NY State Senate Bill 2009-S4059

Senate Bill S4059

2009-2010 Legislative Session

Provides for a right of health maintenance organization enrollees to continue to receive services from a provider who disaffiliates

download bill text pdf

Archive: Last Bill Status - In Senate Committee Insurance Committee

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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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 06, 2010	referred to insurance
Apr 08, 2009	referred to insurance

2009-S4059 (ACTIVE) - Details

See Assembly Version of this Bill:: A633
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§4803 & 4804, Ins L; amd §§4403 & 4406-d, Pub Health L
Versions Introduced in Other Legislative Sessions:: 2011-2012: A1808
2013-2014: A366
2015-2016: A1932
2017-2018: A256
2019-2020: A5033
2021-2022: A2299
2023-2024: A5129

2009-S4059 (ACTIVE) - Summary

Extends period during which health maintenance organization enrollees may continue to receive services from a health care provider who disaffiliates from 60 or 90 days to 1 year, or in case of terminal illness, until the time of such insured's death; bars incentives which induce a provider to provide health care to an enrollee in a manner inconsistent with law.

2009-S4059 (ACTIVE) - Sponsor Memo

                                 BILL NUMBER:  S4059

 TITLE OF BILL :
An act to amend the insurance law and the public health law, in
relation to access to health care providers in managed care plans


 PURPOSE :
To provide patients who are enrolling in a managed care plan the
opportunity to have access to their current health care provider and,
similarly, to allow patients whose health care providers are excluded
from a managed care plan's panel of providers to continue to see that
health care professional for a limited period of time.

 SUMMARY OF PROVISIONS :
Section one amends subsection (e) of section 4803 of the insurance law
to provide that an insurer may not terminate a contract for
participation in the in-network benefits portion of an insurer's
managed care network, or refuse to renew such contract, solely because
a health care provider has issued an opinion relating to whether or
not a patient is terminally ill.

Section 2 amends subsection (e) of section 4804 of the insurance law
to provide that if a health care provider in an insurer's in-network
benefits portion of a managed care product either leaves the network
or is excluded from the HMO's panel of providers, after having been

affiliated with such managed care product, that provider's patients
may continue to receive health care services from him or her for a
period of up to one year, or, in the case of terminally ill patients,
until such time of the patient's death. Section 2 also amends
subsection (f) of section 4804 of the Insurance Law to provide new
insureds in an insurer's in-network benefits portion of a provider
network the option to continue to receive health care services from
his or her current health care provider for a period of up to one
year, or, in the case of terminally ill patients, until such time of
the patient's death. In both instances, this access to continuity of
care will not be available if the health care provider has been
disenrolled from the managed care plan for a reason involving imminent
harm to a patient, fraud or disciplinary action by a state licensing
board. Moreover, the access to continuity of care will only take
effect upon the attending health care provider's agreement to accept
the reimbursement rate established by the HMO, adhere to the plan's
quality assurance requirements and adhere to the organization's other
policies and procedures.

Section 3 amends section 4804 of the Insurance Law by adding new
subdivisions (g) and (h) to define the term "terminal illness or
condition" and, in keeping with the provisions the Legislature enacted
with the mastectomy treatment legislation, to prohibit offensive
financial arrangements.

Section 4 amends paragraph (e) of subdivision 6 of section 4403 of the
Public Health Law to provide that if a health care provider in a
health maintenance organization network either leaves the network or
is excluded from the HMO's panel of providers, after having been
affiliated with such HMO, that provider's patients may continue to
receive health care services from him or her for a period of up to one
year, or, in the case of terminally ill patients, until such time of
the patient's death.

Section 4 also amends paragraph (f) of subdivision 6 of section 4403
of the Public Health Law to provide new enrollees in an HMO the option
to continue to receive health care services from his or her current
health care provider for a period of up to one year, or, in the case
of terminally ill patients, until such time of the patient's death. In
both paragraphs, this access to continuity of care will not be avail
able if the health care provider has been disenrolled from the managed
care plan for a reason involving imminent harm to a patient, fraud or
disciplinary action by a state licensing board.  Additionally, the
access to continuity of care will only take effect upon the attending
health care provider's agreement to accept the reimbursement rate
established by the HMO, adhere to the plan's quality assurance
requirements and adhere to the organization's other policies and
procedures.

Section 5 amends section 4403 of the Public Health Law by adding new
subdivisions 7 and 8 to define the term "terminal illness or
condition" and, in keeping with the provisions the Legislature enacted
with the mastectomy treatment legislation, to prohibit offensive
financial arrangements.

Section 6 amends subdivision 5 of section 4406-d of the Public Health
Law to provide that a health care plan may not terminate a contract
for employment, or refuse to renew such contract, solely because a
health care provider has issued an opinion relating to whether or not
a patient is terminally ill.

Section 7 contains the effective date, which is 120 days.

 JUSTIFICATION :
This bill proposed to build upon the historic changes made on behalf
of health care consumers in the 1995 Managed Care Reform Act.
Included among the numerous provisions of that Act was a provision
that patients undergoing a course of treatment could continue that
treatment with their health care provider for 90 days, if the provider
became disaffiliated with the HMO provider panel, or for 60 days if
the person enrolled in an HMO which did not have a provider on its
panel. In addition, the Act provided for continuity of care for
pregnant women who had entered their second trimester of pregnancy,
through the provision of post-partum care.  This bill would expand
those provisions in ways which meaningfully add to the continuity of a
patient's care. It would do so by allowing a patient to continue an
established relationship with his or her health care provider for up
to one year following a change which would otherwise deny access to
the provider. In the case of terminally ill patients, this proposal
would allow such patients to continue to receive care from their
current provider until the time of their deaths.

In virtually every situation where a patient has an established,
ongoing relationship with his or her health care provider (which would
likely cause such patient to exercise the option provided by this
bill) the provision of health care services is both enhanced and
streamlined with the provider's familiarity with the patient. A deep
understanding of a patient's history, previous treatments and attitude
are important factors which assist a health care provider in making
clinical decisions which are likely to be of benefit to the patient.
In the case of terminally ill patients, this proposal would allow such
people to have the comfort of being ministered to by a familiar
provider, which may help to ease the trauma and increase the comfort
of the terminal patient.

Importantly, this bill would not add to the expense of health
insurance (either purchased by the individual or by an employer)
because it does not mandate coverage where none exists.

In addition, this measure would not add to the cost of the HMO or
other managed care entity providing care. In every instance addressed
in this bill, the insurer is receiving payment for the health care of
the insured in question. The only issue addressed is who will provide
treatment to the patient. Inasmuch as this bill would not change
current law which mandates the provider to continue to accept the
reimbursement set by the insurer (which cannot be more than the
reimbursement paid to in-plan providers) there is no added expense to
the insurer, with the minor exception of some additional
administrative work.

This bill further protects both the patient and the HMO by making the
continuity of care an option to be exercised by the patient (not a
mandatory benefit) and providing that this option would not apply to
providers who have been disenrolled for reasons related to
incompetence, criminal action or professional misconduct. Finally,
this bill increases the applicability of provisions prohibiting
offensive financial arrangements enacted in early 1997 so that
incentives to induce providers to act in a manner contrary to these
statutes would be prohibited.

 LEGISLATIVE HISTORY :
2007-08 - A.512 - Passed Assembly 2005-06- A.1240- Passed
Assembly/S.2759 - Referred to Insurance 2003-04 - A.1l61 - Passed
Assembly 2001-02: A.5880 - Passed Assembly/S.4845 Referred to
Insurance

 FISCAL IMPLICATIONS :
None to State.

 EFFECTIVE DATE :
This act shall take effect 120 days after it becomes law.

2009-S4059 (ACTIVE) - Bill Text download pdf

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

                                  4059

                       2009-2010 Regular Sessions

                            I N  S E N A T E

                              April 8, 2009
                               ___________

Introduced  by  Sen. SCHNEIDERMAN -- read twice and ordered printed, and
  when printed to be committed to the Committee on Insurance

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
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-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD02588-01-9

S. 4059                             2

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
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. 4059                             3

  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,
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

S. 4059                             4

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.

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