S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                    408
 
                        2019-2020 Regular Sessions
 
                           I N  A S S E M B L Y
 
                                (PREFILED)
 
                              January 9, 2019
                                ___________
 
 Introduced by M. of A. CAHILL -- read once and referred to the Committee
   on Insurance
 
 AN  ACT to amend the insurance law, in relation to including certain out
   of home services such as transition from a hospital, nursing  facility
   or  other institutional setting to the home within home care insurance
   coverage
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Subparagraphs (C), (D) and (E) of paragraph 1 of subsection
 (k)  of  section 3221 of the insurance law, subparagraphs (C) and (D) as
 amended by chapter 557 of the laws of  2000,  are  amended  to  read  as
 follows:
   (C)  Home care means the care and treatment of a covered person who is
 under the care of a  physician  [but  only  if]  AND  WHO  REQUIRES  THE
 SERVICES  OF  AN  AGENCY DESCRIBED IN SUBPARAGRAPH (D) OF THIS PARAGRAPH
 FOR: TRANSITION OF THE COVERED PERSON FROM HOSPITAL, NURSING FACILITY OR
 OTHER INSTITUTIONAL SETTING TO HOME; REHABILITATION, RECOVERY OR MEDICAL
 MANAGEMENT OF THE COVERED PERSON AT HOME  FOLLOWING  HOSPITALIZATION  OR
 FOLLOWING  CARE IN A NURSING FACILITY OR OTHER INSTITUTIONAL SETTING; OR
 MEDICAL MANAGEMENT OF A CONDITION PREDISPOSING THE COVERED INDIVIDUAL TO
 hospitalization [or], confinement in a nursing facility [as  defined  in
 subchapter  XVIII  of the federal Social Security Act, 42 U.S.C. §§ 1395
 et seq, would otherwise have been required] OR THE NEED FOR  OTHER  OUT-
 OF-HOME SERVICES OTHERWISE COVERED UNDER THE CONTRACT if home care [was]
 IS not provided, and the plan covering the home health service is estab-
 lished and approved in writing by such physician.
   (D)  Home  care  shall  be  provided  by  an agency possessing a valid
 certificate of approval or license issued pursuant to article thirty-six
 of the public health law and shall consist of one or more of the follow-
 ing:
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                       [ ] is old law to be omitted.
                                                            LBD00215-01-9

 A. 408                              2
 
   (i) Part-time or intermittent home nursing care by or under the super-
 vision of a registered professional nurse (R.N.).
   (ii) Part-time or intermittent home health aide services which consist
 primarily of caring for the patient.
   (iii)  Physical,  occupational or speech therapy, SOCIAL WORK, RESPIR-
 ATORY THERAPY AND NUTRITIONAL COUNSELING, if provided by the home health
 service or agency.
   (iv) Medical supplies, drugs and medications prescribed  by  a  physi-
 cian, and laboratory services by or on behalf of a certified home health
 agency  or  licensed  home care services agency to the extent such items
 would have been covered under the contract if  the  covered  person  had
 been  hospitalized  or confined in a skilled nursing facility as defined
 in subchapter XVIII of the federal Social Security  Act,  42  U.S.C.  §§
 1395 et seq.
   (E)  For  the purpose of determining the benefits for home care avail-
 able to a covered person, [each visit by a member of a  home  care  team
 shall  be  considered as one home care visit; the contract may contain a
 limitation on the number of home care visits, but not  less  than  forty
 such  visits  in any calendar year or in any continuous period of twelve
 months, for each person covered under the contract; four hours  of  home
 health  aide service shall be considered as one home care visit] NOTHING
 IN THIS PARAGRAPH SHALL BE CONSTRUED TO PREVENT THE MANAGEMENT OR UTILI-
 ZATION REVIEW OF HOME CARE BENEFITS, INCLUDING THE  USE  OF  PREAUTHORI-
 ZATION  AND  APPROPRIATENESS  CRITERIA  AS TO THE LEVEL AND INTENSITY OF
 TREATMENT APPLICABLE TO HOME CARE, PROVIDED HOWEVER THAT ANY SUCH DETER-
 MINATIONS MAY BE SUBJECT TO APPEAL  UNDER  ARTICLE  FORTY-NINE  OF  THIS
 CHAPTER.
   §  2.  Paragraph  3 of subsection (a) of section 4303 of the insurance
 law, subparagraphs (A), (B) and (C) as amended by  chapter  557  of  the
 laws  of  2000 and subparagraph (D) as amended by chapter 21 of the laws
 of 1990, is amended to read as follows:
   (3) For home care to residents in this state. Such home care  coverage
 shall  be  included  at  the  inception  of  all new contracts and, with
 respect to all other contracts, added at any  anniversary  date  of  the
 contract  subject  to  evidence  of  insurability.  Such coverage may be
 subject to an annual deductible of not more than fifty dollars for  each
 covered  person  and  may  be  subject  to a coinsurance provision which
 provides for coverage of not  less  than  seventy-five  percent  of  the
 reasonable  cost  of  services  for  which  payment may be made. No such
 corporation need provide such coverage to persons eligible for medicare.
   (A) Home care shall mean the care and treatment of  a  covered  person
 who is under the care of a physician [but only if:
   (i)]  AND WHO REQUIRES THE SERVICES OF AN AGENCY DESCRIBED IN SUBPARA-
 GRAPH (B) OF THIS PARAGRAPH FOR: TRANSITION OF THE COVERED  PERSON  FROM
 HOSPITAL,  NURSING  FACILITY OR OTHER INSTITUTIONAL SETTING TO HOME; FOR
 REHABILITATION, RECOVERY OR MEDICAL MANAGEMENT OF THE COVERED PERSON  AT
 HOME  FOLLOWING  HOSPITALIZATION OR FOLLOWING CARE IN A NURSING FACILITY
 OR OTHER INSTITUTIONAL SETTING; OR MEDICAL  MANAGEMENT  OF  A  CONDITION
 PREDISPOSING THE COVERED INDIVIDUAL TO hospitalization [or], confinement
 in  a  nursing  facility  [as  defined in subchapter XVIII of the Social
 Security Act, 42 U.S.C.  §  1395  et  seq,  would  otherwise  have  been
 required]  OR  THE NEED FOR OTHER OUT-OF-HOME SERVICES OTHERWISE COVERED
 UNDER THE POLICY, if home care [was] IS not provided, and
   [(ii)] the plan covering the home health service  is  established  and
 approved in writing by such physician.

 A. 408                              3
 
   (B)  Home  care  shall  be  provided  by  an agency possessing a valid
 certificate of approval or license issued pursuant to article thirty-six
 of the public health law.
   (C) Home care shall consist of one or more of the following:
   (i) part-time or intermittent home nursing care by or under the super-
 vision of a registered professional nurse (R.N.),
   (ii) part-time or intermittent home health aide services which consist
 primarily of caring for the patient,
   (iii)  physical,  occupational or speech therapy, SOCIAL WORK, RESPIR-
 ATORY THERAPY AND NUTRITIONAL COUNSELING, if provided by the home health
 service or agency, and
   (iv) medical supplies, drugs and medications prescribed  by  a  physi-
 cian, and laboratory services by or on behalf of a certified home health
 agency  or  licensed  home care services agency to the extent such items
 would have been covered or provided under the contract  if  the  covered
 person  had  been hospitalized or confined in a skilled nursing facility
 as defined in subchapter XVIII of the Social Security Act, 42  U.S.C.  §
 1395 et seq.
   (D)  For  the purpose of determining the benefits for home care avail-
 able to a covered person, [each visit by a member of a  home  care  team
 shall  be  considered as one home care visit. The contract may contain a
 limitation on the number of home care visits, but not  less  than  forty
 such  visits  in any calendar year or in any continuous period of twelve
 months, for each covered person. Four hours of home health aide  service
 shall  be  considered as one home care visit. Every contract issued by a
 hospital  service  corporation  or  health  service  corporation   which
 provides coverage supplementing part A and part B of subchapter XVIII of
 the  Social  Security  Act, 42 U.S.C. § 1395 et seq, must make available
 and, if requested by a subscriber holding a direct payment  contract  or
 by all subscribers in a group remittance group or by the contract holder
 in  the case of group contracts issued pursuant to section four thousand
 three hundred five of this article,  provide  coverage  of  supplemental
 home  care visits beyond those provided by part A and part B, sufficient
 to produce an aggregate coverage of three hundred sixty-five  home  care
 visits  per  contract  year. Such coverage shall be provided pursuant to
 regulations prescribed by the  superintendent.  Written  notice  of  the
 availability  of such coverage shall be delivered to the group remitting
 agent or group contract holder prior to inception of such  contract  and
 annually thereafter, except that this notice shall not be required where
 a  policy  covers  two  hundred  or  more employees or where the benefit
 structure was the subject of collective bargaining affecting persons who
 are employed in more than one state] NOTHING IN THIS PARAGRAPH SHALL  BE
 CONSTRUED  TO  PREVENT THE MANAGEMENT OR UTILIZATION REVIEW OF HOME CARE
 BENEFITS, INCLUDING THE  USE  OF  PREAUTHORIZATION  AND  APPROPRIATENESS
 CRITERIA  AS  TO THE LEVEL AND INTENSITY OF TREATMENT APPLICABLE TO HOME
 CARE, PROVIDED HOWEVER THAT ANY SUCH DETERMINATIONS MAY  BE  SUBJECT  TO
 APPEAL UNDER ARTICLE FORTY-NINE OF THIS CHAPTER.
   § 3. This act shall take effect January 1, 2021 and shall apply to all
 policies  and contracts issued, renewed, modified, altered or amended on
 or after such date.