S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   5278
 
                        2023-2024 Regular Sessions
 
                           I N  A S S E M B L Y
 
                               March 7, 2023
                                ___________
 
 Introduced  by M. of A. GUNTHER -- read once and referred to the Commit-
   tee on Insurance
 
 AN ACT to amend the insurance  law,  in  relation  to  health  insurance
   coverage of physical and occupational 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, FURTHER, THAT SUCH TERMS SHALL NOT IMPOSE CO-PAYMENTS IN
 EXCESS  OF  TWENTY PERCENT OF THE TOTAL REIMBURSEMENT TO THE PROVIDER OF
 CARE.
   § 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,
 item  (ii)  as amended by chapter 479 of the laws of 2022, 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
 physician  for  the  employee  or other member of the insured group, the

  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD09646-01-3
              

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 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,  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[.]; AND
   (III) 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.
   § 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, PROVIDED HOWEVER, THAT NO POLICY OF GROUP ACCI-
 DENT, 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;
   § 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. CO-PAYMENTS RELATED TO REIMBURSEMENT FOR SUCH SERVICES  SHALL  NOT
 EXCEED  TWENTY  PERCENT  OF  THE  TOTAL REIMBURSEMENT TO THE PROVIDER OF
 CARE,
   §  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.  ANY  CO-PAYMENTS  RELATED TO REIMBURSEMENT FOR PHYSICAL
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 THERAPY SERVICES SHALL NOT EXCEED TWENTY PERCENT OF THE TOTAL REIMBURSE-
 MENT TO THE PROVIDER OF CARE.
   § 6. This act shall take effect on the one hundred eightieth day after
 it shall have become a law.