BILL NUMBER: S4431
SPONSOR: COMRIE
 
TITLE OF BILL:
An act to amend the insurance law and the public health law, in relation
to access to health care providers in managed care plans
 
PURPOSE:
To provide patients who are enrolling in a managed care plan the oppor-
tunity to have access to their current health care provider and, simi-
larly, to allow patients whose health care providers are excluded from a
managed care plan's panel of providers to continue to see that health
care professional for a limited period of time.
 
SUMMARY OF PROVISIONS:
Section one of the bill amends subsection (e) of § 4803 of the insurance
law to provide that an insurer may not terminate a contract for partic-
ipation in the in-network benefits portion of an insurer's managed care
network, or refuse to renew such contract, solely because a health care
provider has issued an opinion relating to whether or not a patient is
terminally ill.
Section two of the bill amends subsections (e) and (f) of § 4804 of the
insurance law. Subsection (e) provides that if a health care provider in
an insurer's in-network benefits portion of a managed care product
either leaves the network or is excluded from the HMO's panel of provid-
ers, after having been affiliated with such managed care product, that
provider's patients may continue to receive health care services from
him or her for a period of up to one year, or, in the case of terminally
ill patients, until such time of the patient's death.
Subsection (f) provides new insured's in an insurer's in-network bene-
fits portion of a provider network the option to continue to receive
health care services from his or her current health care provider for a
period of up to one year, or, in the case of terminally ill patients,
until such time of the patient's death. In both instances, this access
to continuity of care will not be available if the health care provider
has been disenrolled from the managed care plan for a reason involving
imminent harm to a patient, fraud or disciplinary action by a state
licensing board.Moreover, the access to continuity of care will only
take effect upon the attending health care provider's agreement to
accept the reimbursement rate established by the HMO, adhere to the
plan's quality assurance requirements and adhere to the organization's
other policies and procedures.
Section three of the bill adds subsections (g) and (h) to § 4804 of the
insurance law to define the term "terminal illness or condition" and, in
keeping with the provisions the Legislature enacted with the mastectomy
treatment legislation, to prohibit offensive financial arrangements.
Section four of the bill amends paragraphs (e) and (f) of subdivision 6
of § 4403 of the public health law. Paragraph (e) provides that if a
health care provider in a health maintenance organization network either
leaves the network or is excluded from the HMO's panel of providers,
after having been affiliated with such HMO, that provider's patients may
continue to receive health care services from him or her for a period of
up to one year, or, if the insured has entered the second trimester of
pregnancy until the patient has received post-partum care directly
related to the delivery, or, in the case of terminally ill patients,
until such time of the patient's death.
Paragraph (f) provide new enrollees in an HMO the option to continue to
receive health care services from his or her current healthcare provider
for a period of up to one year, or, in the case of terminally ill
patients, until such time of the patient's death. In both paragraphs,
this access to continuity of care will not be available if the health
care provider has been disenrolled from the managed care plan for a
reason involving imminent harm to a patient, fraud or disciplinary
action by a state licensing board. Additionally, the access to continu-
ity of care will only take effect upon the attending health care provid-
er's agreement to accept the reimbursement rate established by the HMO,
adhere to the plan's quality assurance requirements and adhere to the
organization's other policies and procedures.
Section five of the bill adds subdivisions 10 and 11 to § 4403 of the
public health law to define the term "terminal illness or condition"
and, in keeping with the provisions the Legislature enacted with the
mastectomy treatment legislation, to prohibit offensive financial
arrangements.
Section six of the bill amends subdivision 5 of § 4406-d of the public
health law to provide that a health care plan may not terminate a
contract for employment, or refuse to renew such contract, solely
because a health care provider has issued an opinion relating to whether
or not a patient is terminally ill.
Section seven of the bill provides the effective date.
 
JUSTIFICATION:
This bill proposed to build upon the historic changes made on behalf of
health care consumers in the 1995 Managed Care Reform Act. Included
among the numerous provisions of that Act was a provision that patients
undergoing a course of treatment could continue that treatment with
their health care provider for 90 days, if the provider became disaffil-
iated with the HMO provider panel or for 60 days if the person enrolled
in an HMO which did not have a provider on its panel. In addition, the
Act provided for continuity of care for pregnant women who had entered
their second trimester of pregnancy, through the provision of post-par-
tum care.
This bill would expand those provisions in ways which meaningfully add
to the continuity of a patient's care. It would do so by allowing a
patient to continue an established relationship with his or her health-
care provider for up to one year following a change which would other-
wise deny access to the provider. In the case of terminally ill
patients, this proposal would allow such patients to continue to receive
care from their current provider until the time of their death. In
virtually every situation where a patient has an established, ongoing
relationship with his or her health care provider (which would likely
cause such patient to exercise the option provided by this bill) the
provision of health care services is both enhanced and streamlined with
the provider's familiarity with the patient. A deep understanding of a
patient's history, previous treatments and attitude are important
factors which assist a health care provider in making clinical decisions
which are likely to be of benefit to the patient.
In the case of terminally ill patients, this proposal would allow such
people to have the comfort of being ministered to by a familiar provid-
er, which may help to ease the trauma and increase the comfort of the
terminal patient. Importantly, this bill would not add to the expense of
health insurance either purchased by the individual or by an employer)
because it does not mandate coverage where none exists. In addition,
this measure would not add to the cost of the HMO or other managed care
entity providing care.In every instance addressed in this bill, the
insurer is receiving payment for the health care of the insured in ques-
tion. The only issue addressed is who will provide treatment to the
patient. Inasmuch as this bill would not change current law which
mandates the provider to continue to accept the reimbursement set by the
insurer (which cannot be more than the reimbursement paid to in-plan
providers) there is no added expense to the insurer, with the minor
exception of some additional administrative work.
This bill further protects both the patient and the HMO by making the
continuity of care an option to be exercised by the patient (not a
mandatory benefit) and providing that this option would not apply to
providers who have been disenrolled for reasons related to incompetence,
criminal action or professional misconduct. Finally, this bill
increases the applicability of provisions prohibiting offensive finan-
cial arrangements enacted in early 1997 so that incentives to induce
providers to act in a manner contrary to these statutes would be prohib-
ited.
 
PRIOR LEGISLATIVE HISTORY:
2023-2024: 56576 Comrie/ A5129 Dinowitz
2021-22: A.2299 - Health
2019-20: A.5033 - Health
2017-18:A.256 - A.1932Third Reading Calendar - Third Reading Calendar
2015-16:
2013-14:A.366-B- Third Reading Calendar
2011-12:A.1808- Passed Assembly
2009-10:A.633-Passed Assembly /S.4059Insurance
2005-06:A.1240 -Passed Assembly /S.2759- Insurance
2003-04:A.1161 -Passed Assembly
2001-02:A.5880 -Passed Assembly /S.4845- Insurance
 
FISCAL IMPLICATIONS:
None to the State.
 
EFFECTIVE DATE:
One hundred twentieth day after becoming law and shall apply to all
contracts issued, renewed, modified or amended on and after such date.

Statutes affected:
S4431: 4803 insurance law, 4803(e) insurance law, 4804 insurance law, 4403 public health law, 4406-d public health law, 4406-d(5) public health law