NY State Senate Bill 2023-S6576

Senate Bill S6576

2023-2024 Legislative Session

Provides for a right of health maintenance organization enrollees to continue to receive services from a provider who disaffiliates

download bill text pdf

Current Bill Status - In Senate Committee Insurance Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 03, 2024	referred to insurance
Apr 27, 2023	referred to insurance

2023-S6576 (ACTIVE) - Details

See Assembly Version of this Bill:: A5129
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§4803 & 4804, Ins L; amd §§4403 & 4406-d, Pub Health L
Versions Introduced in Other Legislative Sessions:: 2009-2010: A633
2011-2012: A1808
2013-2014: A366
2015-2016: A1932
2017-2018: A256
2019-2020: A5033
2021-2022: A2299

2023-S6576 (ACTIVE) - Summary

Extends period during which health maintenance organization enrollees may continue to receive services from a health care provider who disaffiliates from 60 or 90 days to 1 year, or in case of terminal illness, until the time of such insured's death; bars incentives which induce a provider to provide health care to an enrollee in a manner inconsistent with law.

2023-S6576 (ACTIVE) - Sponsor Memo

                                 
BILL NUMBER: S6576

SPONSOR: COMRIE
 
TITLE OF BILL:

An act to amend the insurance law and the public health law, in relation
to access to health care providers in managed care plans

 
PURPOSE:

To provide patients who are enrolling in a managed care plan the oppor-
tunity to have access to their current health care provider and, simi-
larly, to allow patients whose health care providers are excluded from a
managed care plan's panel of providers to continue to see that health
care professional for a limited period of time.

 
SUMMARY OF PROVISIONS:

Section one of the bill amends subsection (e) of § 4803 of the insurance
law to provide that an insurer may not terminate a contract for partic-
ipation in the in-network benefits portion of an insurer's managed care
network, or refuse to renew such contract, solely because a health care

provider has issued an opinion relating to whether or not a patient is
terminally ill.

Section two of the bill amends subsections (e) and (f) of § 4804 of the
insurance law. Subsection (e) provides that if a health care provider in
an insurer's in-network benefits portion of a managed care product
either leaves the network or is excluded from the HMO's panel of provid-
ers, after having been affiliated with such managed care product, that
provider's patients may continue to receive health care services from
him or her for a period of up to one year, or, in the case of terminally
ill patients, until such time of the patient's death.

Subsection (f) provides new insured's in an insurer's in-network bene-
fits portion of a provider network the option to continue to receive
health care services from his or her current health care provider for a
period of up to one year, or, in the case of terminally ill patients,
until such time of the patient's death. In both instances, this access
to continuity of care will not be available if the health care provider
has been disenrolled from the managed care plan for a reason involving
imminent harm to a patient, fraud or disciplinary action by a state
licensing board.Moreover, the access to continuity of care will only
take effect upon the attending health care provider's agreement to
accept the reimbursement rate established by the HMO, adhere to the
plan's quality assurance requirements and adhere to the organization's
other policies and procedures.

Section three of the bill adds subsections (g) and (h) to § 4804 of the
insurance law to define the term "terminal illness or condition" and, in
keeping with the provisions the Legislature enacted with the mastectomy
treatment legislation, to prohibit offensive financial arrangements.

Section four of the bill amends paragraphs (e) and (f) of subdivision 6
of § 4403 of the public health law. Paragraph (e) provides that if a
health care provider in a health maintenance organization network either
leaves the network or is excluded from the HMO's panel of providers,
after having been affiliated with such HMO, that provider's patients may
continue to receive health care services from him or her for a period of
up to one year, or, if the insured has entered the second trimester of
pregnancy until the patient has received post-partum care directly
related to the delivery, or, in the case of terminally ill patients,
until such time of the patient's death.

Paragraph (f) provide new enrollees in an HMO the option to continue to
receive health care services from his or her current healthcare provider
for a period of up to one year, or, in the case of terminally ill
patients, until such time of the patient's death.

In both paragraphs, this access to continuity of care will not be avail-
able if the health care provider has been disenrolled from the managed
care plan for a reason involving imminent harm to a patient, fraud or
disciplinary action by a state licensing board.  Additionally, the
access to continuity of care will only take effect upon the attending
health care provider's agreement to accept the reimbursement rate estab-
lished by the HMO, adhere to the plan's quality assurance requirements
and adhere to the organization's other policies and procedures.

Section five of the bill adds subdivisions 10 and 11 to § 4403 of the
public health law to define the term "terminal illness or condition"
and, in keeping with the provisions the Legislature enacted with the
mastectomy treatment legislation, to prohibit offensive financial
arrangements.

Section six of the bill amends subdivision 5 of § 4406-d of the public
health law to provide that a health care plan may not terminate a
contract for employment, or refuse to renew such contract, solely
because a health care provider has issued an opinion relating to whether
or not a patient is terminally ill.

Section seven of the bill provides the effective date.

 
JUSTIFICATION:

This bill proposed to build upon the historic changes made on behalf of
health care consumers in the 1995 Managed Care Reform Act.

Included among the numerous provisions of that Act was a provision that
patients undergoing a course of treatment could continue that treatment
with their health care provider for 90 days, if the provider became
disaffiliated with the HMO provider panel or for 60 days if the person
enrolled in an HMO which did not have a provider on its panel. In addi-
tion, the Act provided for continuity of care for pregnant women who had
entered their second trimester of pregnancy, through the provision of
post-partum care.

This bill would expand those provisions in ways which meaningfully add
to the continuity of a patient's care. It would do so by allowing a
patient to continue an established relationship with his or her health-
care provider for up to one year following a change which would other-
wise deny access to the provider. In the case of terminally ill
patients, this proposal would allow such patients to continue to receive
care from their current provider until the time of their death.

In virtually every situation where a patient has an established, ongoing
relationship with his or her health care provider (which would likely
cause such patient to exercise the option provided by this bill) the
provision of health care services is both enhanced and streamlined with
the provider's familiarity with the patient. A deep understanding of a
patient's history, previous treatments and attitude are important
factors which assist a health care provider in making clinical decisions
which are likely to be of benefit to the patient.

In the case of terminally ill patients, this proposal would allow such
people to have the comfort of being ministered to by a familiar provid-
er, which may help to ease the trauma and increase the comfort of the
terminal patient. Importantly, this bill would not add to the expense of
health insurance either purchased by the individual or by an employer)
because it does not mandate coverage where none exists.

In addition, this measure would not add to the cost of the HMO or other
managed care entity providing care.In every instance addressed in this
bill, the insurer is receiving payment for the health care of the
insured in question. The only issue addressed is who will provide treat-
ment to the patient. Inasmuch as this bill would not change current law
which mandates the provider to continue to accept the reimbursement set
by the insurer (which cannot be more than the reimbursement paid to
in-plan providers) there is no added expense to the insurer, with the
minor exception of some additional administrative work.

This bill further protects both the patient and the HMO by making the
continuity of care an option to be exercised by the patient (not a
mandatory benefit) and providing that this option would not apply to
providers who have been disenrolled for reasons related to incompetence,
criminal action or professional misconduct.

Finally, this bill increases the applicability of provisions prohibiting
offensive financial arrangements enacted in early 1997 so that incen-
tives to induce providers to act in a manner contrary to these statutes
would be prohibited.

 
PRIOR LEGISLATIVE HISTORY:

2021-22: A.2299 - Health

2019-20: A.5033 - Health

2017-18: A.256 - Third Reading Calendar

2015-16: A.1932 - Third Reading Calendar

2013-14: A.366-B - Third Reading Calendar

2011-12: A.1808 - Passed Assembly

2009-10: A.633 - Passed Assembly / S.4059 Insurance

2005-06: A.1240 - Passed Assembly / S.2759 - Insurance

2003-04: A.1161 - Passed Assembly

2001-02: A.5880 - Passed Assembly / S.4845 - Insurance

 
FISCAL IMPLICATIONS:

None to the State.

 
EFFECTIVE DATE:
One hundred twentieth day after becoming law and shall apply to all
contracts issued, renewed, modified or amended on and after such date.

2023-S6576 (ACTIVE) - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   6576
 
                        2023-2024 Regular Sessions
 
                             I N  S E N A T E
 
                              April 27, 2023
                                ___________
 
 Introduced  by  Sen.  COMRIE -- read twice and ordered printed, and when
   printed to be committed 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

 S. 6576                             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
 S. 6576                             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
 S. 6576                             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.

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