BILL NUMBER: S5045
SPONSOR: BAILEY
 
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.
 
JUSTIFICATION:
This bill will protect consumers by prohibiting plans from inappropri-
ately shifting the cost of physical therapy care to consumers by limit-
ing copayments to no more than 20 percent of the total reimbursement to
the provider of care. Under existing law, health plans must cover phys-
ical 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 consum-
er $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 20 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 inappropri-
ately splitting the cost of physical therapy care to consumers.
 
LEGISLATIVE HISTORY:
2009-10: S4321A - Referred to Insurance
2011-12: S4870A
2013-14: S2319A
2015-16: S2SA
2017-13: S5764A
2019-20: 53751
2021-22: 53562
2023-24: 51470 - Vetoed
 
FISCAL IMPLICATIONS:
None.
 
EFFECTIVE DATE:
180 days after it shall have become a law.

Statutes affected:
S5045: 3216 insurance law, 3216(i) insurance law, 4235 insurance law, 4235(f) insurance law, 4301 insurance law, 4301(b) insurance law, 4322 insurance law, 4322(b) insurance law