR WHICH THE SERVICES ARE PROVIDED;
   § 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, PROVIDED, HOWEVER, THAT NO COPAYMENT OR COINSURANCE AMOUNT CHARGED
 TO THE INSURED FOR SERVICES RENDERED FOR EACH DATE OF SERVICE BY A PHYS-
 ICAL THERAPIST LICENSED UNDER ARTICLE  ONE  HUNDRED  THIRTY-SIX  OF  THE
 EDUCATION  LAW  OR  AN OCCUPATIONAL THERAPIST LICENSED UNDER ARTICLE ONE
 HUNDRED FIFTY-SIX OF THE EDUCATION LAW IS GREATER THAN THE COPAYMENT  OR
 COINSURANCE  AMOUNT  IMPOSED ON THE INSURED FOR SERVICES PROVIDED TO THE
 INSURED FOR AN OFFICE VISIT FOR THE SERVICE OF A LICENSED  PRIMARY  CARE
 PHYSICIAN  OR  OSTEOPATH  FOR  THE SAME OR A SIMILAR DIAGNOSED CONDITION
 EVEN IF A DIFFERENT NOMENCLATURE IS USED TO DESCRIBE THE  CONDITION  FOR
 WHICH THE SERVICES ARE PROVIDED,
   §  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,  PROVIDED,  HOWEVER,  THAT  NO  COPAYMENT OR COINSURANCE
 AMOUNT CHARGED TO THE INSURED FOR SERVICES RENDERED  FOR  EACH  DATE  OF
 SERVICE BY A PHYSICAL THERAPIST LICENSED UNDER ARTICLE ONE HUNDRED THIR-
 TY-SIX  OF THE EDUCATION LAW OR AN OCCUPATIONAL THERAPIST LICENSED UNDER
 ARTICLE ONE HUNDRED FIFTY-SIX OF THE EDUCATION LAW IS GREATER  THAN  THE
 COPAYMENT  OR  COINSURANCE  AMOUNT  IMPOSED  ON THE INSURED FOR SERVICES
 S. 5045                             3
 
 PROVIDED TO THE INSURED FOR  AN  OFFICE  VISIT  FOR  THE  SERVICE  OF  A
 LICENSED  PRIMARY  CARE PHYSICIAN OR OSTEOPATH FOR THE SAME OR A SIMILAR
 DIAGNOSED CONDITION EVEN IF A DIFFERENT NOMENCLATURE IS USED TO DESCRIBE
 THE CONDITION FOR WHICH THE SERVICES ARE PROVIDED.
   § 6. This act shall take effect on the one hundred eightieth day after
 it shall have become a law.

co-Sponsors

View additional co-sponsors

2025-S5045A (ACTIVE) - Details

See Assembly Version of this Bill:: A6484
Law Section:: Insurance Law
Laws Affected:: Amd §§3216, 4235, 4301 & 4322, Ins L
Versions Introduced in Other Legislative Sessions:: 2009-2010: S4321, A8171
2011-2012: S4870, A187
2013-2014: S2319, A1666
2015-2016: S28, A1063
2017-2018: S5764, A569
2019-2020: S3751, A405
2021-2022: S3562, A594
2023-2024: S1470, A6345

2025-S5045A (ACTIVE) - Summary

2025-S5045A (ACTIVE) - Sponsor Memo

                                 
BILL NUMBER: S5045A

SPONSOR: BAILEY
 
TITLE OF BILL:

An act to amend the insurance law, in relation to physical and occupa-
tional therapy services

 
PURPOSE:

To limit the imposition of co-payments for physical therapy services to
no more than twenty percent of the reimbursement to the provider of
care.

 
SUMMARY OF PROVISIONS:

Sections 1 through 5 prohibit payors from imposing costs on insureds for
the provision of physical therapy services in excess of 20 percent of
the reimbursement to the provider of care.

 
JUSTIFICATION:

This bill will protect consumers by prohibiting plans from inappropri-
ately shifting the cost of physical therapy care to consumers by limit-
ing copayments to no more than 20 percent of the total reimbursement to
the provider of care. Under existing law, health plans must cover phys-
ical therapy services. Despite that requirement, health plans have
shifted the vast majority of the cost of physical therapy services by
imposing increasingly high co-payments on consumers. Under certain
health plans, co-payments for physical therapy services have exceeded
the reimbursement paid by the plan to the provider of care. This cost
shift has imposed a financial burden on consumers, and it has restricted
access to physical therapy services. Consumers frequently cannot afford
the cost imposed by these copayments for medically necessary physical
therapy care.  physical therapy services generally require multiple
visits over the healing process. A co-payment of $50 for a physical
therapy plan of care of 3 times a week for a month will cost the consum-
er $600 in out-of-pocket expenses which is beyond the means of many
consumers.

As a result, New Yorkers are forgoing medically necessary care running
the risk of worsening the underlying condition or risking re-injury.

This bill would reestablish the obligation of health plans to cover the
expense of physical therapy services by limiting co-payments to no more
than 20 percent of the total reimbursement to the provider of care.

The 20 percent limitation will allow plans to require co-payments that
discourage inappropriate care but will prohibit plans from inappropri-
ately splitting the cost of physical therapy care to consumers.

 
LEGISLATIVE HISTORY:

2009-10: S4321A - Referred to Insurance

2011-12: S4870A

2013-14: S2319A

2015-16: S2SA

2017-13: S5764A

2019-20: S3751

2021-22: S3562

2023-24: S1470 - Vetoed

 
FISCAL IMPLICATIONS:

None.

 
EFFECTIVE DATE:
180 days after it shall have become a law.

2025-S5045A (ACTIVE) - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  5045--A
     Cal. No. 584
 
                        2025-2026 Regular Sessions
 
                             I N  S E N A T E
 
                             February 18, 2025
                                ___________
 
 Introduced  by  Sens.  BAILEY, ASHBY, COMRIE, GALLIVAN, GRIFFO, HELMING,
   MAY, PARKER, SEPULVEDA, STEC -- read twice and  ordered  printed,  and
   when printed to be committed to the Committee on Insurance -- reported
   favorably  from  said  committee,  ordered to first and second report,
   ordered to a third reading, amended and ordered  reprinted,  retaining
   its place in the order of third reading
 
 AN  ACT  to amend the insurance law, in relation to physical and occupa-
   tional 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.  ANY COPAYMENT OR COINSURANCE AMOUNT CHARGED BY AN INSURER TO  THE
 INSURED  FOR  SERVICES  RENDERED  BY A PHYSICAL THERAPIST LICENSED UNDER
 ARTICLE ONE HUNDRED THIRTY-SIX OF THE EDUCATION LAW OR  AN  OCCUPATIONAL
 THERAPIST  LICENSED UNDER ARTICLE ONE HUNDRED FIFTY-SIX OF THE EDUCATION
 LAW SHALL NOT BE MORE THAN TWENTY-FIVE PERCENT GREATER THAN  THE  COPAY-
 MENT  OR  COINSURANCE  AMOUNT  IMPOSED FOR AN OFFICE VISIT TO A LICENSED
 PRIMARY CARE PHYSICIAN OR OSTEOPATH FOR THE SAME OR A SIMILAR  DIAGNOSED
 CONDITION.
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD09380-03-5

 S. 5045--A                          2
 
   § 2. Subparagraph (A) of paragraph 1 of subsection (f) of section 4235
 of  the insurance law is amended by adding a new clause (iii) to read as
 follows:
   (III)  A  POLICY  SHALL  NOT  IMPOSE A COPAYMENT OR COINSURANCE AMOUNT
 CHARGED TO THE INSURED FOR SERVICES RENDERED  BY  A  PHYSICAL  THERAPIST
 LICENSED UNDER ARTICLE ONE HUNDRED THIRTY-SIX OF THE EDUCATION LAW OR AN
 OCCUPATIONAL  THERAPIST  LICENSED UNDER ARTICLE ONE HUNDRED FIFTY-SIX OF
 THE EDUCATION LAW THAT IS MORE THAN TWENTY-FIVE PERCENT GREATER THAN THE
 COPAYMENT OR COINSURANCE  AMOUNT  IMPOSED  FOR  AN  OFFICE  VISIT  TO  A
 LICENSED  PRIMARY  CARE PHYSICIAN OR OSTEOPATH FOR THE SAME OR A SIMILAR
 DIAGNOSED CONDITION.
   § 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.  A POLICY SHALL NOT IMPOSE A COPAYMENT OR COIN-
 SURANCE AMOUNT CHARGED TO THE INSURED FOR SERVICES RENDERED BY  A  PHYS-
 ICAL  THERAPIST  LICENSED  UNDER  ARTICLE  ONE HUNDRED THIRTY-SIX OF THE
 EDUCATION LAW OR AN OCCUPATIONAL THERAPIST LICENSED  UNDER  ARTICLE  ONE
 HUNDRED  FIFTY-SIX  OF  THE  EDUCATION LAW THAT IS MORE THAN TWENTY-FIVE
 PERCENT GREATER THAN THE COPAYMENT OR COINSURANCE AMOUNT IMPOSED FOR  AN
 OFFICE  VISIT  TO A LICENSED PRIMARY CARE PHYSICIAN OR OSTEOPATH FOR THE
 SAME OR A SIMILAR DIAGNOSED CONDITION;
   § 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, PROVIDED, HOWEVER, THAT NO COPAYMENT OR COINSURANCE AMOUNT CHARGED
 TO  THE  INSURED  FOR SERVICES RENDERED BY A PHYSICAL THERAPIST LICENSED
 UNDER ARTICLE ONE HUNDRED THIRTY-SIX OF THE EDUCATION LAW OR AN  OCCUPA-
 TIONAL  THERAPIST  LICENSED  UNDER  ARTICLE ONE HUNDRED FIFTY-SIX OF THE
 EDUCATION LAW SHALL BE MORE THAN TWENTY-FIVE PERCENT  GREATER  THAN  THE
 COPAYMENT  OR  COINSURANCE  AMOUNT  IMPOSED  FOR  AN  OFFICE  VISIT TO A
 LICENSED PRIMARY CARE PHYSICIAN OR OSTEOPATH FOR THE SAME OR  A  SIMILAR
 DIAGNOSED CONDITION,
   §  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,  PROVIDED,  HOWEVER,  THAT  NO  COPAYMENT OR COINSURANCE
 AMOUNT CHARGED TO THE INSURED FOR SERVICES RENDERED BY A PHYSICAL THERA-
 PIST LICENSED UNDER ARTICLE ONE HUNDRED THIRTY-SIX OF THE EDUCATION  LAW
 OR  AN  OCCUPATIONAL THERAPIST LICENSED UNDER ARTICLE ONE HUNDRED FIFTY-
 SIX OF THE EDUCATION LAW SHALL BE MORE THAN TWENTY-FIVE PERCENT  GREATER
 THAN  THE COPAYMENT OR COINSURANCE AMOUNT IMPOSED FOR AN OFFICE VISIT TO
 A LICENSED PRIMARY CARE PHYSICIAN OR OSTEOPATH FOR THE SAME OR A SIMILAR
 DIAGNOSED CONDITION.
   § 6. This act shall take effect January 1, 2027.

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Senate Bill S5045A

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Sponsored By

Current Bill Status - On Floor Calendar

Bill Amendments

co-Sponsors

2025-S5045 - Details

2025-S5045 - Summary

2025-S5045 - Sponsor Memo

2025-S5045 - Bill Text download pdf

co-Sponsors

2025-S5045A (ACTIVE) - Details

2025-S5045A (ACTIVE) - Summary

2025-S5045A (ACTIVE) - Sponsor Memo

2025-S5045A (ACTIVE) - Bill Text download pdf

Comments