A. 6741-A (Bradley) / S. 3180-A (Duane) "Out of Network Clinical Laboratories."
This bill would require managed care plans, to reimburse out-of-network providers of clinical laboratory services when plan participants are referred to such laboratories for services by an in-network provider. This bill was referred to the Senate Finance Committee from the Senate Codes Committee. For a more detailed analysis of this bill please view this memorandum in opposition.
A. 3896 (Mayersohn) / S. 1752 (Stavisky) "4-tier Prescription Coverage Prohibition."
This bill would prohibit the implementation of "4-teir" prescription drug coverage plans in New York State. This bill was referred to Senate Codes from the Senate Health Committee. For a more detailed analysis of this bill please view this memorandum in opposition.
A. 301 (Millman) / S. 3840 (Duane) "Utilization Review for Rare Diseases."
This bill seeks to expand the "likely to benefit" standard used by the External Appeal process for clinical trials to the treatment of Rare Diseases. It has passed the Assembly and is on the Senate Health Committee Agenda.
A. 792 (Gottfried) "Utilization Review Reform."
This bill would substantially alter the current utilization review process. Specifically, the bill would require a utilization review agent to take into consideration the time of day, day of the week care was provided, and the presenting symptoms in reviewing denials of coverage. Moreover, this bill would deem any determination made outside the utilization review time frame as an approval as well as authorize health care providers to appeal concurrent denials on behalf of patients. Finally, this bill would require a utilization review agent that has made a verbal preauthorization or approval to "immediately" thereafter supply the provider with a written confirmation of the approval by email, fax, or by posting a copy of the approval on the insurer's website.
A.723 (Gottfried) / S. 3450 (Oppenheimer) "Definition of Clinical Peer Reviewer."
This bill would require the initial determination of medical necessity on a claim to be made by a board certified specialist in the same or similar specialty as the physician who recommended the treatment under review.
A. 213 (Markey) / S.1803 (Breslin) "Temporary Out-of-Network Dialysis Treatments."
This bill would require insurers to provide coverage for out-of-network dialysis. Specifically, this bill would prohibit insurers from denying coverage to an insured who receives dialysis from an out-of-network provider where the healthcare provider treating the insured issues a written order for dialysis treatment and the insured notifies the insurer of the date or dates of such treatment 30 days in advance. This bill would limit out-of-network dialysis coverage to 4 four requests not to exceed 15 treatments a year. In addition, the bill limits reimbursement to the amount the insurer would have paid for the same treatment performed in- network. Any excess amount charged by the provider would be the responsibility of the insured.
A. 214 (Jeffries) "Insurance Reimbursement of Wages for Organ Donors."
This Bill would require insurers to reimburse private employers for wages paid to an employee while such employee is on a leave of absence to serve as an organ or bone marrow donor.
A. 217 (Latimer) "Third-Party Notification of Termination."
This bill would require insurers and HMOs to allow individuals over 65 years old to designate a 3rd party to receive notices of failure to pay premiums or cancellation due to the failure to pay premiums. In addition, insurers would be required to annually provide notice to eligible insureds of this option.
A. 301 (Millman) "Review of Rare Diseases."
This bill seeks to unnecessarily and unjustifiably relax the existing standard used in medical necessity determinations for not only external appeals but internal utilization review decisions for a specified and expanding set of rare diseases which are listed by the National Institutes of Health Office of Rare Diseases.
A. 376 (Jacobs) "Audiological Exams."
This bill would require insurers to provide coverage for annual audiological examinations and evaluations performed by a licensed physician or licensed audiologist. This bill would also require coverage for an unlimited number of speech language pathology examinations and evaluations that are recommended by a licensed physician, licensed audiologist or licensed speech language pathologist, upon completion of the annual examination. A. 633 (Dinowitz) "Disaffiliated Providers." This bill would decrease the ability of managed care health plans to control quality and cost issues within their provider networks, and would significantly increase administrative costs associated with both provider and enrollee transitions. Existing law allows patients to continue receiving care from a non-participating provider for a period of 60 or 90 days depending on circumstances. This bill would significantly expand these time periods by allowing patients to receive care for up to a year or an indefinite period of time if the individual was diagnosed with a terminal condition.
A. 693 (Jacobs) "Smoking Cessation Mandate."
This bill would require insurers to provide coverage for the cost of smoking cessation programs for their enrollees. Specifically, insurance plans would be mandated to provide four hundred dollars worth of coverage on an annual basis towards the cost of a prescription smoking cessation program.
A. 726 (Gottfried) "In-Network Referrals."
This bill would prevent insurers from requiring that in-network providers refer only to other in-network providers. Specifically, this bill would prohibit insurers from restricting a health care provider from referring an insured to another provider based solely on the provider's participation status in the insured's health plan network.
A. 728 (Gottfried) "Third-Party Notification of External Appeals."
This bill would eliminate the $50 application fee an insured must pay in order to file an external appeal. In addition, the bill requires that notification be provided to the patient's designee and the healthcare provider of a utilization review final adverse determination and an external appeal determination.
A. 729 (Gottfried) "Grounds for External Appeal."
This bill would establish unclear and unjustified standards for medical necessity external appeals and give undue weight to the recommendations of providers that lack appropriate qualifications. Specifically, this bill would result in the existence of two competing standards to be used in determining medical necessity external appeals without providing any guidance for when each standard should be applied.
A. 764 (Gottfried) "Newly Licensed Providers."
This bill would require managed care plans to allow newly licensed health care professionals to become participating providers and provide services and receive payment from the network while their applications are pending.
A. 767 (Gottfried) "Health Plan Liability."
This bill imposes unfair liability standards on health insurers and managed care health plans making routine coverage determinations. Enactment of this bill would actually diminish the accessibility of health care services and the affordability of health care coverage.
A. 770 (Gunther) "Prosthetic Devices."
This bill would require health plans to cover prosthetic devices in a manner that is equal to or greater than the coverage provided by Medicare. Due to the broad definition given to prosthetics by Medicare, the bill is overreaching and will have unintended consequences.
A. 792 (Gottfried) "Utilization Review Standard."
This bill would impose an arbitrary utilization review standard, allow providers, at the expense of their patients, to appeal concurrent adverse determinations, deem medical necessity determinations outside the utilization review time period approved and create unnecessary preauthorization notification requirements given existing law.
A. 1267 (Colton) "Mail Order Pharmacy Restrictions."
This bill severely limits insurers' flexibility in providing cost effective prescription drug benefits. This bill would prohibit policies covering prescription drugs from requiring that the drugs be purchased through a mail-order pharmacy. Restrictions on mail-service pharmacies unfairly limit the ability of insurers and employers to design cost-effective prescription drug benefits and ultimately harms consumers by raising the cost of prescription coverage.
A. 1370 (Hoyt) / S. 1930 (Lavalle) "Naturopathy Certification."
This bill would establish criteria for the certification of naturopathic medicine and would create the profession of Naturopathic Medicine professionals. In addition, this measure would license naturopaths and allow them to prescribe, administer, dispense and perform natural therapies, to prescribe and administer drugs, immunizing agents, diagnostic tests and devices, and to order laboratory tests. Subsequently, this bill would place the health of New Yorkers at risk by allowing inadequately trained individuals to provide health care treatment.
A. 2008 (Gottfried) "PBM Regulation."
This bill would severely limit insurers' flexibility in providing cost-effective prescription drug benefits by imposing onerous reporting, accounting and disclosure requirements on pharmacy benefit manager (PBMs). Specifically, the bill imposes a fiduciary duty on PBMs, creates a trust for all funds received by a PBM, requires disclosure of financial transactions and mandates disclosure of terms and conditions of all contractual arrangements.
A. 2368 (O'Donnell) "Domestic Partner Coverage."
This would set forth an unclear and overly broad mandate for health insurance coverage for domestic partners. Specifically, this bill would alter the definition of family in the insurance law to include domestic partners thus requiring insurers to provide health insurance to an insured's domestic partner.
A. 2875 (Weinstein) "Subrogation."
This bill would prohibit insurers from recovering medical expenses in the settlement of an action where their insured's injuries were caused by another party.
A. 3122 (Bradley) "File and Use."
This bill subjects health insurers to a discretionary rate approval process on premium rate increases of greater than 5% for direct pay and Medicare supplemental policies. In addition, this bill would increase the minimum loss ratios for individual, small group and Medicare supplemental policies.
A. 3165 (Bradley) "Participating Provider Web-Lists."
This bill seeks to penalize health plans that voluntarily offer a list of participating providers via the plan’s website for failure to remove providers who no longer participate with the plan within thirty (30) days. In addition, this bill would require that services rendered by non-participating providers whose names appear on the website be reimbursed for services at out-of-network (OON) rates.
A. 4301 (Canestrari) "Collective Negotiations."
This bill provides for “collective negotiation” by physicians and other health care providers. Although this legislation purports to create new authority to permit physicians to collectively negotiate with payers, it is actually a transparent attempt to exempt physicians from the state’s anti-trust laws.
A. 4572 (Rivera) / S. 185 (Morahan) "PTSD Expansion of Timothy's Law."
This bill would: 1) add “Post Traumatic Stress Disorder” (PTSD) to the list of biologically based mental illnesses that insurers and health maintenance organizations are required to cover under “Timothy’s Law”; and, 2) authorize the Commissioner of Mental Health to participate in the ongoing study the impact of Timothy’s law.
S. 417 (Breslin) "Health Plan Responsibility."
This bill would impose unfair responsibility standards on health insurers and managed care health plans making routine coverage determinations. Perversely, enactment of this bill would actually diminish the accessibility of health care services and the affordability of health care coverage.
S. 529 (Alesi) "Hearing Aid Coverage."
This bill would entitle hearing impaired consumers, 16 years of age or older, to receive reimbursement of $1,000 every three years for the costs associated with the purchase of up to two hearing aids. Hearing impaired children, 15 and younger, would be entitled to reimbursement of $1,000 for services related to the purchase of up to two hearing aids every two years.
S. 650 (Larkin) "Small Business Insurance Cooperatives."
This bill would establish private health care purchasing cooperatives to expand health care choices for sole proprietors and small employers in New York.
S. 1646 (Huntley) "Timothy's Law Extension."
This bill would make Timothy’s Law permanent and impose duplicative reporting requirements on the Office of Mental Health.
