S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                   633

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 7, 2009
                               ___________

Introduced  by  M.  of A. DINOWITZ, PHEFFER, GALEF, HOOPER, GOTTFRIED --
  Multi-Sponsored by --  M.  of  A.  ALFANO,  BARRA,  BOYLAND,  BRENNAN,
  COLTON,  GIANARIS,  LIFTON,  SWEENEY  -- read once and referred to the
  Committee on Health

AN ACT to amend the insurance law and the public health law, in relation
  to access to health care providers in managed care plans

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.  Subsection  (e)  of section 4803 of the insurance law, as
added by chapter 705 of the laws of 1996, is amended to read as follows:
  (e) No insurer shall terminate or  refuse  to  renew  a  contract  for
participation in the in-network benefits portion of an insurer's network
for  a  managed care product solely because the health care professional
has: (1) advocated on behalf of an insured; (2) [has] filed a  complaint
against  the  insurer; (3) [has] appealed a decision of the insurer; (4)
provided information or filed a report pursuant  to  section  forty-four
hundred  six-c of the public health law; [or] (5) requested a hearing or
review pursuant to this section; OR (6) RENDERED  AN  OPINION  REGARDING
WHETHER  AN INSURED'S ILLNESS IS TERMINAL PURSUANT TO SECTION FOUR THOU-
SAND EIGHT HUNDRED FOUR OF THIS ARTICLE.
  S 2. Subsections (e) and (f) of section 4804 of the insurance law,  as
added  by  chapter  705  of  the  laws  of  1996, are amended to read as
follows:
  (e) (1) If an insured's health  care  provider  leaves  the  insurer's
in-network  benefits  portion  of its network of providers for a managed
care product for reasons other than those for which the  provider  would
not  be  eligible  to  receive  a  hearing  pursuant to paragraph one of
subsection (b) of section  [forty-eight]  FOUR  THOUSAND  EIGHT  hundred
three of this [chapter] ARTICLE, the insurer shall permit the insured to
continue  [an  ongoing  course of treatment with] TO RECEIVE HEALTH CARE

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
              

                                                           LBD02588-01-9

A. 633                              2

PROCEDURES, TREATMENTS, AND SERVICES FROM the insured's  current  health
care  provider  during  a transitional period of (i) up to [ninety days]
ONE YEAR from the date of notice to the insured of the provider's disaf-
filiation  from  the  insurer's  network[;]  or  (ii) if the insured has
[entered the second trimester of pregnancy at the time of the provider's
disaffiliation, for a transitional period that includes the provision of
post-partum care directly related to the delivery] A TERMINAL ILLNESS OR
CONDITION, UNTIL THE TIME OF SUCH INSURED'S DEATH.
  (2)  Notwithstanding  the  provisions  of  paragraph   one   of   this
subsection,  such  care  shall  be  authorized by the insurer during the
transitional period only if the  health  care  provider  agrees  (i)  to
continue  to accept reimbursement from the insurer at the rates applica-
ble prior to the start of the transitional period as  payment  in  full;
(ii)  to  adhere  to the insurer's quality assurance requirements and to
provide to the insurer necessary medical  information  related  to  such
care; and (iii) to otherwise adhere to the insurer's policies and proce-
dures, including, but not limited to, procedures regarding referrals and
obtaining  pre-authorization and a treatment plan approved by the insur-
er.
  (f) If a new insured whose health care provider is not a member of the
insurer's in-network benefits portion of the provider network enrolls in
the managed care product,  the  insurer  shall  permit  the  insured  to
continue  [an  ongoing  course of treatment with] TO RECEIVE HEALTH CARE
PROCEDURES, TREATMENTS, AND SERVICES FROM the insured's  current  health
care  provider  during  a  transitional period of up to [sixty days] ONE
YEAR from the effective date of enrollment OR, if [(1)] the insured  has
a [life-threatening disease or condition or a degenerative and disabling
disease or condition or (2) the insured has entered the second trimester
of  pregnancy  at the time of enrollment, in which case the transitional
period shall include the provision of post-partum care directly  related
to  the  delivery] TERMINAL ILLNESS OR CONDITION, UNTIL THE TIME OF SUCH
INSURED'S DEATH.  If an insured elects to continue to receive care  from
such  health care provider pursuant to this [paragraph] SUBSECTION, such
care shall be authorized by the insurer for the transitional period only
if the health care provider agrees (A) to accept reimbursement from  the
insurer  at  rates  established by the insurer as payment in full, which
rates shall be no more than the level  of  reimbursement  applicable  to
similar  providers  within the in-network benefits portion of the insur-
er's network for such services; (B) to adhere to the  insurer's  quality
assurance  requirements  and  agrees to provide to the insurer necessary
medical information related to such care; and (C) to otherwise adhere to
the insurer's policies and procedures, including, but  not  limited  to,
procedures  regarding  referrals  and  obtaining pre-authorization and a
treatment plan approved  by  the  insurer.    In  no  event  shall  this
subsection  be  construed  to require an insurer to provide coverage for
benefits not otherwise covered or to  diminish  or  impair  pre-existing
condition limitations contained within the insured's contract.
  S  3.  Section  4804 of the insurance law is amended by adding two new
subsections (g) and (h) to read as follows:
  (G) FOR THE PURPOSES OF THIS SECTION, THE TERM  "TERMINAL  ILLNESS  OR
CONDITION"  SHALL  MEAN AN ILLNESS OR CONDITION WHICH, IN THE OPINION OF
THE PHYSICIAN OF THE PATIENT SUFFERING FROM  SUCH  TERMINAL  ILLNESS  OR
CONDITION, IS LIKELY TO CAUSE OR BE A MAJOR CONTRIBUTING FACTOR IN CAUS-
ING SUCH PATIENT'S DEATH WITHIN THREE YEARS.
  (H)  PROVIDER  INCENTIVES  (MONETARY  OR  OTHERWISE)  TO A HEALTH CARE
PROVIDER RELATING TO PROCEDURES, TREATMENTS,  OR  SERVICES  PURSUANT  TO

A. 633                              3

THIS  SECTION,  WHICH  ARE  INTENDED TO HAVE THE EFFECT OF INDUCING SUCH
PROVIDER TO PROVIDE CARE TO AN INSURED IN  A  MANNER  INCONSISTENT  WITH
THIS SECTION, ARE PROHIBITED.
  S  4.  Paragraphs  (e) and (f) of subdivision 6 of section 4403 of the
public health law, as added by chapter 705 of  the  laws  of  1996,  are
amended to read as follows:
  (e)  (1) If an enrollee's health care provider leaves the health main-
tenance organization's network of providers for reasons other than those
for which the provider would not be eligible to receive a hearing pursu-
ant to paragraph [a]  (A)  of  subdivision  two  of  section  forty-four
hundred  six-d  of this [chapter] ARTICLE, the health maintenance organ-
ization shall permit the enrollee to  continue  [an  ongoing  course  of
treatment  with]  TO  RECEIVE  HEALTH  CARE  PROCEDURES, TREATMENTS, AND
SERVICES FROM the enrollee's current health care provider during a tran-
sitional period of (i) up to [ninety days] ONE YEAR  from  the  date  of
notice  to the enrollee of the provider's disaffiliation from the organ-
ization's network[;] or (ii) if the enrollee  has  [entered  the  second
trimester of pregnancy at the time of the provider's disaffiliation, for
a  transitional  period  that includes the provision of post-partum care
directly related to the delivery] A TERMINAL ILLNESS OR CONDITION, UNTIL
THE TIME OF SUCH ENROLLEE'S DEATH.
  (2) Notwithstanding the provisions of subparagraph one of  this  para-
graph, such care shall be authorized by the health maintenance organiza-
tion  during  the  transitional  period only if the health care provider
agrees (i) to continue to accept reimbursement from the  health  mainte-
nance  organization  at  the  rates applicable prior to the start of the
transitional period as payment in full; (ii) to adhere to the  organiza-
tion's quality assurance requirements and to provide to the organization
necessary  medical information related to such care; and (iii) to other-
wise adhere to the organization's policies  and  procedures,  including,
but not limited to, procedures regarding referrals and obtaining pre-au-
thorization and a treatment plan approved by the organization.
  (f)  If  a  new enrollee whose health care provider is not a member of
the health maintenance organization's provider network  enrolls  in  the
health  maintenance  organization,  the  organization  shall  permit the
enrollee to continue [an ongoing course of treatment  with]  TO  RECEIVE
HEALTH  CARE  PROCEDURES,  TREATMENTS,  AND SERVICES FROM the enrollee's
current health care provider during  a  transitional  period  of  up  to
[sixty  days]  ONE  YEAR from the effective date of enrollment, if [(i)]
the enrollee has a [life-threatening disease or condition or a degenera-
tive and disabling disease or condition or (ii) the enrollee has entered
the second trimester of pregnancy at the effective date  of  enrollment,
in  which  case  the  transitional period shall include the provision of
post-partum care directly related to the delivery] TERMINAL  ILLNESS  OR
CONDITION,  UNTIL  THE  TIME  OF SUCH ENROLLEE'S DEATH.   If an enrollee
elects to continue to receive care from such health care provider pursu-
ant to this paragraph, such care shall be authorized by the health main-
tenance organization for the transitional period only if the health care
provider agrees (A) to accept reimbursement from the health  maintenance
organization at rates established by the health maintenance organization
as  payment  in  full,  which  rates  shall be no more than the level of
reimbursement applicable to similar providers within the health  mainte-
nance  organization's  network  for  such services; (B) to adhere to the
organization's quality assurance requirements and agrees to  provide  to
the organization necessary medical information related to such care; and
(C)  to  otherwise adhere to the organization's policies and procedures,

A. 633                              4

including, but  not  limited  to,  procedures  regarding  referrals  and
obtaining  pre-authorization and a treatment plan approved by the organ-
ization.  In no event shall this paragraph be  construed  to  require  a
health  maintenance  organization  to  provide coverage for benefits not
otherwise covered or to diminish or impair pre-existing condition  limi-
tations contained within the subscriber's contract.
  S  5.  Section  4403 of the public health law is amended by adding two
new subdivisions 7 and 8 to read as follows:
  7. FOR THE PURPOSES OF THIS SECTION, "TERMINAL ILLNESS  OR  CONDITION"
SHALL  MEAN  AN ILLNESS OR CONDITION WHICH, IN THE OPINION OF THE PHYSI-
CIAN OF THE PATIENT SUFFERING FROM SUCH TERMINAL ILLNESS  OR  CONDITION,
IS  LIKELY  TO  CAUSE  OR BE A MAJOR CONTRIBUTING FACTOR IN CAUSING SUCH
PATIENT'S DEATH WITHIN THREE YEARS.
  8. PROVIDER INCENTIVES  (MONETARY  OR  OTHERWISE)  TO  A  HEALTH  CARE
PROVIDER RELATING TO PROCEDURES, TREATMENTS, OR SERVICES PROVIDED PURSU-
ANT  TO THIS SECTION, WHICH ARE INTENDED TO INDUCE OR HAVE THE EFFECT OF
INDUCING SUCH PROVIDER TO PROVIDE CARE TO AN ENROLLEE IN A MANNER INCON-
SISTENT WITH THIS SECTION, ARE PROHIBITED.
  S 6. Subdivision 5 of section 4406-d of  the  public  health  law,  as
added by chapter 705 of the laws of 1996, is amended to read as follows:
  5.  No  health  care plan shall terminate a contract or employment, or
refuse to renew a contract, solely because a health care provider has:
  (a) advocated on behalf of an enrollee;
  (b) filed a complaint against the health care plan;
  (c) appealed a decision of the health care plan;
  (d) provided information or filed a report pursuant to section  forty-
four hundred six-c of this article; [or]
  (e) requested a hearing or review pursuant to this section; OR
  (F)  RENDERED  AN  OPINION  REGARDING  WHETHER  A PATIENT'S ILLNESS IS
TERMINAL PURSUANT TO SECTION FORTY-FOUR HUNDRED THREE OF THIS ARTICLE.
  S 7. This act shall take effect on the one hundred twentieth day after
it shall have become a law and shall  apply  to  all  contracts  issued,
renewed, modified or amended on and after such date.