NY State Senate Bill 2017-S5764A

Senate Bill S5764A

2017-2018 Legislative Session

Provides that no policy of group accident, group health or group accident and health shall impose copayments for physical or occupational therapy greater than copays for similar services provided by a physician

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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 03, 2018	referred to insurance
May 09, 2017	print number 5764a
May 09, 2017	amend and recommit to insurance
Apr 28, 2017	referred to insurance

Bill Amendments

Original

A (Active)

2017-S5764 - Details

See Assembly Version of this Bill:: A569
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
2015-2016: S28, A1063
2019-2020: S3751, A405
2021-2022: S3562, A594
2023-2024: S1470, A6345

2017-S5764 - Summary

Provides that no policy of group accident, group health or group accident and health shall impose copayments for physical or occupational therapy greater than the copay for similar services provided by a physician.

2017-S5764 - Sponsor Memo

                                 BILL NUMBER:  S5764

 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
2015-2016 S.28A/A.1063A

 FISCAL IMPLICATIONS :

None

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

2017-S5764 - Bill Text download pdf

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   5764
 
                        2017-2018 Regular Sessions
 
                             I N  S E N A T E
 
                              April 28, 2017
                                ___________
 
 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  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.
   § 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
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.

                                                            LBD01314-01-7

 S. 5764                             2
 
 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.
 § 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.
   § 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;
   § 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

 S. 5764                             3
 
 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,
   § 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.
   § 6. This act shall take effect on the one hundred eightieth day after
 it shall have become a law.

co-Sponsors

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2017-S5764A (ACTIVE) - Details

See Assembly Version of this Bill:: A569
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
2015-2016: S28, A1063
2019-2020: S3751, A405
2021-2022: S3562, A594
2023-2024: S1470, A6345

2017-S5764A (ACTIVE) - Summary

2017-S5764A (ACTIVE) - Sponsor Memo

                                 BILL NUMBER:  S5764A

 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
2015-2016 S.28A/A.1063A

 FISCAL IMPLICATIONS :

None

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

2017-S5764A (ACTIVE) - Bill Text download pdf

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  5764--A
 
                        2017-2018 Regular Sessions
 
                             I N  S E N A T E
 
                              April 28, 2017
                                ___________
 
 Introduced  by  Sen.  DeFRANCISCO -- read twice and ordered printed, and
   when printed to be committed to the Committee on Insurance --  commit-
   tee  discharged, bill amended, ordered reprinted as amended and recom-
   mitted 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.    AN  INSURER  SHALL NOT IMPOSE A COPAYMENT OR COINSURANCE AMOUNT
 CHARGED TO THE INSURED FOR SERVICES RENDERED FOR EACH DATE OF SERVICE BY
 A PHYSICAL THERAPIST LICENSED UNDER ARTICLE ONE  HUNDRED  THIRTY-SIX  OF
 THE  EDUCATION  LAW  OR AN OCCUPATIONAL THERAPIST LICENSED UNDER ARTICLE
 ONE HUNDRED FIFTY-SIX OF THE EDUCATION LAW  THAT  IS  GREATER  THAN  THE
 COPAYMENT  OR  COINSURANCE  AMOUNT  IMPOSED  ON THE INSURED FOR SERVICES
 PROVIDED TO THE INSURED FOR  AN  OFFICE  VISIT  FOR  THE  SERVICE  OF  A
 LICENSED  PRIMARY  CARE PHYSICIAN OR OSTEOPATH FOR THE SAME OR A SIMILAR
 DIAGNOSED CONDITION EVEN IF A DIFFERENT NOMENCLATURE IS USED TO DESCRIBE
 THE CONDITION FOR WHICH THE SERVICES ARE PROVIDED.
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD01314-02-7

 S. 5764--A                          2
 
   § 2. Subparagraph (A) of paragraph 1 of subsection (f) of section 4235
 of the insurance law is amended by adding a new clause (iii) to read  as
 follows:
   (III)  A  POLICY  SHALL  NOT  IMPOSE A COPAYMENT OR COINSURANCE AMOUNT
 CHARGED TO THE INSURED FOR SERVICES RENDERED FOR EACH DATE OF SERVICE BY
 A PHYSICAL THERAPIST LICENSED UNDER ARTICLE ONE  HUNDRED  THIRTY-SIX  OF
 THE  EDUCATION  LAW  OR AN OCCUPATIONAL THERAPIST LICENSED UNDER ARTICLE
 ONE HUNDRED FIFTY-SIX OF THE EDUCATION LAW  THAT  IS  GREATER  THAN  THE
 COPAYMENT  OR  COINSURANCE  AMOUNT  IMPOSED  ON THE INSURED FOR SERVICES
 PROVIDED TO THE INSURED FOR  AN  OFFICE  VISIT  FOR  THE  SERVICE  OF  A
 LICENSED  PRIMARY  CARE PHYSICIAN OR OSTEOPATH FOR THE SAME OR A SIMILAR
 DIAGNOSED CONDITION EVEN IF A DIFFERENT NOMENCLATURE IS USED TO DESCRIBE
 THE CONDITION FOR WHICH THE SERVICES ARE PROVIDED.
   § 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.  A POLICY SHALL NOT IMPOSE A COPAYMENT OR COIN-
 SURANCE AMOUNT CHARGED TO THE INSURED FOR  SERVICES  RENDERED  FOR  EACH
 DATE  OF  SERVICE  BY  A  PHYSICAL  THERAPIST LICENSED UNDER ARTICLE ONE
 HUNDRED THIRTY-SIX OF THE EDUCATION LAW  OR  AN  OCCUPATIONAL  THERAPIST
 LICENSED  UNDER  ARTICLE ONE HUNDRED FIFTY-SIX OF THE EDUCATION LAW THAT
 IS GREATER THAN THE COPAYMENT  OR  COINSURANCE  AMOUNT  IMPOSED  ON  THE
 INSURED FOR SERVICES PROVIDED TO THE INSURED FOR AN OFFICE VISIT FOR THE
 SERVICE  OF  A LICENSED PRIMARY CARE PHYSICIAN OR OSTEOPATH FOR THE SAME
 OR A SIMILAR DIAGNOSED CONDITION EVEN IF  A  DIFFERENT  NOMENCLATURE  IS
 USED TO DESCRIBE THE CONDITION FOR WHICH THE SERVICES ARE PROVIDED;
   § 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, PROVIDED, HOWEVER, THAT NO COPAYMENT OR COINSURANCE AMOUNT CHARGED
 TO THE INSURED FOR SERVICES RENDERED FOR EACH DATE OF SERVICE BY A PHYS-
 ICAL THERAPIST LICENSED UNDER ARTICLE  ONE  HUNDRED  THIRTY-SIX  OF  THE
 EDUCATION  LAW  OR  AN OCCUPATIONAL THERAPIST LICENSED UNDER ARTICLE ONE
 HUNDRED FIFTY-SIX OF THE EDUCATION LAW IS GREATER THAN THE COPAYMENT  OR
 COINSURANCE  AMOUNT  IMPOSED ON THE INSURED FOR SERVICES PROVIDED TO THE
 INSURED FOR AN OFFICE VISIT FOR THE SERVICE OF A LICENSED  PRIMARY  CARE
 PHYSICIAN  OR  OSTEOPATH  FOR  THE SAME OR A SIMILAR DIAGNOSED CONDITION
 EVEN IF A DIFFERENT NOMENCLATURE IS USED TO DESCRIBE THE  CONDITION  FOR
 WHICH THE SERVICES ARE PROVIDED,
   §  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,  PROVIDED,  HOWEVER,  THAT  NO  COPAYMENT OR COINSURANCE
 AMOUNT CHARGED TO THE INSURED FOR SERVICES RENDERED  FOR  EACH  DATE  OF
 SERVICE BY A PHYSICAL THERAPIST LICENSED UNDER ARTICLE ONE HUNDRED THIR-
 TY-SIX  OF THE EDUCATION LAW OR AN OCCUPATIONAL THERAPIST LICENSED UNDER
 ARTICLE ONE HUNDRED FIFTY-SIX OF THE EDUCATION LAW IS GREATER  THAN  THE
 COPAYMENT  OR  COINSURANCE  AMOUNT  IMPOSED  ON THE INSURED FOR SERVICES

 S. 5764--A                          3
 
 PROVIDED TO THE INSURED FOR  AN  OFFICE  VISIT  FOR  THE  SERVICE  OF  A
 LICENSED  PRIMARY  CARE PHYSICIAN OR OSTEOPATH FOR THE SAME OR A SIMILAR
 DIAGNOSED CONDITION EVEN IF A DIFFERENT NOMENCLATURE IS USED TO DESCRIBE
 THE CONDITION FOR WHICH THE SERVICES ARE PROVIDED.
   § 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 S5764A

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Sponsored By

John A. DeFrancisco