BILL NUMBER: S1544

SPONSOR: COMRIE
 
TITLE OF BILL:

An act to amend the social services law, in relation to requiring Medi-
care and Medicaid managed care providers to provide coverage for out-of-
network health care under certain circumstances

 
PURPOSE:

To allow patients who have established a long term relationship with
their health care providers to continue to receive treatment from their
health care provider if the health care provider is no longer an in
network provider.

 
SUMMARY OF PROVISIONS:

Section one of the bill states that the act shall be known and may be
cited as the "patient choice of health care provider protection act."

Section two of the bill amends clause (F) of subparagraph (iii) of para-
              

graph (a) of subdivision 4 of § 364-j of the social services law to
require that managed care providers approve a single patient agreement
between a patient and their healthcare professional, regardless if the
health care professional is or is not a provider under the patient's
managed provider network, when requested by a patient who has estab-
lished a long term relationship with the healthcare professional. This
section also requires that the healthcare professional be paid the
managed care provider's in network rates. This section further defines
"long term relationship" to mean a treatment relationship of longer than
ninety days and where the healthcare professional provided medical
assistance to the patient at least ten times. This section also stipu-
lates that the provisions of this clause shall not apply if the managed
care provider has been made aware of any reported allegations of fraud,
abuse, or malpractice by the health care provider. In addition, this
section requires that coverage be included at the time of application
for medical assistance under this article, or, for coverage already in
effect, on any anniversary date of the coverage subject to evidence of
eligibility for medical assistance under this article.  Finally, this
section states that the coverage may be subject to annual deductibles
and co-payments as deemed appropriate by the commissioner of health and
as are consistent with those established for other benefits for medical
assistance under this article.

Section three of the bill provides the effective date.

 
JUSTIFICATION:

Requiring insurance policies to provide coverage for out of network
health care providers under certain circumstances will permit the
patient to have more deference into their health care during their time
of need. An individual should be able to have control over his or her
entire medical selection process especially during critical stages when
the only aspect the public may be able to control, is the health care
professional that asses them with their medical issues.  This prevents
state funded insurance companies from removing a primary care physician
from the public use with lack of reasoning.  This re-establishes the
patients comfort as their primary concern.  Absent fraud or possible
indicators of medical malpractice, a providers networks unilateral deci-
sion to terminate the services obtained by a health care professional
should never take priority over the benefits of health care constituen-
cy, and the trusted established rapport between a patient and his or her
health care giver, whether its developed directly through his or her own
experiences or through another sources referral.

 
PRIOR LEGISLATIVE HISTORY:

2022: S3735

 
FISCAL IMPLICATIONS:

To be determined.

 
EFFECTIVE DATE:;
Ninetieth day after becoming law.