Provides that no policy of group accident, group health or group accident and health shall impose copayments for physical or occupational therapy greater than the copay for similar services provided by a physician.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A405
SPONSOR: Cahill (MS)
 
TITLE OF BILL:
An act to amend the insurance law, in relation to physical therapy
services
 
PURPOSE:
To limit the imposition of co-payments for physical therapy services to
no more than twenty percent of the reimbursement to the provider of
care.
 
SUMMARY OF PROVISIONS:
Sections 1 through 5 prohibit payors from imposing costs on insureds for
the provision of physical therapy services in excess of 20 percent of
the reimbursement to the provider of care.
Section 6. Effective Date.
 
JUSTIFICATION:
This bill will protect consumers by prohibiting plans from inappropri-
ately shifting the cost of physical therapy care to consumers by limit-
ing co-payments to no more than 20 percent of the total reimbursement to
the provider of care. Under existing law, health plans must cover phys-
ical therapy services. Despite that requirement, health plans have
shifted the vast majority of the cost of physical therapy services by
imposing increasingly high co-payments on consumers. Under certain
health plans, co-payments for physical therapy services have exceeded
the reimbursement paid by the plan to the provider of care.
This cost shift has imposed a financial burden on consumers, and it has
restricted access to physical therapy services. Consumers frequently
cannot afford the cost imposed by these copayments for medically neces-
sary physical therapy care. Physical therapy services generally require
multiple visits over the healing process. A co-payment of $50 for a
physical therapy plan of care of 3 times a week for a month will cost
the consumer $600 in out-of-pocket expenses which is beyond the means of
many consumers. As a result, New Yorkers are forgoing medically neces-
sary care running the risk of worsening the underlying condition or
risking re-injury.
This bill would reestablish the obligation of health plans to cover the
expense of physical therapy services by limiting co-payments to no more
than twenty percent of the total reimbursement to the provider of care.
The 20 percent limitation will allow plans to require co-payments that
discourage inappropriate care but will prohibit plans from inappropri-
ately shifting the cost of physical therapy care to consumers.
 
LEGISLATIVE HISTORY:
2017-2018: A.569A - Referred to Insurance
2015-2016: A.1063A Referred to Insurance
2009-2010: A.8171A Referred to Insurance
2011-2012: A.187A - Amend and Recommit to Insurance
2013-2014: A.1666A - Amend and Recommit to Insurance
 
FISCAL IMPLICATIONS:
None.
 
EFFECTIVE DATE:
This act shall take effect on the one hundred eightieth day after it
shall have become a law.
STATE OF NEW YORK
________________________________________________________________________
405
2019-2020 Regular Sessions
IN ASSEMBLY(Prefiled)
January 9, 2019
___________
Introduced by M. of A. CAHILL, BARRETT, BLANKENBUSH, DiPIETRO, FAHY,
HUNTER, MALLIOTAKIS, B. MILLER, RIVERA, SANTABARBARA, STECK, WEPRIN --
Multi-Sponsored by -- M. of A. ABBATE, ABINANTI, ARROYO, BENEDETTO,
BRAUNSTEIN, COLTON, CRESPO, CROUCH, CUSICK, CYMBROWITZ, DINOWITZ,
ENGLEBRIGHT, GALEF, GARBARINO, GIGLIO, GOTTFRIED, GUNTHER, HAWLEY,
HEVESI, JAFFEE, LENTOL, LIFTON, LUPARDO, MAGNARELLI, McDONOUGH,
MOSLEY, OTIS, PALMESANO, PAULIN, PEOPLES-STOKES, PERRY, PRETLOW,
QUART, RAIA, RAMOS, L. ROSENTHAL, SIMON, STEC, STIRPE, THIELE, WOER-
NER, ZEBROWSKI -- read once and referred to the Committee on Insurance
AN ACT to amend the insurance law, in relation to physical therapy
services
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Paragraph 23 of subsection (i) of section 3216 of the
2 insurance law, as added by chapter 593 of the laws of 2000, is amended
3 to read as follows:
4 (23) If a policy provides for reimbursement for physical and occupa-
5 tional therapy service which is within the lawful scope of practice of a
6 duly licensed physical or occupational therapist, an insured shall be
7 entitled to reimbursement for such service whether the said service is
8 performed by a physician or through a duly licensed physical or occupa-
9 tional therapist, provided however, that nothing contained herein shall
10 be construed to impair any terms of such policy including appropriate
11 utilization review and the requirement that said service be performed
12 pursuant to a medical order, or a similar or related service of a physi-
13 cian. An insurer shall not impose a copayment or coinsurance amount
14 charged to the insured for services rendered for each date of service by
15 a physical therapist licensed under article one hundred thirty-six of
16 the education law or an occupational therapist licensed under article
17 one hundred fifty-six of the education law that is greater than the
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD01964-01-9
A. 405 2
1 copayment or coinsurance amount imposed on the insured for services
2 provided to the insured for an office visit for the service of a
3 licensed primary care physician or osteopath for the same or a similar
4 diagnosed condition even if a different nomenclature is used to describe
5 the condition for which the services are provided.
6 § 2. Subparagraph (A) of paragraph 1 of subsection (f) of section 4235
7 of the insurance law is amended by adding a new clause (iii) to read as
8 follows:
9 (iii) a policy shall not impose a copayment or coinsurance amount
10 charged to the insured for services rendered for each date of service by
11 a physical therapist licensed under article one hundred thirty-six of
12 the education law or an occupational therapist licensed under article
13 one hundred fifty-six of the education law that is greater than the
14 copayment or coinsurance amount imposed on the insured for services
15 provided to the insured for an office visit for the service of a
16 licensed primary care physician or osteopath for the same or a similar
17 diagnosed condition even if a different nomenclature is used to describe
18 the condition for which the services are provided.
19 § 3. Subparagraph (A) of paragraph 4 of subsection (f) of section 4235
20 of the insurance law, as amended by chapter 593 of the laws of 2000, is
21 amended to read as follows:
22 (A) any physical and occupational therapy service which is within the
23 lawful scope of practice of a licensed physical and occupational thera-
24 pist, a subscriber to such policy shall be entitled to reimbursement for
25 such service, whether the said service is performed by a physician or
26 licensed physical and occupational therapist pursuant to prescription or
27 referral by a physician. A policy shall not impose a copayment or coin-
28 surance amount charged to the insured for services rendered for each
29 date of service by a physical therapist licensed under article one
30 hundred thirty-six of the education law or an occupational therapist
31 licensed under article one hundred fifty-six of the education law that
32 is greater than the copayment or coinsurance amount imposed on the
33 insured for services provided to the insured for an office visit for the
34 service of a licensed primary care physician or osteopath for the same
35 or a similar diagnosed condition even if a different nomenclature is
36 used to describe the condition for which the services are provided;
37 § 4. Subparagraph (G) of paragraph 1 of subsection (b) of section 4301
38 of the insurance law, as amended by chapter 593 of the laws of 2000, is
39 amended to read as follows:
40 (G) physical and occupational therapy care provided through licensed
41 physical and occupational therapists upon the prescription of a physi-
42 cian, provided, however, that no copayment or coinsurance amount charged
43 to the insured for services rendered for each date of service by a phys-
44 ical therapist licensed under article one hundred thirty-six of the
45 education law or an occupational therapist licensed under article one
46 hundred fifty-six of the education law is greater than the copayment or
47 coinsurance amount imposed on the insured for services provided to the
48 insured for an office visit for the service of a licensed primary care
49 physician or osteopath for the same or a similar diagnosed condition
50 even if a different nomenclature is used to describe the condition for
51 which the services are provided,
52 § 5. Paragraph 13 of subsection (b) of section 4322 of the insurance
53 law, as added by chapter 504 of the laws of 1995, is amended to read as
54 follows:
55 (13) Outpatient physical therapy up to ninety visits per condition per
56 calendar year, provided, however, that no copayment or coinsurance
A. 405 3
1 amount charged to the insured for services rendered for each date of
2 service by a physical therapist licensed under article one hundred thir-
3 ty-six of the education law or an occupational therapist licensed under
4 article one hundred fifty-six of the education law is greater than the
5 copayment or coinsurance amount imposed on the insured for services
6 provided to the insured for an office visit for the service of a
7 licensed primary care physician or osteopath for the same or a similar
8 diagnosed condition even if a different nomenclature is used to describe
9 the condition for which the services are provided.
10 § 6. This act shall take effect on the one hundred eightieth day after
11 it shall have become a law.