S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   4177
 
                        2021-2022 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             February 1, 2021
                                ___________
 
 Introduced  by  M.  of  A.  LAVINE,  ABINANTI, COLTON, GOTTFRIED, QUART,
   SEAWRIGHT, TAYLOR, SIMON, STIRPE -- Multi-Sponsored by  --  M.  of  A.
   HEVESI -- read once and referred to the Committee on Health
 
 AN ACT to amend the public health law and the insurance law, in relation
   to health care professional applications and terminations

   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Subdivisions 2, 3, 4, 5, 6, 7, 8 and 9 of section 4406-d of
 the public health law, as added by chapter 705 of the laws of 1996,  are
 amended to read as follows:
   2.  (a) A health care plan shall not terminate OR NOT RENEW a contract
 with a health care professional unless the health care plan provides  to
 the  health  care  professional a written explanation of the reasons for
 the proposed contract termination and an opportunity  for  a  review  or
 hearing  as  hereinafter provided. This section shall not apply in cases
 involving imminent harm to patient care, a determination of fraud, or  a
 final  disciplinary  action  by a state licensing board or other govern-
 mental agency that impairs the health  care  professional's  ability  to
 practice.
   (b)  The  notice  of  the proposed contract termination OR NON-RENEWAL
 provided by the health care plan to the health care  professional  shall
 include:
   (i) the reasons for the proposed action;
   (ii) notice that the health care professional has the right to request
 a  hearing  or  review, at the professional's discretion, before a panel
 [appointed by the health care plan] COMPRISED OF  NO  FEWER  THAN  THREE
 HEALTH CARE PROFESSIONALS LICENSED TO PRACTICE IN THE STATE OF NEW YORK;
   (iii)  a time limit of not less than thirty days within which a health
 care professional may request a hearing; and
   (iv) a time limit for a hearing date which must be held within  thirty
 days after the date of receipt of a request for a hearing.

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

                                                            LBD06602-01-1

 A. 4177                             2
 
   (c)  The  hearing panel shall be comprised of three [persons appointed
 by the health care plan] HEALTH CARE PROFESSIONALS LICENSED TO  PRACTICE
 BY  THE  STATE  OF NEW YORK IN THE SAME PROFESSION AS THE SUBJECT OF THE
 REVIEW, ONE OF WHOM IS APPOINTED BY THE HEALTH CARE PLAN, ONE OF WHOM IS
 APPOINTED  BY  THE  HEALTH  CARE  PROFESSIONAL WHO IS THE SUBJECT OF THE
 HEARING. THE REMAINING MEMBER OF THE PANEL SHALL BE CHOSEN BY THE  OTHER
 TWO PANEL MEMBERS. At least one person on such panel shall be a clinical
 peer  in  the  same  discipline and the same or similar specialty as the
 health care professional under review. The hearing panel may consist  of
 more  than  three  persons, provided however that the number of clinical
 peers on such panel shall constitute one-third  or  more  of  the  total
 membership  of  the  panel  AND  PROVIDED  FURTHER THAT THE RATIO OF THE
 NUMBER OF HEALTH CARE PROFESSIONALS APPOINTED BY THE HEALTH CARE PLAN TO
 THE NUMBER OF HEALTH CARE PROFESSIONALS APPOINTED BY THE SUBJECT OF  THE
 HEARING  TO  THE NUMBER OF HEALTH CARE PROFESSIONALS CHOSEN BY THE OTHER
 PANEL MEMBERS REMAINS ONE TO ONE TO ONE.
   (d) The hearing panel shall render a decision on the  proposed  action
 in  a  timely  manner.  Such decision shall include reinstatement of the
 health care professional by the  health  care  plan,  provisional  rein-
 statement  subject  to  conditions  set forth by the health care plan or
 termination of the health care  professional.  Such  decision  shall  be
 provided in writing to the health care professional.
   (e) A decision by the hearing panel to terminate OR NOT RENEW a health
 care professional shall be effective not less than thirty days after the
 receipt by the health care professional of the hearing panel's decision;
 provided,  however,  that the provisions of paragraph (e) of subdivision
 six of section [four thousand four] FORTY-FOUR  hundred  three  of  this
 article shall apply to such termination OR NON-RENEWAL.
   (f) In no event shall termination be effective earlier than sixty days
 from the receipt of the notice of termination.
   3.  [Either party to a contract may exercise a right of non-renewal at
 the expiration of the contract  period  set  forth  therein  or,  for  a
 contract  without  a  specific  expiration  date,  on each January first
 occurring after the contract has been in effect for at least  one  year,
 upon  sixty  days notice to the other party; provided, however, that any
 non-renewal shall not constitute a  termination  for  purposes  of  this
 section.
   4.] A health care plan shall develop and implement policies and proce-
 dures to ensure that health care professionals are regularly informed of
 information  maintained by the health care plan to evaluate the perform-
 ance or practice of the health care professional. The health  care  plan
 shall consult with health care professionals in developing methodologies
 to  collect  and analyze health care professional profiling data. Health
 care plans shall provide any such information  and  profiling  data  and
 analysis  to health care professionals. Such information, data or analy-
 sis shall be provided on a periodic basis appropriate to the nature  and
 amount  of  data  and  the  volume and scope of services provided.   Any
 profiling data used to evaluate the performance or practice of a  health
 care  professional  shall  be  measured  against  stated criteria and an
 appropriate group of health care professionals using  similar  treatment
 modalities serving a comparable patient population. Upon presentation of
 such  information  or data, each health care professional shall be given
 the opportunity to discuss the unique nature of the health care  profes-
 sional's  patient population which may have a bearing on the health care
 professional's profile and to work cooperatively with  the  health  care
 plan to improve performance.

 A. 4177                             3
 
   [5.]  4. 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.
   [6.] 5. Except as provided herein, no contract or agreement between  a
 health  care  plan  and  a  health  care  professional shall contain any
 provision which shall supersede or impair a health  care  professional's
 right to notice of reasons for termination OR NON-RENEWAL and the oppor-
 tunity  for a hearing or review concerning such termination OR NON-RENE-
 WAL.
   [7.] 6. Any contract provision in violation of this section  shall  be
 deemed to be void and unenforceable.
   [8.]  7. For purposes of this section, "health care plan" shall mean a
 health maintenance organization licensed pursuant to article forty-three
 of the insurance law or certified pursuant to this article or  an  inde-
 pendent  practice  association  certified or recognized pursuant to this
 article.
   [9.] 8. For purposes of this section, "health care professional" shall
 mean a health care professional licensed, registered or certified pursu-
 ant to title eight of the education law.
   § 2. Subsections (b), (c), (d), (e), (f), (g) and (h) of section  4803
 of  the  insurance law, as added by chapter 705 of the laws of 1996, are
 amended to read as follows:
   (b) (1) An insurer shall not terminate OR NOT RENEW a contract with  a
 health  care  professional  for participation in the in-network benefits
 portion of the insurer's network for a managed care product  unless  the
 insurer  provides  to the health care professional a written explanation
 of the reasons for the proposed contract termination and an  opportunity
 for  a review or hearing as hereinafter provided. This section shall not
 apply in cases involving imminent harm to patient care, a  determination
 of  fraud,  or a final disciplinary action by a state licensing board or
 other governmental agency that impairs the  health  care  professional's
 ability to practice.
   (2)  The  notice  of  the proposed contract termination OR NON-RENEWAL
 provided by the insurer to the health care professional shall include:
   (i) the reasons for the proposed action;
   (ii) notice that the health care professional has the right to request
 a hearing or review, at the professional's discretion,  before  a  panel
 [appointed  by the insurer] COMPRISED OF NO FEWER THAN THREE HEALTH CARE
 PROFESSIONALS LICENSED TO PRACTICE BY THE STATE OF NEW YORK;
   (iii) a time limit of not less than thirty days within which a  health
 care professional may request a hearing or review; and
   (iv)  a  time  limit  for a hearing date which must be held within not
 less than thirty days after the date of receipt of a request for a hear-
 ing.
   (3) The hearing panel shall be comprised of three  [persons  appointed
 by  the  insurer]  HEALTH CARE PROFESSIONALS LICENSED TO PRACTICE BY THE
 STATE OF NEW YORK IN THE SAME PROFESSION AS THE SUBJECT OF  THE  REVIEW,
 ONE OF WHOM IS APPOINTED BY THE INSURER, ONE OF WHOM IS APPOINTED BY THE
 HEALTH  CARE PROFESSIONAL WHO IS THE SUBJECT OF THE HEARING. THE REMAIN-
 ING MEMBER OF THE PANEL SHALL BE CHOSEN BY THE OTHER TWO PANEL  MEMBERS.

 A. 4177                             4
 
 At  least  one person on such panel shall be a clinical peer in the same
 discipline and the same or similar specialty as the health care  profes-
 sional  under  review.  The hearing panel may consist of more than three
 persons,  provided  however  that  the  number of clinical peers on such
 panel shall constitute one-third or more of the total membership of  the
 panel  AND  PROVIDED FURTHER THAT THE RATIO OF THE NUMBER OF HEALTH CARE
 PROFESSIONALS APPOINTED BY THE HEALTH CARE PLAN TO THE NUMBER OF  HEALTH
 CARE PROFESSIONALS APPOINTED BY THE SUBJECT OF THE HEARING TO THE NUMBER
 OF  HEALTH  CARE  PROFESSIONALS  CHOSEN  BY  THE TWO OTHER PANEL MEMBERS
 REMAINS ONE TO ONE TO ONE.
   (4) The hearing panel shall render a decision on the  proposed  action
 in  a  timely  manner.  Such decision shall include reinstatement of the
 health care  professional  by  the  insurer,  provisional  reinstatement
 subject  to  conditions  set  forth by the insurer or termination of the
 health care professional. Such decision shall be provided in writing  to
 the health care professional.
   (5) A decision by the hearing panel to terminate OR NOT RENEW a health
 care professional shall be effective not less than thirty days after the
 receipt by the health care professional of the hearing panel's decision;
 provided, however, that the provisions of subsection (e) of section four
 thousand  eight  hundred four OF THIS ARTICLE shall apply to such termi-
 nation.
   (6) In no event shall termination OR NON-RENEWAL be effective  earlier
 than sixty days from the receipt of the notice of termination OR NON-RE-
 NEWAL.
   (c)  [Either  party  to a contract for participation in the in-network
 benefits portion of an insurer's network for a managed care product  may
 exercise a right of non-renewal at the expiration of the contract period
 set forth therein or, for a contract without a specific expiration date,
 on  each  January  first occurring after the contract has been in effect
 for at least one year, upon  sixty  days  notice  to  the  other  party;
 provided,  however,  that  any non-renewal shall not constitute a termi-
 nation for purposes of this section.
   (d)] An insurer shall develop and implement policies and procedures to
 ensure that health care providers participating in [the] the  in-network
 benefits  portion of an insurer's network for a managed care product are
 regularly informed of information maintained by the insurer to  evaluate
 the performance or practice of the health care professional. The insurer
 shall consult with health care professionals in developing methodologies
 to  collect  and analyze provider profiling data. Insurers shall provide
 any such information and profiling data and  analysis  to  these  health
 care professionals. Such information, data or analysis shall be provided
 on a periodic basis appropriate to the nature and amount of data and the
 volume and scope of services provided. Any profiling data used to evalu-
 ate the performance or practice of such a health care professional shall
 be  measured  against stated criteria and an appropriate group of health
 care professionals using similar treatment modalities serving a compara-
 ble patient population. Upon presentation of such information  or  data,
 each  such  health  care  professional shall be given the opportunity to
 discuss the unique nature of  the  health  care  professional's  patient
 population which may have a bearing on the professional's profile and to
 work cooperatively with the insurer to improve performance.
   [(e)] (D) 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

 A. 4177                             5
 
 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.
   [(f)]  (E) Except as provided herein, no contract or agreement between
 an insurer and a health  care  professional  for  participation  in  the
 in-network  benefits  portion of an insurer's network for a managed care
 product shall contain any provision which shall supersede  or  impair  a
 health care professional's right to notice of reasons for termination OR
 NON-RENEWAL  and  the  opportunity  for a hearing concerning such termi-
 nation OR NON-RENEWAL.
   [(g)] (F) Any contract provision in violation of this section shall be
 deemed to be void and unenforceable.
   [(h)] (G) For purposes of this  section,  "health  care  professional"
 shall  mean a health care professional licensed, registered or certified
 pursuant to title eight of the education law.
   § 3. This act shall take effect immediately.