What's happening
This bill prohibits insurers from charging higher copayments or coinsurance for physical or occupational therapy than for primary care office visits for similar conditions.
Why it matters
Makes physical and occupational therapy more affordable for patients. by preventing insurers from setting higher out-of-pocket costs (copays or coinsurance) for these therapies compared to visits to primary care doctors for similar conditions. This could remove a significant financial barrier for people who need ongoing rehabilitation.
Addresses inequity in health coverage. by standardizing patient cost-sharing, regardless of whether care is delivered by a physician, physical therapist, or occupational therapist for the same diagnosis, even if insurance companies use different terminology. This reduces opportunities for insurers to shift costs to patients through technicalities.
Potentially encourages earlier and more consistent use of therapy services,. which can lead to better health outcomes and possibly lower long-term healthcare costs if patients are able to access necessary care without prohibitive costs.
Supports fair competition between healthcare providers. by ensuring that reimbursement structures do not unfairly disadvantage physical and occupational therapists compared to physicians, potentially expanding patient choice and access to appropriate care.
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Who cares
Headline styles
Cap Copays for Therapy
Plain English, a few words. Used as the page title.
Sponsors
History
- Referred to insurance
- Print number 5764a
- Amend and recommit to insurance
- Referred to insurance
Companion bill
The same bill in the other chamber. A bill becomes law when one version passes both houses and the governor signs it, so either number can carry it.
Limit Therapy Copays
In Assembly Committee · Insurance · Sponsor Kevin Cahill
Full text
3 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
5764--A
2017-2018 Regular Sessions
IN SENATE
April 28, 2017
Introduced by Sen. DeFRANCISCO -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee
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 Assembly, do enact as follows:
Section 1. Paragraph 23 of subsection (i) of section 3216 of the insurance law, as added by chapter 593 of the laws of 2000, is amended to read as follows:
(23) If a policy provides for reimbursement for physical and occupational therapy service which is within the lawful scope of practice of a duly licensed physical or occupational therapist, an insured shall be entitled to reimbursement for such service whether the said service is performed by a physician or through a duly licensed physical or occupational therapist, provided however, that nothing contained herein shall be construed to impair any terms of such policy including appropriate utilization review and the requirement that said service be performed pursuant to a medical order, or a similar or related service of a physician. An insurer shall not impose a copayment or coinsurance amount charged to the insured for services rendered for each date of service by a physical therapist licensed under article one hundred thirty-six of the education law or an occupational therapist licensed under article one hundred fifty-six of the education law that is greater than the copayment or coinsurance amount imposed on the insured for services provided to the insured for an office visit for the service of a licensed primary care physician or osteopath for the same or a similar diagnosed condition even if a different nomenclature is used to describe the condition for which the services are provided.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD01314-02-7
S. 5764--A 2
§ 2. Subparagraph (A) of paragraph 1 of subsection (f) of section 4235 of the insurance law is amended by adding a new clause (iii) to read as follows:
(iii) a policy shall not impose a copayment or coinsurance amount charged to the insured for services rendered for each date of service by a physical therapist licensed under article one hundred thirty-six of the education law or an occupational therapist licensed under article one hundred fifty-six of the education law that is greater than the copayment or coinsurance amount imposed on the insured for services provided to the insured for an office visit for the service of a licensed primary care physician or osteopath for the same or a similar diagnosed condition even if a different nomenclature is used to describe the condition for which the services are provided.
§ 3. Subparagraph (A) of paragraph 4 of subsection (f) of section 4235 of the insurance law, as amended by chapter 593 of the laws of 2000, is amended to read as follows:
(A) any physical and occupational therapy service which is within the lawful scope of practice of a licensed physical and occupational therapist, a subscriber to such policy shall be entitled to reimbursement for such service, whether the said service is performed by a physician or licensed physical and occupational therapist pursuant to prescription or referral by a physician. A policy shall not impose a copayment or coinsurance amount charged to the insured for services rendered for each date of service by a physical therapist licensed under article one hundred thirty-six of the education law or an occupational therapist licensed under article one hundred fifty-six of the education law that is greater than the copayment or coinsurance amount imposed on the insured for services provided to the insured for an office visit for the service of a licensed primary care physician or osteopath for the same or a similar diagnosed condition even if a different nomenclature is used to describe the condition for which the services are provided;
§ 4. Subparagraph (G) of paragraph 1 of subsection (b) of section 4301 of the insurance law, as amended by chapter 593 of the laws of 2000, is amended to read as follows:
(G) physical and occupational therapy care provided through licensed physical and occupational therapists upon the prescription of a physician, provided, however, that no copayment or coinsurance amount charged to the insured for services rendered for each date of service by a physical therapist licensed under article one hundred thirty-six of the education law or an occupational therapist licensed under article one hundred fifty-six of the education law is greater than the copayment or coinsurance amount imposed on the insured for services provided to the insured for an office visit for the service of a licensed primary care physician or osteopath for the same or a similar diagnosed condition even if a different nomenclature is used to describe the condition for which the services are provided,
§ 5. Paragraph 13 of subsection (b) of section 4322 of the insurance law, as added by chapter 504 of the laws of 1995, is amended to read as follows:
(13) Outpatient physical therapy up to ninety visits per condition per calendar year, provided, however, that no copayment or coinsurance amount charged to the insured for services rendered for each date of service by a physical therapist licensed under article one hundred thirty-six of the education law or an occupational therapist licensed under article one hundred fifty-six of the education law is greater than the copayment or coinsurance amount imposed on the insured for services
S. 5764--A 3
provided to the insured for an office visit for the service of a licensed primary care physician or osteopath for the same or a similar diagnosed condition even if a different nomenclature is used to describe the condition for which the services are provided.
§ 6. This act shall take effect on the one hundred eightieth day after it shall have become a law.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
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 inappropriately shifting the cost of physical therapy care to consumers by limiting co-payments to no more than 20 percent of the total reimbursement to the provider of care. Under existing law, health plans must cover physical 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 necessary 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 necessary 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 inappropriately shifting the cost of physical therapy care to consumers.
Legislative history
2009-2010 A.8171-A Referred to Insurance 2011-2012 S.4870A/A.187A 2013-2014 S.2319A/A.1666A 2015-2016 S.28A/A.1063A
Fiscal implications
None
Effective date
180 days after it shall have become a law.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.