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

                                  1932

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                            January 13, 2015
                               ___________

Introduced  by  M.  of  A.  DINOWITZ, GOTTFRIED, GALEF, HOOPER, CLARK --
  Multi-Sponsored by -- M.  of A. BRENNAN, COLTON, LIFTON --  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
PROCEDURES,  TREATMENTS,  AND SERVICES FROM the insured's current health
care provider during a transitional period of (i) up  to  [ninety  days]

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD00904-01-5
              

A. 1932                             2

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; OR 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] TERMINAL ILLNESS OR CONDITION, UNTIL THE TIME OF
SUCH INSURED'S DEATH, or (2) the insured has entered the second  trimes-
ter  of  pregnancy  at the time of enrollment, in which case the transi-
tional period shall include the provision of post-partum  care  directly
related  to  the delivery.   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 transi-
tional  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  insurer'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  proce-
dures, including, but not limited to, procedures regarding referrals and
obtaining  pre-authorization and a treatment plan approved by the insur-
er.  In no event shall this subsection be construed to require an insur-
er 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

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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, OR (III) IF THE ENROLLEE HAS A  TERMI-
NAL 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, OR  if  (i)
the enrollee has a [life-threatening disease or condition or a degenera-
tive  and disabling disease or condition] TERMINAL ILLNESS OR CONDITION,
UNTIL THE TIME OF SUCH  ENROLLEE'S  DEATH,  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.  If an
enrollee elects to continue  to  receive  care  from  such  health  care
provider  pursuant  to  this paragraph, such care shall be authorized by
the health maintenance 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 main-
tenance organization as payment in full, which rates shall  be  no  more
than  the  level of reimbursement applicable to similar providers within
the health maintenance 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

A. 1932                             4

referrals  and obtaining pre-authorization and a treatment plan approved
by the organization.  In no event shall this paragraph be  construed  to
require  a health maintenance organization to provide coverage for bene-
fits  not otherwise covered or to diminish or impair pre-existing condi-
tion limitations contained within the subscriber's contract.
  S 5. Section 4403 of the public health law is amended  by  adding  two
new subdivisions 9 and 10 to read as follows:
  9.  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.
  10.  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.