Relates to including certain out of home services such as transition from a hospital, nursing facility or other institutional setting to the home within home care insurance coverage

The bill maintains these baseline standards for coverage while updating the 40+ year-old specifications for: a covered individual's receipt of services, the listed services that certified/licensed agencies actually provide, and the cost and utilization control mechanisms now used by insurers.

Specifically, sections one and two of the bill, respectively, amend

§ 3221 and § 4303 of the insurance law to update the following in each section:

* Consistent with current hospital and medical care practice, the bill modernizes the specifications for the covered individual to be for an individual who requires services for: (i)transition from a hospital, nursing facility or other institutional setting to home;(ii) rehabilitation, recovery or medical management at home following hospitalization or institutional care; or (iii) medical management of a condition predisposing the covered individual to hospitalization or confinement in a nursing facility or to the need for other out-of-home services otherwise covered under the contract or policy if home care is not provided.

* Updates the reference to a home care agency's authorized list of services (now specified in § 3221 and § 4303 as nursing, home health aide, physical therapy, occupational therapy or speech therapy) to reflect other services the agency actually provides which include social work, respiratory therapy and nutritional counseling, which are likewise proven vital to cost-effective and necessary care in the modem delivery system.

* Replaces outdated mechanisms for utilization and cost controls (e.g., replaces the existing law's 40 visit minimum) with contemporary and more dynamic controls used in insurance and managed care, such as management or utilization review of home care benefits, or use of preauthorization and appropriateness criteria as to the level and intensity of treatment applicable to home care.

Section three of the bill provides for an effective date of January 1, 2006, and applicability to policies and contracts issued, renewed, modified or amended on or after such date.

Justification

This bill provides long overdue updates to antiquated sections of the State Insurance Law that stipulate the coverage for home care services.

The current home care coverage provisions, adopted in the early 1970s, were written and set forth for the health care system as it existed at that time.

In that era:

* Hospitals were reimbursed per diem and without today's limitations on length of stay; many of today's complex procedures did not exist, nor did cases of such brief, even same-day, turnarounds; patients being discharged were nowhere near today's level of continuing, intense and complex medical need.

* Nursing homes were the primary health system option for chronically ill, unlike today where home care plays a dominant role.

* Transition of patients from hospitals to home, or from nursing homes (particularly rehab patients) to home, was not the major, complex hurdle that it is today, nor the level of priority medical focus that today is addressed substantially through home care-hospital-physician partnership.

* Today's technologies for delivery of services and comprehensive medical management between physicians and home care agencies (such as telehealth/telemedicine) did not exist.

* Home care itself was not the integrated and heavily relied-upon model evidenced in today's system.

The type of system that framed the now 40+ year-old insurance law provisions bears little resemblance to the health care system of today.

This bill's modernization of the law would delineate the conditions of home care coverage consistent with today's state of the art health and medical care practices. It would support the operation of the entire health care system, synchronize coverage to the newest models and innovations of care, promote cost-savings and efficiency, and most importantly benefit covered individuals. It would also preserve and enhance the original statue's intent of utilizing home care to prevent avoidable hospitalizations, emergency room use and other higher cost medical services use.

Legislative history

New Bill

Fiscal implications

This bill will promote increased cost-efficiency and savings in the health care system.

Effective date

The bill would take effect January 1, 2017, and apply to policies and contracts issued, renewed, modified or amended on or after such date.