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

Section 2 amends subsection (e) of section 4804 of the insurance law to provide 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 providers, 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. Section 2 also amends subsection (f) of section 4804 of the Insurance Law to provide new insureds in an insurer's in-network benefits 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 3 amends section 4804 of the Insurance Law by adding new subdivisions (g) and (h) 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 4 amends paragraph (e) of subdivision 6 of section 4403 of the Public Health Law to provide 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, in the case of terminally ill patients, until such time of the patient's death.

Section 4 also amends paragraph (f) of subdivision 6 of section 4403 of the Public Health Law to provide new enrollees in an HMO 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 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 established by the HMO, adhere to the plan's quality assurance requirements and adhere to the organization's other policies and procedures.

Section 5 amends section 4403 of the Public Health Law by adding new subdivisions 7 and 8 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 6 amends subdivision 5 of section 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 7 contains the effective date, which is 120 days.

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 addition, 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 otherwise 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 deaths.

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 provider, 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 treatment 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 incentives to induce providers to act in a manner contrary to these statutes would be prohibited.

Legislative history

2007-08 - A.512 - Passed Assembly 2005-06- A.1240- Passed Assembly/S.2759 - Referred to Insurance 2003-04 - A.1l61 - Passed Assembly 2001-02: A.5880 - Passed Assembly/S.4845 Referred to Insurance

Fiscal implications

None to State.

Effective date

This act shall take effect 120 days after it becomes law.