NY State Senate Bill 2015-S28A

Senate Bill S28A

2015-2016 Legislative Session

Provides that no policy of group accident, group health or group accident and health shall impose copayments in excess of 20 percent of total reimbursement to the provider of care

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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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Actions

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 06, 2016	referred to insurance
May 06, 2015	print number 28a
May 06, 2015	amend and recommit to insurance
Jan 07, 2015	referred to insurance

Bill Amendments

Original

A (Active)

co-Sponsors

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2015-S28 - Details

See Assembly Version of this Bill:: A1063
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3216, 4235, 4301 & 4322, Ins L
Versions Introduced in Other Legislative Sessions:: 2009-2010: S4321, A8171
2011-2012: S4870, A187
2013-2014: S2319, A1666
2017-2018: S5764, A569
2019-2020: S3751, A405
2021-2022: S3562, A594
2023-2024: S1470, A6345

2015-S28 - Summary

Provides that no policy of group accident, group health or group accident and health shall impose co-payments in excess of twenty percent of total reimbursement to the provider of care.

2015-S28 - Sponsor Memo

                                 BILL NUMBER:  S28

 TITLE OF BILL :  An act to amend the insurance law, in relation to
physical therapy services

 PURPOSE :  To limit the imposition of co-payments for physical
therapy services to no more than twenty percent of the reimbursement
to the provider of care.

 SUMMARY OF PROVISIONS :

Sections 1 through 5 prohibit payors from imposing costs on insureds
for the provision of physical therapy services in excess of 20 percent
of the reimbursement to the provider of care.

Section 6. Effective Date.

 JUSTIFICATION :  This bill will protect consumers by prohibiting
plans from inappropriately shifting the cost of physical therapy care
to consumers by limiting co-payments to no more than 20 percent of the
total reimbursement to the provider of care. Under existing law,
health plans must cover physical therapy services. Despite that
requirement, health plans have shifted the vast majority of the cost
of physical therapy services by imposing increasingly high co-payments
on consumers. Under certain health plans, co-payments for physical
therapy services have exceeded the reimbursement paid by the plan to

the provider of care.

This cost shift has imposed a financial burden on consumers, and it
has restricted access to physical therapy services. Consumers
frequently cannot afford the cost imposed by these copayments for
medically necessary physical therapy care. physical therapy services
generally require multiple visits over the healing process. A
co-payment of $50 for a physical therapy plan of care of 3 times a
week for a month will cost the consumer $600 in out-of-pocket expenses
which is beyond the means of many consumers. As a result, New Yorkers
are forgoing medically necessary care running the risk of worsening
the underlying condition or risking re-injury.

This bill would reestablish the obligation of health plans to cover
the expense of physical therapy services by limiting co-payments to no
more than twenty percent of the total reimbursement to the provider of
care. The 20 percent limitation will allow plans to require
co-payments that discourage inappropriate care but will prohibit plans
from inappropriately shifting the cost of physical therapy care to
consumers.

 LEGISLATIVE HISTORY :  2009-2010 A.8171-A Referred to Insurance
2011-2012 S.4870A/A.187A 2013-2014 S.2319A/A.1666A

 FISCAL IMPLICATIONS : None

 EFFECTIVE DATE :  180 days after it shall have become a law.

2015-S28 - Bill Text download pdf

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

                                   28

                       2015-2016 Regular Sessions

                            I N  S E N A T E

                               (PREFILED)

                             January 7, 2015
                               ___________

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

AN ACT to amend the insurance  law,  in  relation  to  physical  therapy
  services

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

  Section 1. Paragraph 23 of subsection  (i)  of  section  3216  of  the
insurance  law,  as added by chapter 593 of the laws of 2000, is amended
to read as follows:
  (23) If a policy provides for reimbursement for physical  and  occupa-
tional therapy service which is within the lawful scope of practice of a
duly  licensed  physical  or occupational therapist, an insured shall be
entitled to reimbursement for such service whether the said  service  is
performed  by a physician or through a duly licensed physical or occupa-
tional therapist, provided however, that nothing contained herein  shall
be  construed  to  impair any terms of such policy including appropriate
utilization review and the requirement that said  service  be  performed
pursuant to a medical order, or a similar or related service of a physi-
cian  PROVIDED THAT SUCH TERMS SHALL NOT IMPOSE CO-PAYMENTS IN EXCESS OF
TWENTY PERCENT OF THE TOTAL REIMBURSEMENT TO THE PROVIDER OF CARE.
  S 2. Subparagraph (A) of paragraph 1 of subsection (f) of section 4235
of the insurance law, as amended by chapter 219 of the laws of 2011,  is
amended to read as follows:
  (A)  Any  policy of group accident, group health or group accident and
health insurance may include provisions for the payment by  the  insurer
of  benefits  for  expenses  incurred on account of hospital, medical or
surgical care or physical and occupational therapy by licensed  physical
and  occupational  therapists  upon  the  prescription  or referral of a
physician for the employee or other member of  the  insured  group,  the
employee's or member's spouse, the employee's or member's child or chil-

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

                                                           LBD01104-01-5

S. 28                               2

dren, or other persons chiefly dependent upon the employee or member for
support and maintenance; provided that:
  (i)  a  policy  of  hospital,  medical, surgical, or prescription drug
expense insurance that provides coverage for children shall provide such
coverage to a married or unmarried child until attainment of  age  twen-
ty-six,  without  regard  to  financial  dependence,  residency with the
employee or member, student status, or employment, except a policy  that
is  a  grandfathered  health  plan  may, for plan years beginning before
January first, two thousand fourteen, exclude coverage of an adult child
under age twenty-six who is eligible to enroll in an  employer-sponsored
health  plan other than a group health plan of a parent. For purposes of
this item, "grandfathered health plan" means  coverage  provided  by  an
insurer  in  which an individual was enrolled on March twenty-third, two
thousand ten for as long as the coverage maintains grandfathered  status
in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.
S 18011(e); and
  (ii) a policy under which coverage terminates at a specified age shall
not  so terminate with respect to an unmarried child who is incapable of
self-sustaining employment by reason of  mental  illness,  developmental
disability, mental retardation, as defined in the mental hygiene law, or
physical handicap and who became so incapable prior to attainment of the
age  at  which  coverage  would  otherwise  terminate and who is chiefly
dependent upon such employee or  member  for  support  and  maintenance,
while  the  insurance of the employee or member remains in force and the
child remains in such condition, if the insured employee or  member  has
within thirty-one days of such child's attainment of the termination age
submitted  proof  of  such  child's incapacity as described herein.   NO
POLICY OF GROUP ACCIDENT, GROUP HEALTH  OR  GROUP  ACCIDENT  AND  HEALTH
INSURANCE  SHALL  IMPOSE  CO-PAYMENTS IN EXCESS OF TWENTY PERCENT OF THE
TOTAL REIMBURSEMENT TO THE PROVIDER OF CARE.
  S 3. Subparagraph (A) of paragraph 4 of subsection (f) of section 4235
of the insurance law, as amended by chapter 593 of the laws of 2000,  is
amended to read as follows:
  (A)  any physical and occupational therapy service which is within the
lawful scope of practice of a licensed physical and occupational  thera-
pist, a subscriber to such policy shall be entitled to reimbursement for
such  service,  whether  the said service is performed by a physician or
licensed physical and occupational therapist pursuant to prescription or
referral by a physician; AND A POLICY OF GROUP ACCIDENT, GROUP HEALTH OR
GROUP ACCIDENT AND HEALTH INSURANCE  SHALL  NOT  IMPOSE  CO-PAYMENTS  IN
EXCESS  OF  TWENTY PERCENT OF THE TOTAL REIMBURSEMENT TO THE PROVIDER OF
CARE;
  S 4. Subparagraph (G) of paragraph 1 of subsection (b) of section 4301
of the insurance law, as amended by chapter 593 of the laws of 2000,  is
amended to read as follows:
  (G)  physical  and occupational therapy care provided through licensed
physical and occupational therapists upon the prescription of  a  physi-
cian  AND  ANY CO-PAYMENTS RELATED TO REIMBURSEMENT FOR PHYSICAL THERAPY
SERVICES SHALL NOT EXCEED TWENTY PERCENT OF THE TOTAL  REIMBURSEMENT  TO
THE PROVIDER OF CARE,
  S  5.  Paragraph 13 of subsection (b) of section 4322 of the insurance
law, as added by chapter 504 of the laws of 1995, is amended to read  as
follows:
  (13) Outpatient physical therapy up to ninety visits per condition per
calendar  year  AND  ANY  CO-PAYMENTS  RELATED TO REIMBURSEMENT FOR SUCH

S. 28                               3

SERVICES SHALL NOT EXCEED TWENTY PERCENT OF THE TOTAL  REIMBURSEMENT  TO
THE PROVIDER OF CARE.
  S 6. This act shall take effect on the one hundred eightieth day after
it shall have become a law.

co-Sponsors

View additional co-sponsors

2015-S28A (ACTIVE) - Details

See Assembly Version of this Bill:: A1063
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3216, 4235, 4301 & 4322, Ins L
Versions Introduced in Other Legislative Sessions:: 2009-2010: S4321, A8171
2011-2012: S4870, A187
2013-2014: S2319, A1666
2017-2018: S5764, A569
2019-2020: S3751, A405
2021-2022: S3562, A594
2023-2024: S1470, A6345

2015-S28A (ACTIVE) - Summary

Provides that no policy of group accident, group health or group accident and health shall impose co-payments in excess of twenty percent of total reimbursement to the provider of care.

2015-S28A (ACTIVE) - Sponsor Memo

                                BILL NUMBER:S28A

TITLE OF BILL:  An act to amend the insurance law, in relation to
physical therapy services

PURPOSE:  To limit the imposition of co-payments for physical therapy
services to no more than twenty percent of the reimbursement to the
provider of care.

SUMMARY OF PROVISIONS:

Sections 1 through 5 prohibit payors from imposing costs on insureds
for the provision of physical therapy services in excess of 20 percent
of the reimbursement to the provider of care.

Section 6. Effective Date.

JUSTIFICATION:  This bill will protect consumers by prohibiting plans
from inappropriately shifting the cost of physical therapy care to
consumers by limiting co-payments to no more than 20 percent of the
total reimbursement to the provider of care. Under existing law,
health plans must cover physical therapy services. Despite that
requirement, health plans have shifted the vast majority of the cost
of physical therapy services by imposing increasingly high co-payments
on consumers. Under certain health plans, co-payments for physical
therapy services have exceeded the reimbursement paid by the plan to

the provider of care.

This cost shift has imposed a financial burden on consumers, and it
has restricted access to physical therapy services. Consumers
frequently cannot afford the cost imposed by these copayments for
medically necessary physical therapy care. physical therapy services
generally require multiple visits over the healing process. A
co-payment of $50 for a physical therapy plan of care of 3 times a
week for a month will cost the consumer $600 in out-of-pocket expenses
which is beyond the means of many consumers. As a result, New Yorkers
are forgoing medically necessary care running the risk of worsening
the underlying condition or risking re-injury.

This bill would reestablish the obligation of health plans to cover
the expense of physical therapy services by limiting co-payments to no
more than twenty percent of the total reimbursement to the provider of
care. The 20 percent limitation will allow plans to require
co-payments that discourage inappropriate care but will prohibit plans
from inappropriately shifting the cost of physical therapy care to
consumers.

LEGISLATIVE HISTORY:  2009-2010 A.8171-A Referred to Insurance
2011-2012 S.4870A/A.187A 2013-2014 S.2319A/A.1666A

FISCAL IMPLICATIONS: None

EFFECTIVE DATE:  180 days after it shall have become a law.

2015-S28A (ACTIVE) - Bill Text download pdf

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

                                  28--A

                       2015-2016 Regular Sessions

                            I N  S E N A T E

                               (PREFILED)

                             January 7, 2015
                               ___________

Introduced  by  Sens.  DeFRANCISCO,  AVELLA,  BOYLE, MARCHIONE, MARTINS,
  PANEPINTO, YOUNG -- read twice and ordered printed, and  when  printed
  to be committed to the Committee on Insurance -- committee discharged,
  bill  amended,  ordered  reprinted  as amended and recommitted to said
  committee

AN ACT to amend the insurance  law,  in  relation  to  physical  therapy
  services

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

  Section 1. Paragraph 23 of subsection  (i)  of  section  3216  of  the
insurance  law,  as added by chapter 593 of the laws of 2000, is amended
to read as follows:
  (23) If a policy provides for reimbursement for physical  and  occupa-
tional therapy service which is within the lawful scope of practice of a
duly  licensed  physical  or occupational therapist, an insured shall be
entitled to reimbursement for such service whether the said  service  is
performed  by a physician or through a duly licensed physical or occupa-
tional therapist, provided however, that nothing contained herein  shall
be  construed  to  impair any terms of such policy including appropriate
utilization review and the requirement that said  service  be  performed
pursuant to a medical order, or a similar or related service of a physi-
cian  PROVIDED THAT SUCH TERMS SHALL NOT IMPOSE CO-PAYMENTS IN EXCESS OF
TWENTY PERCENT OF THE TOTAL REIMBURSEMENT TO THE  PROVIDER  OF  CARE  OR
DIFFERENT  DEDUCTIBLES, CO-PAYMENTS OR CO-INSURANCE AMOUNTS ON THE BASIS
OF THE SETTING IN WHICH SUCH PHYSICAL THERAPY SERVICES ARE  RENDERED  OR
WHETHER THE SERVICES ARE PERFORMED BY A PHYSICAL THERAPIST OR PHYSICIAN.
  S 2. Subparagraph (A) of paragraph 1 of subsection (f) of section 4235
of  the insurance law, as amended by chapter 219 of the laws of 2011, is
amended to read as follows:

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01104-02-5

S. 28--A                            2

  (A) Any policy of group accident, group health or group  accident  and
health  insurance  may include provisions for the payment by the insurer
of benefits for expenses incurred on account  of  hospital,  medical  or
surgical  care or physical and occupational therapy by licensed physical
and  occupational  therapists  upon  the  prescription  or referral of a
physician for the employee or other member of  the  insured  group,  the
employee's or member's spouse, the employee's or member's child or chil-
dren, or other persons chiefly dependent upon the employee or member for
support and maintenance; provided that:
  (i)  a  policy  of  hospital,  medical, surgical, or prescription drug
expense insurance that provides coverage for children shall provide such
coverage to a married or unmarried child until attainment of  age  twen-
ty-six,  without  regard  to  financial  dependence,  residency with the
employee or member, student status, or employment, except a policy  that
is  a  grandfathered  health  plan  may, for plan years beginning before
January first, two thousand fourteen, exclude coverage of an adult child
under age twenty-six who is eligible to enroll in an  employer-sponsored
health  plan other than a group health plan of a parent. For purposes of
this item, "grandfathered health plan" means  coverage  provided  by  an
insurer  in  which an individual was enrolled on March twenty-third, two
thousand ten for as long as the coverage maintains grandfathered  status
in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.
S 18011(e); and
  (ii) a policy under which coverage terminates at a specified age shall
not  so terminate with respect to an unmarried child who is incapable of
self-sustaining employment by reason of  mental  illness,  developmental
disability, mental retardation, as defined in the mental hygiene law, or
physical handicap and who became so incapable prior to attainment of the
age  at  which  coverage  would  otherwise  terminate and who is chiefly
dependent upon such employee or  member  for  support  and  maintenance,
while  the  insurance of the employee or member remains in force and the
child remains in such condition, if the insured employee or  member  has
within thirty-one days of such child's attainment of the termination age
submitted  proof  of  such  child's incapacity as described herein.   NO
POLICY OF GROUP ACCIDENT, GROUP HEALTH  OR  GROUP  ACCIDENT  AND  HEALTH
INSURANCE  SHALL  IMPOSE  CO-PAYMENTS IN EXCESS OF TWENTY PERCENT OF THE
TOTAL REIMBURSEMENT TO THE PROVIDER OF CARE  OR  DIFFERENT  DEDUCTIBLES,
CO-PAYMENTS OR CO-INSURANCE AMOUNTS ON THE BASIS OF THE SETTING IN WHICH
SUCH  PHYSICAL THERAPY SERVICES ARE RENDERED OR WHETHER THE SERVICES ARE
PERFORMED BY A PHYSICAL THERAPIST OR PHYSICIAN.
  S 3. Subparagraph (A) of paragraph 4 of subsection (f) of section 4235
of the insurance law, as amended by chapter 593 of the laws of 2000,  is
amended to read as follows:
  (A)  any physical and occupational therapy service which is within the
lawful scope of practice of a licensed physical and occupational  thera-
pist, a subscriber to such policy shall be entitled to reimbursement for
such  service,  whether  the said service is performed by a physician or
licensed physical and occupational therapist pursuant to prescription or
referral by a physician; AND A POLICY OF GROUP ACCIDENT, GROUP HEALTH OR
GROUP ACCIDENT AND HEALTH INSURANCE  SHALL  NOT  IMPOSE  CO-PAYMENTS  IN
EXCESS  OF  TWENTY PERCENT OF THE TOTAL REIMBURSEMENT TO THE PROVIDER OF
CARE OR DIFFERENT DEDUCTIBLES, CO-PAYMENTS OR  CO-INSURANCE  AMOUNTS  ON
THE  BASIS  OF  THE  SETTING IN WHICH SUCH PHYSICAL THERAPY SERVICES ARE
RENDERED OR WHETHER THE SERVICES ARE PERFORMED BY A  PHYSICAL  THERAPIST
OR PHYSICIAN;

S. 28--A                            3

  S 4. Subparagraph (G) of paragraph 1 of subsection (b) of section 4301
of  the insurance law, as amended by chapter 593 of the laws of 2000, is
amended to read as follows:
  (G)  physical  and occupational therapy care provided through licensed
physical and occupational therapists upon the prescription of  a  physi-
cian  AND  ANY CO-PAYMENTS RELATED TO REIMBURSEMENT FOR PHYSICAL THERAPY
SERVICES SHALL NOT EXCEED TWENTY PERCENT OF THE TOTAL  REIMBURSEMENT  TO
THE  PROVIDER  OF CARE OR DIFFERENT DEDUCTIBLES, CO-PAYMENTS OR CO-INSU-
RANCE AMOUNTS ON THE BASIS OF THE SETTING IN WHICH SUCH PHYSICAL THERAPY
SERVICES ARE RENDERED OR WHETHER THE SERVICES ARE PERFORMED BY  A  PHYS-
ICAL THERAPIST OR PHYSICIAN,
  S  5.  Paragraph 13 of subsection (b) of section 4322 of the insurance
law, as added by chapter 504 of the laws of 1995, is amended to read  as
follows:
  (13) Outpatient physical therapy up to ninety visits per condition per
calendar  year  AND  ANY  CO-PAYMENTS  RELATED TO REIMBURSEMENT FOR SUCH
SERVICES SHALL NOT EXCEED TWENTY PERCENT OF THE TOTAL  REIMBURSEMENT  TO
THE  PROVIDER  OF CARE OR DIFFERENT DEDUCTIBLES, CO-PAYMENTS OR CO-INSU-
RANCE AMOUNTS ON THE BASIS OF THE SETTING IN WHICH SUCH PHYSICAL THERAPY
SERVICES ARE RENDERED OR WHETHER THE SERVICES ARE PERFORMED BY  A  PHYS-
ICAL THERAPIST OR PHYSICIAN.
  S 6. This act shall take effect on the one hundred eightieth day after
it shall have become a law.

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Senate Bill S28A

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Sponsored By

Archive: Last Bill Status - In Senate Committee Insurance Committee

Bill Amendments

co-Sponsors

2015-S28 - Details

2015-S28 - Summary

2015-S28 - Sponsor Memo

2015-S28 - Bill Text download pdf

co-Sponsors

2015-S28A (ACTIVE) - Details

2015-S28A (ACTIVE) - Summary

2015-S28A (ACTIVE) - Sponsor Memo

2015-S28A (ACTIVE) - Bill Text download pdf

Comments