A02210 Summary:

BILL NOA02210
 
SAME ASNo Same As
 
SPONSORGottfried
 
COSPNSRDinowitz, Englebright, Galef, Paulin, Cusick, Kavanagh, Rosenthal, Titone
 
MLTSPNSRAubry, Brennan, Colton, Cook, Cymbrowitz, Glick, Gunther, Hooper, Lifton, Perry, Rivera, Robinson
 
Amd S4406-c, Pub Health L; amd SS3217-b & 4325, Ins L
 
Relates to certain prohibitions in contracts or agreements by health maintenance organizations; prohibits clauses which entitle reimbursement at the lowest price or rate; prohibits contracts which restrict referral of patients based solely upon a health care provider's status with a managed care product; prohibits disclosure of an enrollee's diagnosis on a prescription as a condition for authorizing coverage for payment or dispensing of a prescription; and prohibits contracts which allow for the substitution of a pharmaceutical drug or agent by any person other than the prescribing health care professional.
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A02210 Actions:

BILL NOA02210
 
01/15/2015referred to health
03/03/2015reported referred to ways and means
05/27/2015reported
05/29/2015advanced to third reading cal.469
01/06/2016referred to health
01/21/2016reported
01/22/2016advanced to third reading cal.342
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A02210 Memo:

NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A2210
 
SPONSOR: Gottfried (MS)
  TITLE OF BILL: An act to amend the public health law and the insur- ance law, in relation to certain contracts or agreements by health main- tenance organizations   PURPOSE OR GENERAL IDEA OF BILL: This legislation would prohibit or restrict a number of practices between HMOs and Health Care Providers.   SUMMARY OF SPECIFIC PROVISIONS: This bill adds four new subdivisions to section 4406-c of the Public Health Law. Subdivision 6 would prohibit the use of "mast favored nation" clauses which arbitrarily lower reimbursement levels far the provision of health care services. Subdivisions 9 and 10 would ban the use of contract language which prohibits the ability of a physician to make referrals to other health care providers. Subdivision 11 would ban contract language which mandates the provision of a patient's diagnosis on the written prescription as a condition for covering a prescription drug. Subdivision 12 would prohibit insurers from mandating the substitution of a pharmaceutical agent (other than a generic equivalent) by any person other than the prescribing professional or a pharmacist with whom a prescribing physician has a collaboration agreement permitting substi- tution. The bill also makes the same changes to section 3217-b and 4325 of the Insurance Law.   JUSTIFICATION: Frequently, physicians and other health care providers provide health care to the uninsured and economically disadvantaged with very little or no compensation. Unfortunately, managed care insurance plans have created a disincentive to the provision of free and reduced cast care by inserting clauses into their contracts which requires a physician, or other health care provider, to accept reimbursement far a treatment/procedure at the lowest amount such provider has charged any entity far the same treatment. Consequently, if a physician wishes to only charge a nominal fee in a particular instance, that physician jeop- ardized his or her reimbursement far all of his or her patients. Physi- cians, hospitals, and other providers should be allowed and encouraged to provide charity care without endangering the future of their prac- tices. Insurance plans should not be permitted to control the referral process, which the treating physician uses to ensure that the patient is seen and treated by the mast appropriate medical professional. The issue of "in-network" or "out-of-network" providers should not be permitted to force treating physicians to refer to "in-network" providers only. While the plans may have different payment arrangements for in and out-of-net- work providers, an outright ban on out-of-network referrals is tanta- mount to a ban on the provision of sound medical advice. Some plans require the provision of the patient's diagnosis, on the prescription, in order to consider coverage for the pharmaceutical drug. Not only is this practice a gross violation of patient privacy, but it serves to break the bonds of confidence between the patient and physi- cians and can place some patients in the awkward position of having to choose between receiving important medications and divulging personal health information. In addition, a growing number of insurance plans are arbitrarily requiring the substitution of "similar" pharmaceutical agents (as opposed to generic equivalents.) This can be at the expense of the patient's health, as the prescribing professional may have, in fact, chosen a certain agent because of a particular quality or certain circumstances or symptoms surrounding the patient's case. Only a treat- ing professional, with full knowledge of the patient's history, should have authority to change a patient's medication.   PRIOR LEGISLATIVE HISTORY: 2002: A.10543 - advanced to 3rd reading 2003-2004: A.3446- passed Assembly 2005-2006: A.2204- passed Assembly 2007-2008: A.4607-B - passed Assembly 2009-2010: A.726-A - passed Assembly 2011-2012: A. 594 - passed Assembly 2013-2014: A4466-A - passed Assembly   FISCAL IMPLICATIONS: None   EFFECTIVE DATE: This act shall take effect 180 days after it shall have become law.
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A02210 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          2210
 
                               2015-2016 Regular Sessions
 
                   IN ASSEMBLY
 
                                    January 15, 2015
                                       ___________
 
        Introduced  by M. of A. GOTTFRIED, DINOWITZ, ENGLEBRIGHT, GALEF, PAULIN,
          CUSICK, KAVANAGH, ROSENTHAL, TITONE -- Multi-Sponsored by -- M. of  A.
          AUBRY,  BRENNAN,  COLTON,  COOK,  CYMBROWITZ, GLICK, GUNTHER, HEASTIE,
          HOOPER, LIFTON, PERRY, RIVERA, ROBINSON, SCARBOROUGH -- read once  and
          referred to the Committee on Health
 
        AN ACT to amend the public health law and the insurance law, in relation
          to certain contracts or agreements by health maintenance organizations
 
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
 
     1    Section 1. Subdivision 7 of section 4406-c of the public  health  law,
     2  as added by chapter 705 of the laws of 1996 and as renumbered by chapter
     3  487  of  the  laws  of  2010,  is renumbered subdivision 13 and four new
     4  subdivisions 9, 10, 11 and 12 are added to read as follows:
     5    9. No contract or agreement between a health care plan  and  a  health
     6  care  provider  shall contain any clause which entitles such health care
     7  plan to reimburse the health care provider at the lowest price  or  rate
     8  that  such health care provider has charged another person or entity for
     9  rendering the same treatment or performing the same procedure.
    10    10. No health care plan shall by contract, written policy  or  written
    11  procedure  prohibit any health care provider from referring a patient or
    12  enrollee to a health care provider based solely upon  such  health  care
    13  provider's participation status with the managed care product subscribed
    14  to by the patient or enrollee.
    15    11.  No  health care plan shall by contract, written policy or written
    16  procedure require  the  disclosure  of  an  enrollee's  diagnosis  on  a
    17  prescription  as  a condition for dispensing of a pharmaceutical drug or
    18  agent, unless otherwise required by law.
    19    12. No health care plan shall by contract, written policy or procedure
    20  provide for or allow the substitution of a pharmaceutical drug or  agent
    21  (other  than  a  generic  substitution)  by  any  person  other than the
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD02982-01-5

        A. 2210                             2
 
     1  prescribing health care professional or by a  pharmacist  under  section
     2  sixty-eight hundred one-a of the education law.
     3    §  2.  Subsections (h) and (i) of section 3217-b of the insurance law,
     4  as relettered by chapter  237  of  the  laws  of  2009,  are  relettered
     5  subsections  (m)  and (n) and four new subsections (h), (i), (k) and (l)
     6  are added to read as follows:
     7    (h) No contract or agreement between an  insurer  and  a  health  care
     8  provider  shall  contain any clause which entitles such insurer to reim-
     9  burse the health care provider at the lowest price  or  rate  that  such
    10  health  care provider has charged another person or entity for rendering
    11  the same treatment or performing the same procedure.
    12    (i) No insurer shall by contract, written policy or written  procedure
    13  prohibit  any health care provider from referring an insured to a physi-
    14  cian based solely upon such physician's participation  status  with  the
    15  insurance product subscribed to by the insured.
    16    (k)  No insurer shall by contract, written policy or written procedure
    17  require the disclosure of an insured's diagnosis on a prescription as  a
    18  condition for authorizing the coverage for or payment or dispensing of a
    19  pharmaceutical drug or agent, unless otherwise required by law.
    20    (l)  No  insurer  which maintains a drug formulary, or which contracts
    21  with another entity to maintain a drug  formulary,  shall  by  contract,
    22  written  policy  or procedure provide for or allow the substitution of a
    23  pharmaceutical drug or agent (other than a generic substitution) by  any
    24  person other than the prescribing health care professional or by a phar-
    25  macist under section sixty-eight hundred one-a of the education law.
    26    §  3. Subsections (i) and (j) of section 4325 of the insurance law, as
    27  relettered  by  chapter  487  of  the  laws  of  2010,  are   relettered
    28  subsections  (n)  and (o) and four new subsections (i), (j), (l) and (m)
    29  are added to read as follows:
    30    (i) No contract or agreement between an  insurer  and  a  health  care
    31  provider  shall  contain any clause which entitles such insurer to reim-
    32  burse the health care provider at the lowest price  or  rate  that  such
    33  health  care provider has charged another person or entity for rendering
    34  the same treatment or performing the same procedure.
    35    (j) No insurer shall by contract, written policy or written  procedure
    36  prohibit  any health care provider from referring an insured to a physi-
    37  cian based solely upon such physician's participation  status  with  the
    38  insurance product subscribed to by the insured.
    39    (l)  No insurer shall by contract, written policy or written procedure
    40  require the disclosure of an insured's diagnosis on a prescription as  a
    41  condition for authorizing the coverage for or payment or dispensing of a
    42  pharmaceutical drug or agent, unless otherwise required by law.
    43    (m)  No  insurer  which maintains a drug formulary, or which contracts
    44  with another entity to maintain a drug  formulary,  shall  by  contract,
    45  written  policy  or procedure provide for or allow the substitution of a
    46  pharmaceutical drug or agent (other than a generic substitution) by  any
    47  person other than the prescribing health care professional or by a phar-
    48  macist under section sixty-eight hundred one-a of the education law.
    49    § 4. This act shall take effect on the one hundred eightieth day after
    50  it  shall have become a law, provided that the relettering of subsection
    51  (n) of section 3217-b and the relettering of subsection (o)  of  section
    52  4325  of  the  insurance law made by sections two and three of this act,
    53  respectively, shall not affect the repeal of such subsections and  shall
    54  be deemed repealed therewith.
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