S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   5033
 
                        2019-2020 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             February 6, 2019
                                ___________
 
 Introduced  by M. of A. DINOWITZ, GOTTFRIED, GALEF -- Multi-Sponsored by
   -- M. of A.  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.
   § 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.
              

                                                            LBD00637-01-9

 A. 5033                             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.
   §  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

 A. 5033                             3
 
 PROVIDER TO PROVIDE CARE TO AN INSURED IN  A  MANNER  INCONSISTENT  WITH
 THIS SECTION, ARE PROHIBITED.
   §  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. 5033                             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.
   § 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.
   §  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.
   § 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.