S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   5129
 
                        2023-2024 Regular Sessions
 
                           I N  A S S E M B L Y
 
                               March 2, 2023
                                ___________
 
 Introduced by M. of A. DINOWITZ -- Multi-Sponsored by -- M. of A. COLTON
   -- read once and referred to the Committee on Insurance
 
 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,
 subsection (e) as amended by section 9 of subpart B of part AA of  chap-
 ter 57 of the laws of 2022 and subsection (f) 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  provide  written
 notice  to  the  insured of the provider's disaffiliation and permit the
 insured to continue [an ongoing course of  treatment  with]  TO  RECEIVE
 HEALTH  CARE  PROCEDURES,  TREATMENTS,  AND  SERVICES FROM the insured's
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD09883-01-3
              

 A. 5129                             2
 
 current health care provider during a transitional period of: (A) [nine-
 ty days] ONE YEAR from the later of  the  date  of  the  notice  to  the
 insured  of  the provider's disaffiliation from the insurer's network or
 the  effective  date of the provider's disaffiliation from the insurer's
 network; [or] (B) if the insured is pregnant at the time of the  provid-
 er's  disaffiliation, the duration of the pregnancy and post-partum care
 directly related to the delivery; OR (C) A TERMINAL  ILLNESS  OR  CONDI-
 TION, UNTIL THE TIME OF SUCH INSURED'S DEATH.
   (2) During the transitional period the health care provider shall: (A)
 continue  to accept reimbursement from the insurer at the rates applica-
 ble prior to the start of  the  transitional  period,  and  continue  to
 accept  the in-network cost-sharing from the insured, if any, as payment
 in full; (B) adhere to the insurer's quality assurance requirements  and
 provide  to  the  insurer  necessary medical information related to such
 care; and (C) otherwise adhere to the insurer's policies and  procedures
 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
 A. 5129                             3
 
 THIS  SECTION,  WHICH  ARE  INTENDED TO HAVE THE EFFECT OF INDUCING SUCH
 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, paragraph (e) as amended by section 10 of  subpart  B
 of  part AA of chapter 57 of the laws of 2022 and paragraph (f) 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  of  subdivision two of section forty-four hundred
 six-d of this [chapter] ARTICLE,  the  health  maintenance  organization
 shall provide written notice to the enrollee of the provider's disaffil-
 iation  and permit the enrollee to continue an [ongoing course of treat-
 ment with] TO RECEIVE HEALTH CARE PROCEDURES, TREATMENTS,  AND  SERVICES
 FROM  the  enrollee's current health care provider during a transitional
 period of:  (i) [ninety days] ONE YEAR from the later of the date of the
 notice to the enrollee of the provider's disaffiliation from the  organ-
 ization's network or the effective date of the provider's disaffiliation
 from  the  organization's network[;] or (ii) if the enrollee is pregnant
 at the time of the provider's disaffiliation, the duration of the  preg-
 nancy and post-partum care directly related to the delivery, OR (III) IF
 THE ENROLLEE HAS A TERMINAL ILLNESS OR CONDITION, UNTIL THE TIME OF SUCH
 ENROLLEE'S DEATH.
   (2) During the transitional period the health care provider shall: (i)
 continue  to  accept reimbursement from the health maintenance organiza-
 tion at the rates applicable prior to  the  start  of  the  transitional
 period,  and  continue  to  accept  the in-network cost-sharing from the
 enrollee, if any, as payment in full; (ii) adhere to the  organization's
 quality assurance requirements and to provide to the organization neces-
 sary  medical  information  related  to  such  care; and (iii) otherwise
 adhere to the organization's policies and procedures, including but  not
 limited  to  procedures regarding referrals and obtaining pre-authoriza-
 tion 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
 A. 5129                             4
 
 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
 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 10 and 11 to read as follows:
   10. 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.
   11. 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.