S T A T E O F N E W Y O R K
________________________________________________________________________
5074--A
2015-2016 Regular Sessions
I N A S S E M B L Y
February 12, 2015
___________
Introduced by M. of A. McDONALD, LAVINE, MONTESANO, MILLER, GUNTHER,
LIFTON -- Multi-Sponsored by -- M. of A. DUPREY, HOOPER, SIMANOWITZ --
read once and referred to the Committee on Health -- reported and
referred to the Committee on Ways and Means -- committee discharged,
bill amended, ordered reprinted as amended and recommitted to said
committee
AN ACT to amend the social services law, the insurance law and the
public health law, in relation to preserving access to quality complex
rehabilitation technology for patients with complex medical needs
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Short title. This act shall be known and may be cited as
the "complex needs patient act".
S 2. Legislative intent. It is the intent of the legislature to:
1. protect access for complex needs patients to quality complex reha-
bilitation technology;
2. establish and improve standards and safeguards relating to the
provision of complex rehabilitation technology; and
3. provide quality support for complex needs patients to stay in the
home or community setting, prevent institutionalization, and prevent
hospitalizations and other costly secondary complications.
S 3. The social services law is amended by adding a new section 367-j
to read as follows:
S 367-J. COMPLEX NEEDS PATIENT ACT. 1. DEFINITIONS. AS USED IN THIS
SECTION:
(A) "COMPLEX NEEDS PATIENT" MEANS AN INDIVIDUAL WITH SIGNIFICANT PHYS-
ICAL OR FUNCTIONAL IMPAIRMENT RESULTING FROM A MEDICAL CONDITION OR
DISEASE INCLUDING, BUT NOT LIMITED TO: SPINAL CORD INJURY, TRAUMATIC
BRAIN INJURY, CEREBRAL PALSY, MUSCULAR DYSTROPHY, SPINA BIFIDA, OSTEO-
GENESIS IMPERFECTA, ARTHROGRYPOSIS, AMYOTROPHIC LATERAL SCLEROSIS,
MULTIPLE SCLEROSIS, DEMYELINATING DISEASE, MYELOPATHY, MYOPATHY,
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD06571-03-5
A. 5074--A 2
PROGRESSIVE MUSCULAR ATROPHY, ANTERIOR HORN CELL DISEASE, POST-POLIO
SYNDROME, CEREBELLAR DEGENERATION, DYSTONIA, HUNTINGTON'S DISEASE,
SPINOCEREBELLAR DISEASE, AND CERTAIN TYPES OF AMPUTATION, PARALYSIS OR
PARESIS.
(B) "COMPLEX REHABILITATION TECHNOLOGY" MEANS PRODUCTS CLASSIFIED AS
DURABLE MEDICAL EQUIPMENT WITHIN THE MEDICARE PROGRAM AS OF JANUARY
FIRST, TWO THOUSAND FIFTEEN THAT ARE INDIVIDUALLY CONFIGURED FOR INDI-
VIDUALS TO MEET THEIR SPECIFIC AND UNIQUE MEDICAL, PHYSICAL AND FUNC-
TIONAL NEEDS AND CAPACITIES FOR BASIC AND FUNCTIONAL ACTIVITIES OF DAILY
LIVING. SUCH PRODUCTS INCLUDE, BUT ARE NOT LIMITED TO: INDIVIDUALLY
CONFIGURED MANUAL AND POWER WHEELCHAIRS AND ACCESSORIES, ADAPTIVE SEAT-
ING AND POSITIONING ITEMS AND ACCESSORIES, AND OTHER SPECIALIZED EQUIP-
MENT SUCH AS STANDING FRAMES AND GAIT TRAINERS AND ACCESSORIES.
(C) "EMPLOYEE" MEANS A PERSON WHOSE TAXES ARE WITHHELD BY A QUALIFIED
COMPLEX REHABILITATION TECHNOLOGY SUPPLIER AND REPORTED TO THE INTERNAL
REVENUE SERVICE.
(D) "HEALTHCARE COMMON PROCEDURE CODING SYSTEM", OR "HCPCS", MEANS THE
BILLING CODES USED BY MEDICARE AND OVERSEEN BY THE FEDERAL CENTERS FOR
MEDICARE AND MEDICAID SERVICES THAT ARE BASED ON THE CURRENT PROCEDURAL
TECHNOLOGY CODES DEVELOPED BY THE AMERICAN MEDICAL ASSOCIATION.
(E) "INDIVIDUALLY CONFIGURED" MEANS A DEVICE WITH A COMBINATION OF
SIZES, FEATURES, ADJUSTMENTS OR MODIFICATIONS THAT ARE CONFIGURED OR
DESIGNED BY A QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLIER FOR A
SPECIFIC INDIVIDUAL BY MEASURING, FITTING, PROGRAMMING, ADJUSTING OR
ADAPTING THE DEVICE SO THAT THE DEVICE IS CONSISTENT WITH THE INDIVID-
UAL'S MEDICAL CONDITION, PHYSICAL AND FUNCTIONAL NEEDS AND CAPABILITIES,
BODY SIZE, PERIOD OF NEED AND INTENDED USE AS DETERMINED BY AN ASSESS-
MENT OR EVALUATION BY A QUALIFIED HEALTH CARE PROFESSIONAL.
(F) "MIXED HCPCS CODES" MEANS HEALTHCARE COMMON PROCEDURE CODING
SYSTEM CODES THAT REFER TO A MIX OF COMPLEX REHABILITATION TECHNOLOGY
PRODUCTS AND STANDARD MOBILITY AND ACCESSORY PRODUCTS.
(G) "PURE HCPCS CODES" MEANS HEALTHCARE COMMON PROCEDURE CODING SYSTEM
CODES THAT REFER EXCLUSIVELY TO COMPLEX REHABILITATION TECHNOLOGY
PRODUCTS.
(H) "QUALIFIED COMPLEX REHABILITATION TECHNOLOGY PROFESSIONAL" MEANS
AN INDIVIDUAL WHO IS CERTIFIED AS AN ASSISTIVE TECHNOLOGY PROFESSIONAL
(ATP) BY THE REHABILITATION ENGINEERING AND ASSISTIVE TECHNOLOGY SOCIETY
OF NORTH AMERICA (RESNA).
(I) "QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLIER" MEANS A
COMPANY OR ENTITY THAT:
(I) IS ACCREDITED BY A RECOGNIZED ACCREDITING ORGANIZATION;
(II) IS AN ENROLLED MEDICARE SUPPLIER AND MEETS THE SUPPLIER AND QUAL-
ITY STANDARDS ESTABLISHED FOR DURABLE MEDICAL EQUIPMENT SUPPLIERS
INCLUDING THOSE FOR COMPLEX REHABILITATION TECHNOLOGY UNDER THE MEDICARE
PROGRAM;
(III) HAS AT LEAST ONE EMPLOYEE WHO IS A QUALIFIED COMPLEX REHABILI-
TATION TECHNOLOGY PROFESSIONAL AVAILABLE TO ANALYZE THE NEEDS AND CAPAC-
ITIES OF COMPLEX NEEDS PATIENTS IN CONSULTATION WITH A QUALIFIED HEALTH
CARE PROFESSIONAL AND PARTICIPATE IN THE SELECTION OF APPROPRIATE
COMPLEX REHABILITATION TECHNOLOGY AND PROVIDE TRAINING IN THE PROPER USE
OF THE COMPLEX REHABILITATION TECHNOLOGY;
(IV) REQUIRES A QUALIFIED COMPLEX REHABILITATION TECHNOLOGY PROFES-
SIONAL BE PHYSICALLY PRESENT FOR THE EVALUATION AND DETERMINATION OF
APPROPRIATE COMPLEX REHABILITATION TECHNOLOGY FOR COMPLEX NEEDS
PATIENTS;
A. 5074--A 3
(V) HAS THE CAPABILITY TO PROVIDE SERVICE AND REPAIR BY QUALIFIED
TECHNICIANS FOR ALL COMPLEX REHABILITATION TECHNOLOGY IT SELLS;
(VI) HAS AT LEAST ONE STOREFRONT LOCATION WITHIN NEW YORK STATE; AND
(VII) PROVIDES WRITTEN INFORMATION REGARDING HOW TO RECEIVE SERVICE
AND REPAIR OF COMPLEX REHABILITATION TECHNOLOGY TO THE COMPLEX NEEDS
PATIENT PRIOR TO THE ORDERING OF SUCH TECHNOLOGY.
(J) "QUALIFIED HEALTH CARE PROFESSIONAL" MEANS A HEALTH CARE PROFES-
SIONAL LICENSED BY THE STATE EDUCATION DEPARTMENT WHO HAS NO FINANCIAL
RELATIONSHIP WITH A QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLI-
ER, INCLUDING BUT NOT LIMITED TO A PHYSICIAN, PHYSICAL THERAPIST, OCCU-
PATIONAL THERAPIST, OR OTHER LICENSED HEALTH CARE PROFESSIONAL WHO
PERFORMS SPECIALTY EVALUATIONS WITHIN THE PROFESSIONAL'S SCOPE OF PRAC-
TICE.
2. REIMBURSEMENT AND BILLING PROCEDURES. (A) TO THE EXTENT PERMISSIBLE
UNDER FEDERAL LAW, THE COMMISSIONER SHALL MAINTAIN SPECIFIC REIMBURSE-
MENT AND BILLING PROCEDURES WITHIN THE STATE MEDICAID PROGRAM FOR
COMPLEX REHABILITATION TECHNOLOGY PRODUCTS AND SERVICES TO ENSURE THAT
MEDICAID PAYMENTS FOR SUCH PRODUCTS AND SERVICES PERMIT ADEQUATE ACCESS
TO COMPLEX NEEDS PATIENTS AND TAKES INTO ACCOUNT THE SIGNIFICANT
RESOURCES, INFRASTRUCTURE, AND STAFF NEEDED TO MEET THEIR NEEDS.
(B) PURSUANT TO PARAGRAPH (A) OF THIS SUBDIVISION, THE COMMISSIONER
SHALL, NOT LATER THAN OCTOBER FIRST, TWO THOUSAND SEVENTEEN: (I) DESIG-
NATE PRODUCTS AND SERVICES INCLUDED IN MIXED AND PURE HCPCS BILLING
CODES AS COMPLEX REHABILITATION TECHNOLOGY, AND AS NEEDED, CREATE NEW
BILLING CODES OR CODE MODIFIERS FOR SERVICES AND PRODUCTS COVERED FOR
COMPLEX NEEDS PATIENTS; (II) SET MINIMUM STANDARDS CONSISTENT WITH PARA-
GRAPH (I) OF SUBDIVISION ONE OF THIS SECTION IN ORDER FOR SUPPLIERS TO
BE CONSIDERED QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLIERS
ELIGIBLE FOR MEDICAID REIMBURSEMENT; (III) EXEMPT PRODUCTS OR SERVICES
BILLED UNDER MIXED OR PURE HCPCS CODES FROM INCLUSION IN ANY BIDDING,
SELECTIVE CONTRACTING, REQUEST FOR PROPOSAL, OR SIMILAR INITIATIVE; (IV)
REQUIRE COMPLEX NEEDS PATIENTS RECEIVING A COMPLEX REHABILITATION MANUAL
WHEELCHAIR, POWER WHEELCHAIR, OR SEATING COMPONENT TO BE EVALUATED BY A
QUALIFIED HEALTH CARE PROFESSIONAL AND A QUALIFIED COMPLEX REHABILI-
TATION TECHNOLOGY PROFESSIONAL TO QUALIFY FOR REIMBURSEMENT (SUCH EVALU-
ATION SHALL BE EXEMPT FROM ANY HEALTH CARE PROFESSIONAL CAP); (V) MAKE
OTHER CHANGES AS NEEDED TO PROTECT ACCESS TO COMPLEX REHABILITATION
TECHNOLOGY FOR COMPLEX NEEDS PATIENTS; AND (VI) AFFIRM THAT WITH THE
EXCEPTION OF THOSE ENROLLEES COVERED UNDER A PAYMENT RATE METHODOLOGY
OTHERWISE NEGOTIATED, PAYMENTS FOR COMPLEX REHABILITATION TECHNOLOGY
PROVIDED TO PATIENTS ELIGIBLE FOR MEDICAL ASSISTANCE BY ORGANIZATIONS
OPERATING IN ACCORDANCE WITH THE PROVISIONS OF ARTICLE FORTY-FOUR OF THE
PUBLIC HEALTH LAW OR BY HEALTH MAINTENANCE ORGANIZATIONS ORGANIZED AND
OPERATING IN ACCORDANCE WITH ARTICLE FORTY-THREE OF THE INSURANCE LAW,
SHALL BE THE RATES OF PAYMENT THAT WOULD BE PAID FOR SUCH PAYMENTS UNDER
THE MEDICAL ASSISTANCE PROGRAM AS DETERMINED BY THE COMMISSIONER AND
APPLICABLE TO SERVICES AT THE TIME SUCH SERVICES WERE PROVIDED.
S 4. Section 3217-e of the insurance law, as added by chapter 219 of
the laws of 2011, is amended to read as follows:
S 3217-e. Choice of health care provider. An insurer that is subject
to this article and requires or provides for designation by an insured
of a participating primary care provider shall permit the insured to
designate any participating primary care provider who is available to
accept such individual, and in the case of a child, shall permit the
insured to designate a physician (allopathic or osteopathic) who
specializes in pediatrics as the child's primary care provider if such
A. 5074--A 4
provider participates in the network of the insurer. EVERY POLICY WHICH
PROVIDES MEDICAL, MAJOR MEDICAL, OR SIMILAR COMPREHENSIVE TYPE COVERAGE
SHALL INCLUDE ADEQUATE ACCESS TO SERVICES AND EQUIPMENT PROVIDED BY
QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLIERS, PURSUANT TO
SECTION THREE HUNDRED SIXTY-SEVEN-J OF THE SOCIAL SERVICES LAW, AND
ADOPT THE SUPPLIER STANDARDS CONTAINED THEREIN.
S 5. Section 4306-d of the insurance law, as added by chapter 219 of
the laws of 2011, is amended to read as follows:
S 4306-d. Choice of health care provider. A corporation that is
subject to the provisions of this article and requires or provides for
designation by a subscriber of a participating primary care provider
shall permit the subscriber to designate any participating primary care
provider who is available to accept such individual, and in the case of
a child, shall permit the subscriber to designate a physician (allopath-
ic or osteopathic) who specializes in pediatrics as the child's primary
care provider if such provider participates in the network of the corpo-
ration. EVERY POLICY WHICH PROVIDES MEDICAL, MAJOR MEDICAL, OR SIMILAR
COMPREHENSIVE TYPE COVERAGE SHALL INCLUDE ADEQUATE ACCESS TO SERVICES
AND EQUIPMENT PROVIDED BY QUALIFIED COMPLEX REHABILITATION TECHNOLOGY
SUPPLIERS, PURSUANT TO SECTION THREE HUNDRED SIXTY-SEVEN-J OF THE SOCIAL
SERVICES LAW, AND ADOPT THE SUPPLIER STANDARDS CONTAINED THEREIN.
S 6. Section 4403 of the public health law is amended by adding a new
subdivision 9 to read as follows:
9. EVERY HEALTH MAINTENANCE ORGANIZATION SHALL INCLUDE ADEQUATE ACCESS
TO SERVICES AND EQUIPMENT PROVIDED BY QUALIFIED COMPLEX REHABILITATION
TECHNOLOGY SUPPLIERS, PURSUANT TO SECTION THREE HUNDRED SIXTY-SEVEN-J OF
THE SOCIAL SERVICES LAW, AND ADOPT THE SUPPLIER STANDARDS CONTAINED
THEREIN.
S 7. This act shall take effect on the first of January next succeed-
ing the date on which it shall have become a law, and shall apply to
contracts and policies issued, renewed, modified or amended on or after
such effective date.