What's happening
This bill limits co-payments for physical and occupational therapy to 20% of provider reimbursement, establishes exceptions for visit limits, and increases transparency in health insurance utilization review processes.
Why it matters
Caps out-of-pocket costs. By limiting co-payments for physical and occupational therapy to 20% of the provider’s reimbursement, the bill directly reduces financial barriers for patients, making necessary therapy more accessible and potentially improving recovery outcomes.
Protects access to ongoing therapy. The bill establishes a formal exceptions process for visit limits, allowing patients whose discontinuation of therapy would likely cause harm or further disability—confirmed by a physician—to continue receiving care beyond standard limits. This is crucial for individuals with chronic or severe conditions.
Enhances transparency and fairness in insurance practices. Insurers and health plans must now provide clear clinical review criteria and standards for utilization review upon provider request, and any changes must be reported promptly. This empowers providers to better advocate for their patients and helps ensure denials or restrictions are based on understandable, consistent standards.
Strengthens provider protections. The bill prohibits insurance plans from retaliating against providers who advocate for patients, appeal insurance decisions, or deliver medically necessary care. This safeguards the provider-patient relationship and supports ethical medical advocacy without fear of contract termination or non-renewal.
Albany, before your first meeting.
Every bill that moved yesterday, summarized in a sentence and ranked by impact. The Albany Scorecard follows on Sundays.
Free. Unsubscribe in one click. Want alerts on specific bills? Create an account.
Who cares
Patients receiving physical or occupational therapy
The bill would cap therapy copayments at 20 percent of total provider reimbursement and require an exceptions process for visit limits that includes physician certification of likely disability or harm if services stop.
Physical therapists, occupational therapists and other participating health care providers
The bill would require plans to disclose clinical review criteria upon written request and strengthen protections against retaliation for patient advocacy or ordering or providing medically necessary care.
Health insurers and health care plans
The bill would impose new coverage and utilization review requirements, including outpatient occupational therapy coverage of up to 90 visits per condition per calendar year under the amended benefit provision.
Families using early intervention services
The bill would remove language preserving other policy terms and conditions for early intervention coverage while retaining visit limits and the protection against those visits reducing visits otherwise available.
Headline styles
Expand Therapy Insurance Coverage
Plain English, a few words. Used as the page title.
Sponsors
3 Co-sponsors
History
- Referred to insurance
Companion bills
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.
Expand Therapy Insurance Coverage
In Senate Committee · Insurance · Sponsor Neil D. Breslin
Expand Therapy Insurance Coverage
In Assembly Committee · Insurance · Sponsor Aileen Gunther
Full text
5 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
964
2019-2020 Regular Sessions
IN SENATE
January 9, 2019
Introduced by Sens. YOUNG, ADDABBO, KAMINSKY, KENNEDY -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance
AN ACT to amend the insurance law, in relation to health insurance coverage of physical and occupational therapy services and payment for early intervention services; and to amend the insurance law and the public health law, in relation to the provision of medically necessary care and utilization review
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 provided, further, that such terms shall not impose co-payments in excess of twenty percent of the total reimbursement to the provider of care. Visit limits for physical and occupational therapy services shall be subject to an exceptions process, that shall include the insured's physician certifying that the cessation of services would most likely result in further disability or harm to the insured. Any exceptions process shall be further determined by the superintendent.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD00572-01-9
S. 964 2
§ 2. Subsection (b) of section 3235-a of the insurance law, as added by section 3 of part C of chapter 1 of the laws of 2002, is amended to read as follows:
(b) Where a policy of accident and health insurance, including a contract issued pursuant to article forty-three of this chapter, provides coverage for an early intervention program service, such coverage shall not be applied against any maximum annual or lifetime monetary limits set forth in such policy or contract. Visit limitations [and other terms and conditions of the policy] will continue to apply to early intervention services. However, any visits used for early intervention program services shall not reduce the number of visits otherwise available under the policy or contract for such services.
§ 3. Clause (ii) of subparagraph (A) of paragraph 1 of subsection f of section 4235 of the insurance law, as amended by chapter 219 of the laws of 2011, is amended to read as follows:
(ii) a policy under which coverage terminates at a specified age shall not so terminate with respect to an unmarried child who is incapable of self-sustaining employment by reason of mental illness, developmental disability, mental retardation, as defined in the mental hygiene law, or physical handicap and who became so incapable prior to attainment of the age at which coverage would otherwise terminate and who is chiefly dependent upon such employee or member for support and maintenance, while the insurance of the employee or member remains in force and the child remains in such condition, if the insured employee or member has within thirty-one days of such child's attainment of the termination age submitted proof of such child's incapacity as described [herein] in this clause. No policy of group accident, group health or group accident and health insurance shall impose co-payments in excess of twenty percent of the total reimbursement to the provider of care. Visit limits for physical and occupational services shall be subject to an exceptions process, that shall include an insured's physician certifying that the cessation of services would most likely result in further disability or harm to the insured. Any exceptions process shall be further determined by the superintendent.
§ 4. 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. No policy of group accident, group health or group accident and health insurance shall impose co-payments in excess of twenty percent of the total reimbursement to the provider of care. Visit limits for physical and occupational therapy services shall be subject to an exceptions process, that shall include an insured's physician certifying that the cessation of services would most likely result in further disability or harm to the insured. Any exceptions process shall be further determined by the superintendent;
§ 5. 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. Co-payments related to reimbursement for such services shall not
S. 964 3
exceed twenty percent of the total reimbursement to the provider of care. Visit limits for physical and occupational therapy services shall be subject to an exceptions process, that shall include the covered person's physician certifying that the cessation of services would most likely result in further disability or harm to the covered person. Any exceptions process shall be further determined by the superintendent,
§ 6. Paragraph 13 of subsection (b) of section 4322 of the insurance law, as added by chapter 504 of the laws of 1995, is amended and a new paragraph 13-a is added to read as follows:
(13) Outpatient physical therapy up to ninety visits per condition per calendar year. Any co-payments related to reimbursement for physical therapy services shall not exceed twenty percent of the total reimbursement to the provider of care. Visit limits for physical therapy services shall be subject to an exceptions process, that shall include the covered person's physician certifying that the cessation of services would most likely result in further disability or harm to the covered person. Any exceptions process shall be further determined by the superintendent.
(13-a) Outpatient occupational therapy up to ninety visits per condition per calendar year. Any co-payments related to reimbursement for occupational therapy services shall not exceed twenty percent of the total reimbursement to the provider of care. Visit limits for occupational therapy services shall be subject to an exceptions process, that shall include the covered person's physician certifying that such cessation of services would most likely result in further disability or harm to the covered person. Any exceptions process shall be further determined by the superintendent.
§ 7. Subsection (e) of section 4803 of the insurance law, as added by chapter 705 of the laws of 1996, is amended and a new subsection (a-1) is added to read as follows:
(a-1) Upon written request by a participating health care professional, a health care plan shall provide specific written clinical review criteria relating to a particular condition, disease, service or procedure and, where appropriate, other clinical information which the health care plan or its utilization review agent might consider in its utilization review and the health care plan shall include with the information a description of how it will be used in the utilization review process; provided, however, that to the extent such information is proprietary to the health care plan, the participating health care provider or prospective health care provider shall only use the information for the purposes of assisting the participating health care provider in evaluating covered services provided by the organization, an adverse determination or an appeal of adverse determination.
(e) No insurer shall terminate [or], threaten to terminate, refuse to renew or threaten refusal to renew a contract for participation in the in-network benefits portion of an insurer's network for a managed care product [solely] because the health care professional has (1) advocated on behalf of an insured; (2) has filed a complaint against the insurer; (3) has appealed a decision of the insurer; (4) provided information or filed a report pursuant to section forty-four hundred six-c of the public health law; [or] (5) requested a hearing or review pursuant to this section; or (6) ordered or rendered medically necessary care.
§ 8. Paragraph 1 of subsection (b) of section 4901 of the insurance law, as added by chapter 705 of the laws of 1996, is amended to read as follows:
S. 964 4
(1) The utilization review plan, including but not limited to the clinical review criteria and standards and the definition/standards of medical necessity used under the utilization review plan. A utilization review agent shall report any amendment or changes to the utilization review plan to the superintendent within thirty days of making such amendment or change;
§ 9. Paragraph 4 of subsection (a) of section 4902 of the insurance law, as added by chapter 705 of the laws of 1996, is amended to read as follows:
(4) Establishment of a process for rendering utilization review determinations which shall, at a minimum, include: written procedures to assure that utilization reviews and determinations are conducted within the timeframes established herein; procedures to notify an insured, an insured's designee [and/or] and an insured's health care provider of adverse determinations; and procedures for appeal of adverse determinations including the establishment of an expedited appeals process for denials of continued inpatient care or where there is imminent or serious threat to the health of the insured;
§ 10. The opening paragraph of subsection (d) of section 4905 of the insurance law, as added by chapter 705 of the laws of 1996, is amended to read as follows:
A utilization review agent or the health care plan for which the agent provides utilization review shall not, with respect to utilization review activities, permit or provide compensation or anything of value to its employees, agents, or contractors based on:
§ 11. Subdivision 5 of section 4406-d of the public health law, as added by chapter 705 of the laws of 1996, is amended and a new subdivision 1-a is added to read as follows:
1-a. Upon written request by a participating health care professional, a health care plan shall provide specific written clinical review criteria relating to a particular condition, disease, service or procedure and, where appropriate, other clinical information which the health care plan or its utilization review agent might consider in its utilization review and the health care plan shall include with the information a description of how it will be used in the utilization review process; provided, however, that to the extent such information is proprietary to the health care plan, the participating health care provider or prospective health care provider shall only use the information for the purposes of assisting the participating health care provider in evaluating covered services provided by the organization, an adverse determination or an appeal of adverse determination.
5. No health care plan shall terminate, or threaten to terminate a contract or employment, [or] refuse to renew, or threaten refusal to renew a contract, [solely] because a health care provider has:
(a) advocated on behalf of an enrollee;
(b) filed a complaint against the health care plan;
(c) appealed a decision of the health care plan;
(d) provided information or filed a report pursuant to section fortyfour hundred six-c of this article; [or]
(e) requested a hearing or review pursuant to this section; or
(f) ordered or rendered medically necessary care.
§ 12. Paragraph (a) of subdivision 2 of section 4901 of the public health law, as added by chapter 705 of the laws of 1996, is amended to read as follows:
(a) The utilization review plan, including but not limited to the clinical review criteria and standards and the definition/standards of
S. 964 5
medical necessity used under the utilization review plan. A utilization review agent shall report any amendment or changes to the utilization review plan to the commissioner within thirty days of making such amendment or change;
§ 13. Paragraph (d) of subdivision 1 of section 4902 of the public health law, as added by chapter 705 of the laws of 1996, is amended to read as follows:
(d) Establishment of a process for rendering utilization review determinations which shall, at a minimum, include: written procedures to assure that utilization reviews and determinations are conducted within the timeframes established herein; procedures to notify an enrollee, an enrollee's designee [and/or] and an enrollee's health care provider of adverse determinations; and procedures for appeal of adverse determinations including the establishment of an expedited appeals process for denials of continued inpatient care or where there is imminent or serious threat to the health of the enrollee;
§ 14. The opening paragraph of subdivision 4 of section 4905 of the public health law, as added by chapter 705 of the laws of 1996, is amended to read as follows:
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 health insurance coverage of physical and occupational therapy services and payment for early intervention services; and to amend the insurance law and the public health law, in relation to the provision of medically necessary care and utilization review
Purpose or general idea of bill
To limit the imposition of co-payments for physical and occupational therapy services to no more than twenty percent of the reimbursement to the provider of care. Provides greater disclosure of utilization prac- tices and to prohibit certain practices.
Summary of provisions
Sections 1 through 5 prohibit payors from imposing higher co-pays on consumers for physical and occupational therapy services on the basis of provider or setting.
Read the full memo (804 words)
Sections 6 and 7 would prohibit health care plans from compensating utilization review agents on a percentage basis or other method which would provide a financial incentive to deny claims.
Sections 8 and 9 prohibit a health plan from terminating or refusing to renew a contract on the basis that a provider offered or rendered medically necessary care.
Sections 10 and 11 require utilization review agents to provide adverse determinations to both the provider and the enrollee.
Sections 12 and 13 require utilization review agents to report to the Department of Health and Department of Insurance respectively the clin- ical review criteria and standards and the definition of medical neces- sity used under the utilization plan. Sections 12 and 13 also require utilization review agents to report any amendments to their utilization review plan within thirty days of such amendment.
Sections 14 and 15 allow a health care provider to request clinical review criteria and other clinical information which the health care plan might consider in its utilization review.
Section 16. Effective Date.
Justification
This bill will protect consumers by prohibiting plans from inappropri- ately shifting the cost of therapy care to consumers. It limits co-pay- ments to no more than 20 percent of the total reimbursement to the provider of care. Under existing law, health plans must cover physical and occupational therapy services. Despite that requirement, health plans have shifted the vast majority of the cost of physical and occupa- tional therapy services by imposing increasingly high co-payments on consumers. Under certain health plans, co-payments for 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, affected access to physical and occupational therapy services and defeated the purpose of insurance coverage.
Consumers frequently cannot afford the cost imposed by these copayments for medically necessary physical and occupational therapy care. Physical and occupational therapy services generally require multiple visits over the recovery process. For example, a co-payment of $50 for a occupa- tional therapy plan of care at 3 times a week over one 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 neces- sary care running and the risk of partial recovery, worsening the under- lying condition or risking re-injury.
This bill would reestablish the obligation of health plans to cover the expense of physical and occupational 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 and occupa- tional therapy care to consumers.
Managed care practices have become increasingly aggressive and protections enacted in 1996 have eroded as payors have found ways to implement policies consistent with the law but detrimental to health care. This bill seeks to reestablish fair and appropriate utilization practices consistent with the underlying purpose of the 1996 Managed Care Reform Act.
The provisions of the bill will protect consumers of physical therapy services by prohibiting plans from inappropriately shifting the cost of care onto enrollees by treating independently practicing physical thera- pists as "specialists" triggering specialist level co-payments. The application of specialist co-payments to physical therapy care is a distortion of the concept of specialized care and has led to co-payments of $40 more per visit.
The bill would also prohibit certain utilization review practices detri- mental to quality health care such as the termination of health care providers because they ordered medically necessary care and the compen- sation of utilization review agents by health plans on a basis which awards denial of care. The bill would also require utilization review agents to disclose additional information to regulatory agencies, enrol- lees and participating providers.
Prior legislative history
2017,2018: 8.2134 Referred to Insurance
2016: A.9384 Referred to Insurance
Fiscal implications
None to state.
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.