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

                                  6498

                       2013-2014 Regular Sessions

                          I N  A S S E M B L Y

                              April 4, 2013
                               ___________

Introduced by M. of A. LAVINE -- read once and referred to the Committee
  on Health

AN ACT to amend the public health law and the insurance law, in relation
  to health care professional applications and terminations

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

  Section 1. Section 4406-d of the public health law, as added by  chap-
ter  705 of the laws of 1996, subdivision 1 as amended by chapter 237 of
the laws of 2009, is amended to read as follows;
  S 4406-d. Health care professional applications and terminations.   1.
(a)  A health care plan shall, upon request, make available and disclose
to health care professionals written application procedures and  minimum
qualification requirements which a health care professional must meet in
order  to  be considered by the health care plan. The plan shall consult
with appropriately qualified health care professionals in developing its
qualification requirements. A health care plan shall complete review  of
the health care professional's application to participate in the in-net-
work  portion of the health care plan's network and shall, within ninety
days of receiving a health care professional's completed application  to
participate  in  the  health care plan's network, notify the health care
professional as to: (i) whether he  or  she  is  credentialed;  or  (ii)
whether additional time is necessary to make a determination in spite of
the  health  care plan's best efforts or because of a failure of a third
party to provide necessary  documentation,  or  non-routine  or  unusual
circumstances  require  additional  time  for  review. In such instances
where additional time is  necessary  because  of  a  lack  of  necessary
documentation,  a  health  plan  shall  make every effort to obtain such
information as soon as possible.
  (b) If the completed  application  of  a  newly-licensed  health  care
professional or a health care professional who has recently relocated to
this  state  from another state and has not previously practiced in this

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10089-01-3
              

A. 6498                             2

state, who joins a group practice of health care professionals  each  of
whom  participates  in  the  in-network  portion of a health care plan's
network, is neither approved nor declined within ninety days pursuant to
paragraph (a) of this subdivision, the health care professional shall be
deemed  "provisionally  credentialed" and may participate in the in-net-
work portion of the health care plan's network; provided, however,  that
a  provisionally  credentialed  physician  may  not  be designated as an
enrollee's primary care physician until such time as the  physician  has
been  fully  credentialed. The network participation for a provisionally
credentialed health care professional shall begin on the  day  following
the ninetieth day of receipt of the completed application and shall last
until  the  final credentialing determination is made by the health care
plan. A health care professional shall only be eligible for  provisional
credentialing  if  the group practice of health care professionals noti-
fies the health care plan in writing that, should the application  ulti-
mately  be  denied,  the health care professional or the group practice:
(i) shall refund any payments made by the health care plan  for  in-net-
work  services  provided  by  the provisionally credentialed health care
professional that exceed any out-of-network benefits payable  under  the
enrollee's contract with the health care plan; and (ii) shall not pursue
reimbursement  from  the  enrollee, except to collect the copayment that
otherwise would have been payable had  the  enrollee  received  services
from  a health care professional participating in the in-network portion
of a health care plan's network.  Interest  and  penalties  pursuant  to
section  three  thousand  two hundred twenty-four-a of the insurance law
shall not be assessed based on the denial of a  claim  submitted  during
the  period  when the health care professional was provisionally creden-
tialed; provided, however, that nothing herein shall  prevent  a  health
care  plan  from  paying  a claim from a health care professional who is
provisionally credentialed upon submission of such claim. A health  care
plan  shall  not  deny, after appeal, a claim for services provided by a
provisionally credentialed health care professional solely on the ground
that the claim was not timely filed.
  2. (a) A health care plan shall not terminate OR NOT RENEW a  contract
with  a health care professional unless the health care plan provides to
the health care professional a written explanation of  the  reasons  for
the  proposed  contract  termination  and an opportunity for a review or
hearing as hereinafter provided. This section shall not apply  in  cases
involving  imminent harm to patient care, a determination of fraud, or a
final disciplinary action by a state licensing board  or  other  govern-
mental  agency  that  impairs  the health care professional's ability to
practice.
  (b) The notice of the proposed  contract  termination  OR  NON-RENEWAL
provided  by  the health care plan to the health care professional shall
include:
  (i) the reasons for the proposed action;
  (ii) notice that the health care professional has the right to request
a hearing or review, at the professional's discretion,  before  a  panel
[appointed  by  the  health  care plan] COMPRISED OF NO FEWER THAN THREE
HEALTH CARE PROFESSIONALS LICENSED TO PRACTICE IN THE STATE OF NEW YORK;
  (iii) a time limit of not less than thirty days within which a  health
care professional may request a hearing; and
  (iv)  a time limit for a hearing date which must be held within thirty
days after the date of receipt of a request for a hearing.
  (c) The hearing panel shall be comprised of three  [persons  appointed
by  the health care plan] HEALTH CARE PROFESSIONALS LICENSED TO PRACTICE

A. 6498                             3

BY THE STATE OF NEW YORK IN THE SAME PROFESSION AS THE  SUBJECT  OF  THE
REVIEW, ONE OF WHOM IS APPOINTED BY THE HEALTH CARE PLAN, ONE OF WHOM IS
APPOINTED  BY  THE  HEALTH  CARE  PROFESSIONAL WHO IS THE SUBJECT OF THE
HEARING.  THE REMAINING MEMBER OF THE PANEL SHALL BE CHOSEN BY THE OTHER
TWO PANEL MEMBERS. At least one person on such panel shall be a clinical
peer in the same discipline and the same or  similar  specialty  as  the
health  care professional under review. The hearing panel may consist of
more than three persons, provided however that the  number  of  clinical
peers  on  such  panel  shall  constitute one-third or more of the total
membership of the panel AND PROVIDED  FURTHER  THAT  THE  RATIO  OF  THE
NUMBER OF HEALTH CARE PROFESSIONALS APPOINTED BY THE HEALTH CARE PLAN TO
THE  NUMBER OF HEALTH CARE PROFESSIONALS APPOINTED BY THE SUBJECT OF THE
HEARING TO THE NUMBER OF HEALTH CARE PROFESSIONALS CHOSEN BY  THE  OTHER
PANEL MEMBERS REMAINS ONE TO ONE TO ONE.
  (d)  The  hearing panel shall render a decision on the proposed action
in a timely manner. Such decision shall  include  reinstatement  of  the
health  care  professional  by  the  health care plan, provisional rein-
statement subject to conditions set forth by the  health  care  plan  or
termination  of  the  health  care  professional. Such decision shall be
provided in writing to the health care professional.
  (e) A decision by the hearing panel to terminate OR NOT RENEW a health
care professional shall be effective not less than thirty days after the
receipt by the health care professional of the hearing panel's decision;
provided, however, that the provisions of paragraph (e)  of  subdivision
six  of  section  [four  thousand four] FORTY-FOUR hundred three of this
article shall apply to such termination OR NON-RENEWAL.
  (f) In no event shall termination be effective earlier than sixty days
from the receipt of the notice of termination.
  3. [Either party to a contract may exercise a right of non-renewal  at
the  expiration  of  the  contract  period  set  forth therein or, for a
contract without a specific  expiration  date,  on  each  January  first
occurring  after  the contract has been in effect for at least one year,
upon sixty days notice to the other party; provided, however,  that  any
non-renewal  shall  not  constitute  a  termination for purposes of this
section.
  4.] A health care plan shall develop and implement policies and proce-
dures to ensure that health care professionals are regularly informed of
information maintained by the health care plan to evaluate the  perform-
ance  or  practice of the health care professional. The health care plan
shall consult with health care professionals in developing methodologies
to collect and analyze health care professional profiling  data.  Health
care  plans  shall  provide  any such information and profiling data and
analysis to health care professionals. Such information, data or  analy-
sis  shall be provided on a periodic basis appropriate to the nature and
amount of data and the volume and  scope  of  services  provided.    Any
profiling  data used to evaluate the performance or practice of a health
care professional shall be  measured  against  stated  criteria  and  an
appropriate  group  of health care professionals using similar treatment
modalities serving a comparable patient population. Upon presentation of
such information or data, each health care professional shall  be  given
the  opportunity to discuss the unique nature of the health care profes-
sional's patient population which may have a bearing on the health  care
professional's  profile  and  to work cooperatively with the health care
plan to improve performance.

A. 6498                             4

  [5.] 4. 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.
  [6.] 5. Except as provided herein, no contract or agreement between  a
health  care  plan  and  a  health  care  professional shall contain any
provision which shall supersede or impair a health  care  professional's
right to notice of reasons for termination OR NON-RENEWAL and the oppor-
tunity  for a hearing or review concerning such termination OR NON-RENE-
WAL.
  [7.] 6. Any contract provision in violation of this section  shall  be
deemed to be void and unenforceable.
  [8.]  7. For purposes of this section, "health care plan" shall mean a
health maintenance organization licensed pursuant to article forty-three
of the insurance law or certified pursuant to this article or  an  inde-
pendent  practice  association  certified or recognized pursuant to this
article.
  [9.] 8. For purposes of this section, "health care professional" shall
mean a health care professional licensed, registered or certified pursu-
ant to title eight of the education law.
  S 2. Section 4803 of the insurance law, as added by chapter 705 of the
laws of 1996, subsection (a) as amended by chapter 237 of  the  laws  of
2009, is amended to read as follows:
  S  4803.  Health care professional applications and terminations.  (a)
(1) An insurer which offers a managed care product shall, upon  request,
make  available and disclose to health care professionals written appli-
cation procedures and minimum qualification requirements which a  health
care professional must meet in order to be considered by the insurer for
participation  in  the  in-network  benefits  portion  of  the insurer's
network for the managed care product. The  insurer  shall  consult  with
appropriately  qualified  health  care  professionals  in developing its
qualification requirements for participation in the in-network  benefits
portion of the insurer's network for the managed care product. An insur-
er  shall  complete review of the health care professional's application
to participate in the in-network portion of the insurer's  network  and,
within  ninety  days of receiving a health care professional's completed
application to participate in the insurer's  network,  will  notify  the
health  care  professional as to: (A) whether he or she is credentialed;
or (B) whether additional time is necessary to make a  determination  in
spite  of  the insurer's best efforts or because of a failure of a third
party to provide necessary  documentation,  or  non-routine  or  unusual
circumstances  require  additional  time for review.   In such instances
where additional time is  necessary  because  of  a  lack  of  necessary
documentation,  an insurer shall make every effort to obtain such infor-
mation as soon as possible.
  (2) If the completed  application  of  a  newly-licensed  health  care
professional or a health care professional who has recently relocated to
this  state  from another state and has not previously practiced in this
state, who joins a group practice of health care professionals  each  of
whom  participates in the in-network portion of an insurer's network, is
neither approved nor declined within ninety days pursuant  to  paragraph

A. 6498                             5

one  of  this  subsection, such health care professional shall be deemed
"provisionally credentialed"  and  may  participate  in  the  in-network
portion of an insurer's network; provided, however, that a provisionally
credentialed  physician  may  not  be designated as an insured's primary
care physician until such time as the physician has been  fully  creden-
tialed.  The  network  participation  for  a  provisionally credentialed
health care professional shall begin on the day following the  ninetieth
day  of  receipt  of  the completed application and shall last until the
final credentialing determination is made by the insurer. A health  care
professional shall only be eligible for provisional credentialing if the
group  practice  of  health  care  professionals notifies the insurer in
writing that, should the application ultimately be  denied,  the  health
care  professional  or the group practice: (A) shall refund any payments
made by the insurer for  in-network  services  provided  by  the  provi-
sionally  credentialed  health care professional that exceed any out-of-
network benefits payable under the insured's contract with the  insurer;
and  (B)  shall  not  pursue  reimbursement  from the insured, except to
collect the copayment or coinsurance  that  otherwise  would  have  been
payable  had  the  insured  received services from a health care profes-
sional participating in the in-network portion of an insurer's  network.
Interest  and  penalties  pursuant to section three thousand two hundred
twenty-four-a of this chapter shall not be assessed based on the  denial
of a claim submitted during the period when the health care professional
was  provisionally  credentialed; provided, however, that nothing herein
shall prevent an insurer from paying a claim from a health care  profes-
sional  who is provisionally credentialed upon submission of such claim.
An insurer shall not deny, after appeal, a claim for  services  provided
by  a  provisionally credentialed health care professional solely on the
ground that the claim was not timely filed.
  (b) (1) An insurer shall not terminate OR NOT RENEW a contract with  a
health  care  professional  for participation in the in-network benefits
portion of the insurer's network for a managed care product  unless  the
insurer  provides  to the health care professional a written explanation
of the reasons for the proposed contract termination and an  opportunity
for  a review or hearing as hereinafter provided. This section shall not
apply in cases involving imminent harm to patient care, a  determination
of  fraud,  or a final disciplinary action by a state licensing board or
other governmental agency that impairs the  health  care  professional's
ability to practice.
  (2)  The  notice  of  the proposed contract termination OR NON-RENEWAL
provided by the insurer to the health care professional shall include:
  (i) the reasons for the proposed action;
  (ii) notice that the health care professional has the right to request
a hearing or review, at the professional's discretion,  before  a  panel
[appointed  by the insurer] COMPRISED OF NO FEWER THAN THREE HEALTH CARE
PROFESSIONALS LICENSED TO PRACTICE BY THE STATE OF NEW YORK;
  (iii) a time limit of not less than thirty days within which a  health
care professional may request a hearing or review; and
  (iv)  a  time  limit  for a hearing date which must be held within not
less than thirty days after the date of receipt of a request for a hear-
ing.
  (3) The hearing panel shall be comprised of three  [persons  appointed
by  the  insurer]  HEALTH CARE PROFESSIONALS LICENSED TO PRACTICE BY THE
STATE OF NEW YORK IN THE SAME PROFESSION AS THE SUBJECT OF  THE  REVIEW,
ONE OF WHOM IS APPOINTED BY THE INSURER, ONE OF WHOM IS APPOINTED BY THE
HEALTH  CARE PROFESSIONAL WHO IS THE SUBJECT OF THE HEARING. THE REMAIN-

A. 6498                             6

ING MEMBER OF THE PANEL SHALL BE CHOSEN BY THE OTHER TWO PANEL  MEMBERS.
At  least  one person on such panel shall be a clinical peer in the same
discipline and the same or similar specialty as the health care  profes-
sional  under  review.  The hearing panel may consist of more than three
persons, provided however that the number  of  clinical  peers  on  such
panel  shall constitute one-third or more of the total membership of the
panel AND PROVIDED FURTHER THAT THE RATIO OF THE NUMBER OF  HEALTH  CARE
PROFESSIONALS  APPOINTED BY THE HEALTH CARE PLAN TO THE NUMBER OF HEALTH
CARE PROFESSIONALS APPOINTED BY THE SUBJECT OF THE HEARING TO THE NUMBER
OF HEALTH CARE PROFESSIONALS CHOSEN  BY  THE  TWO  OTHER  PANEL  MEMBERS
REMAINS ONE TO ONE TO ONE.
  (4)  The  hearing panel shall render a decision on the proposed action
in a timely manner. Such decision shall  include  reinstatement  of  the
health  care  professional  by  the  insurer,  provisional reinstatement
subject to conditions set forth by the insurer  or  termination  of  the
health  care professional. Such decision shall be provided in writing to
the health care professional.
  (5) A decision by the hearing panel to terminate OR NOT RENEW a health
care professional shall be effective not less than thirty days after the
receipt by the health care professional of the hearing panel's decision;
provided, however, that the provisions of subsection (e) of section four
thousand eight hundred four OF THIS ARTICLE shall apply to  such  termi-
nation.
  (6)  In no event shall termination OR NON-RENEWAL be effective earlier
than sixty days from the receipt of the notice of termination OR NON-RE-
NEWAL.
  (c) [Either party to a contract for participation  in  the  in-network
benefits  portion of an insurer's network for a managed care product may
exercise a right of non-renewal at the expiration of the contract period
set forth therein or, for a contract without a specific expiration date,
on each January first occurring after the contract has  been  in  effect
for  at  least  one  year,  upon  sixty  days notice to the other party;
provided, however, that any non-renewal shall not  constitute  a  termi-
nation for purposes of this section.
  (d)] An insurer shall develop and implement policies and procedures to
ensure  that  health  care providers participating in the the in-network
benefits portion of an insurer's network for a managed care product  are
regularly  informed of information maintained by the insurer to evaluate
the performance or practice of the health care professional. The insurer
shall consult with health care professionals in developing methodologies
to collect and analyze provider profiling data. Insurers  shall  provide
any  such  information  and  profiling data and analysis to these health
care professionals. Such information, data or analysis shall be provided
on a periodic basis appropriate to the nature and amount of data and the
volume and scope of services provided. Any profiling data used to evalu-
ate the performance or practice of such a health care professional shall
be measured against stated criteria and an appropriate group  of  health
care professionals using similar treatment modalities serving a compara-
ble  patient  population. Upon presentation of such information or data,
each such health care professional shall be  given  the  opportunity  to
discuss  the  unique  nature  of  the health care professional's patient
population which may have a bearing on the professional's profile and to
work cooperatively with the insurer to improve performance.
  [(e)] (D) 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

A. 6498                             7

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.
  [(f)] (E) Except as provided herein, no contract or agreement  between
an  insurer  and  a  health  care  professional for participation in the
in-network benefits portion of an insurer's network for a  managed  care
product  shall  contain  any provision which shall supersede or impair a
health care professional's right to notice of reasons for termination OR
NON-RENEWAL and the opportunity for a  hearing  concerning  such  termi-
nation OR NON-RENEWAL.
  [(g)] (F) Any contract provision in violation of this section shall be
deemed to be void and unenforceable.
  [(h)]  (G)  For  purposes  of this section, "health care professional"
shall mean a health care professional licensed, registered or  certified
pursuant to title eight of the education law.
  S 3. This act shall take effect immediately.