What's happening
This bill allows Medicaid to cover more than the annual limit of therapy visits if medically necessary, as certified by a professional.
Why it matters
This bill increases flexibility for Medicaid recipients who need more therapy than the current annual caps allow, helping those with ongoing or worsening conditions avoid being cut off from necessary care.
By allowing licensed professionals to certify medical necessity, the bill empowers clinicians—not bureaucratic rules—to determine what level of therapy a patient actually needs.
Patients who don’t have developmental disabilities or traumatic brain injuries (who already had exceptions) will now have a pathway to get extended therapy if their condition justifies it, expanding equitable access to vital rehabilitative services.
This change could reduce hospitalizations or complications by ensuring continuous therapy, potentially lowering long-term healthcare costs and improving quality of life for Medicaid recipients.
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Who cares
Headline styles
Expand Medicaid Therapy Visits
Plain English, a few words. Used as the page title.
Sponsors
No co-sponsors yet.
History
- Referred to health
Full text
1 pageUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
8300
IN SENATE
April 27, 2018
Introduced by Sen. COMRIE -- read twice and ordered printed, and when printed to be committed to the Committee on Health
AN ACT to amend the social services law, in relation to providing extended speech, physical or occupational therapy under Medicaid
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Paragraph (h) of subdivision 2 of section 365-a of the social services law, as amended by section 5 of part A of chapter 57 of the laws of 2018, is amended to read as follows:
(h) speech therapy, and when provided at the direction of a physician or nurse practitioner, physical therapy including related rehabilitative services and occupational therapy; provided, however, that speech therapy and occupational therapy each shall be limited to coverage of twenty visits per year; physical therapy shall be limited to coverage of forty visits per year unless the professional at whose direction the therapy or services are provided or the provider of the therapy or services attests to the medical necessity of additional visits; such limitation shall not apply to persons with developmental disabilities or, notwithstanding any other provision of law to the contrary, to persons with traumatic brain injury;
§ 2. This act shall take effect on the one hundred eightieth day after it shall have become a law; provided that, effective immediately, the addition, amendment, and/or repeal of any rules and regulations necessary to implement the provisions of this act on its effective date are authorized and directed to be completed on or before such effective date.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD11217-03-8
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
Title of bill
An act to amend the social services law, in relation to providing extended speech, physical or occupational therapy under Medicaid
Purpose
This bill enables patients to receive coverage of medically necessary speech, physical, and occupational therapy services under Medicaid beyond the 20-visit annual limit.
Summary of provisions
Section one amends Social Services L. 5 365-a(2)h) to allow exceeding the Medicaid limit of 20 therapy visits a year for speech, physical, or occupational therapy for a patient, if the physician or nurse practi- tioner who ordered the therapy attests to the medical necessity of more sessions.
Justification
The 20-visit limit on Medicaid coverage for speech, physical, and occu- pational therapy has resulted in countless denials of medically neces- sary treatment. For many individuals, reaching the twenty-visit cap means forgoing crucial therapy until the next calendar year, which may be months away. Without regular therapy, many individuals lose the progress they had made and even deteriorate. It has left Medicaid recip- ients with disabilities unable to maintain a level of functioning they once had, forced victims of accidents into lifelong pain without the means to regain full functioning, prevented individuals from fully recovering after surgery, and kept people from being able to return to work.
New York Medicaid's speech, physical, and occupational therapy cap is completely out of step with what is happening in commercial insurance and in Medicare. Medicare places an annual dollar limit on coverage of the three therapies but, critically, provides for an exception process allowing coverage beyond the dollar limit where additional therapies are medically necessary.
As part of the required essential health benefits in New York, small group and individual health insurance plans, including qualified health plans and the Essential Plan, currently have a sixty-visit limit on rehabilitative speech, physical, and occupational therapies, and an additional sixty visits per year in a habilitative services benefit for the three therapies.
Managed care plans, through their Medicare Advantage products, are already familiar with exceptions processes sought for these same thera- pies in Medicare. By establishing an exception to the limit, New York will give Medicaid recipients the ability to maintain and improve their functioning so that they can participate to their maximum capacity in daily life. The Medicaid program should no longer seek savings at the expense of individuals. ability to avoid pain, recover from surgery, prevent physical decline, and return to work.
Legislative history
New bill.
Fiscal implications
To be determined. The cost of additional therapy will be offset by the improved health of patients and increased ability to return to taxpaying employment.
Effective date
180 days.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.