Bill Text: NY A02704 | 2017-2018 | General Assembly | Introduced

---

Bill Title: Relates to health care professional applications and terminations.

Spectrum: Strong Partisan Bill (Democrat 11-1)

Status: (Engrossed - Dead) 2018-01-03 - ordered to third reading cal.215 [A02704 Detail]

Download: New_York-2017-A02704-Introduced.html

---

                STATE OF NEW YORK
        ________________________________________________________________________
                                          2704
                               2017-2018 Regular Sessions
                   IN ASSEMBLY
                                    January 23, 2017
                                       ___________
        Introduced  by  M.  of  A.  LAVINE, ABINANTI, COLTON, TITONE, ZEBROWSKI,
          SEAWRIGHT -- Multi-Sponsored by -- M.  of  A.  RA  --  read  once  and
          referred to the Committee on Health
        AN ACT to amend the public health law and the insurance law, in relation
          to health care professional applications and terminations
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
     1    Section 1. Section 4406-d of the public health law, as added by  chap-
     2  ter  705 of the laws of 1996, subdivision 1 as amended by chapter 425 of
     3  the laws of 2016, is amended to read as follows:
     4    § 4406-d. Health care professional applications and terminations.   1.
     5  (a)  A health care plan shall, upon request, make available and disclose
     6  to health care professionals written application procedures and  minimum
     7  qualification requirements which a health care professional must meet in
     8  order  to  be considered by the health care plan. The plan shall consult
     9  with appropriately qualified health care professionals in developing its
    10  qualification requirements. A health care plan shall complete review  of
    11  the health care professional's application to participate in the in-net-
    12  work  portion  of the health care plan's network and shall, within sixty
    13  days of receiving a health care professional's completed application  to
    14  participate  in  the  health care plan's network, notify the health care
    15  professional as to: (i) whether he  or  she  is  credentialed;  or  (ii)
    16  whether  additional time is necessary to make a determination because of
    17  a failure of a third party to provide necessary documentation.  In  such
    18  instances where additional time is necessary because of a lack of neces-
    19  sary documentation, a health plan shall make every effort to obtain such
    20  information  as  soon  as  possible and shall make a final determination
    21  within twenty-one days of receiving the necessary documentation.
    22    (b) If the completed  application  of  a  newly-licensed  health  care
    23  professional or a health care professional who has recently relocated to
    24  this  state  from another state and has not previously practiced in this
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD07878-01-7
        A. 2704                             2
     1  state, who joins a group practice of health care professionals  each  of
     2  whom  participates  in  the  in-network  portion of a health care plan's
     3  network,  is  neither  approved  nor  declined  within  sixty  days   of
     4  submission  of a completed application pursuant to paragraph (a) of this
     5  subdivision, the health care professional shall be deemed "provisionally
     6  credentialed" and may participate  in  the  in-network  portion  of  the
     7  health  care  plan's  network;  provided,  however, that a provisionally
     8  credentialed physician may not be designated as  an  enrollee's  primary
     9  care  physician  until such time as the physician has been fully creden-
    10  tialed. The  network  participation  for  a  provisionally  credentialed
    11  health  care  professional shall begin on the day following the sixtieth
    12  day of receipt of the completed application and  shall  last  until  the
    13  final  credentialing  determination  is  made by the health care plan. A
    14  health care professional shall only be eligible for provisional  creden-
    15  tialing  if the group practice of health care professionals notifies the
    16  health care plan in writing that, should the application  ultimately  be
    17  denied,  the  health  care professional or the group practice: (i) shall
    18  refund any payments made by the health care plan for in-network services
    19  provided by the provisionally credentialed health care professional that
    20  exceed any out-of-network benefits payable under the enrollee's contract
    21  with the health care plan; and (ii) shall not pursue reimbursement  from
    22  the  enrollee, except to collect the copayment that otherwise would have
    23  been payable had the enrollee  received  services  from  a  health  care
    24  professional  participating  in  the in-network portion of a health care
    25  plan's network. Interest and penalties pursuant to section  three  thou-
    26  sand  two  hundred  twenty-four-a  of  the  insurance  law  shall not be
    27  assessed based on the denial of a claim submitted during the period when
    28  the health care professional was provisionally  credentialed;  provided,
    29  however,  that  nothing  herein  shall  prevent  a health care plan from
    30  paying a claim from a health  care  professional  who  is  provisionally
    31  credentialed upon submission of such claim. A health care plan shall not
    32  deny,  after  appeal,  a  claim for services provided by a provisionally
    33  credentialed health care professional solely  on  the  ground  that  the
    34  claim was not timely filed.
    35    2.  (a) A health care plan shall not terminate or not renew a contract
    36  with a health care professional unless the health care plan provides  to
    37  the  health  care  professional a written explanation of the reasons for
    38  the proposed contract termination and an opportunity  for  a  review  or
    39  hearing  as  hereinafter provided. This section shall not apply in cases
    40  involving imminent harm to patient care, a determination of fraud, or  a
    41  final  disciplinary  action  by a state licensing board or other govern-
    42  mental agency that impairs the health  care  professional's  ability  to
    43  practice.
    44    (b)  The  notice  of  the proposed contract termination or non-renewal
    45  provided by the health care plan to the health care  professional  shall
    46  include:
    47    (i) the reasons for the proposed action;
    48    (ii) notice that the health care professional has the right to request
    49  a  hearing  or  review, at the professional's discretion, before a panel
    50  [appointed by the health care plan] comprised of  no  fewer  than  three
    51  health care professionals licensed to practice in the state of New York;
    52    (iii)  a time limit of not less than thirty days within which a health
    53  care professional may request a hearing; and
    54    (iv) a time limit for a hearing date which must be held within  thirty
    55  days after the date of receipt of a request for a hearing.
        A. 2704                             3
     1    (c)  The  hearing panel shall be comprised of three [persons appointed
     2  by the health care plan] health care professionals licensed to  practice
     3  by  the  state  of New York in the same profession as the subject of the
     4  review, one of whom is appointed by the health care plan, one of whom is
     5  appointed  by  the  health  care  professional who is the subject of the
     6  hearing. The remaining member of the panel shall be chosen by the  other
     7  two panel members. At least one person on such panel shall be a clinical
     8  peer  in  the  same  discipline and the same or similar specialty as the
     9  health care professional under review. The hearing panel may consist  of
    10  more  than  three  persons, provided however that the number of clinical
    11  peers on such panel shall constitute one-third  or  more  of  the  total
    12  membership  of  the  panel  and  provided  further that the ratio of the
    13  number of health care professionals appointed by the health care plan to
    14  the number of health care professionals appointed by the subject of  the
    15  hearing  to  the number of health care professionals chosen by the other
    16  panel members remains one to one to one.
    17    (d) The hearing panel shall render a decision on the  proposed  action
    18  in  a  timely  manner.  Such decision shall include reinstatement of the
    19  health care professional by the  health  care  plan,  provisional  rein-
    20  statement  subject  to  conditions  set forth by the health care plan or
    21  termination of the health care  professional.  Such  decision  shall  be
    22  provided in writing to the health care professional.
    23    (e) A decision by the hearing panel to terminate or not renew a health
    24  care professional shall be effective not less than thirty days after the
    25  receipt by the health care professional of the hearing panel's decision;
    26  provided,  however,  that the provisions of paragraph (e) of subdivision
    27  six of section [four thousand four] forty-four  hundred  three  of  this
    28  article shall apply to such termination or non-renewal.
    29    (f) In no event shall termination be effective earlier than sixty days
    30  from the receipt of the notice of termination.
    31    3.  [Either party to a contract may exercise a right of non-renewal at
    32  the expiration of the contract  period  set  forth  therein  or,  for  a
    33  contract  without  a  specific  expiration  date,  on each January first
    34  occurring after the contract has been in effect for at least  one  year,
    35  upon  sixty  days notice to the other party; provided, however, that any
    36  non-renewal shall not constitute a  termination  for  purposes  of  this
    37  section.
    38    4.] A health care plan shall develop and implement policies and proce-
    39  dures to ensure that health care professionals are regularly informed of
    40  information  maintained by the health care plan to evaluate the perform-
    41  ance or practice of the health care professional. The health  care  plan
    42  shall consult with health care professionals in developing methodologies
    43  to  collect  and analyze health care professional profiling data. Health
    44  care plans shall provide any such information  and  profiling  data  and
    45  analysis  to health care professionals. Such information, data or analy-
    46  sis shall be provided on a periodic basis appropriate to the nature  and
    47  amount  of  data  and  the  volume and scope of services provided.   Any
    48  profiling data used to evaluate the performance or practice of a  health
    49  care  professional  shall  be  measured  against  stated criteria and an
    50  appropriate group of health care professionals using  similar  treatment
    51  modalities serving a comparable patient population. Upon presentation of
    52  such  information  or data, each health care professional shall be given
    53  the opportunity to discuss the unique nature of the health care  profes-
    54  sional's  patient population which may have a bearing on the health care
    55  professional's profile and to work cooperatively with  the  health  care
    56  plan to improve performance.
        A. 2704                             4
     1    [5.]  4. No health care plan shall terminate a contract or employment,
     2  or refuse to renew a contract, solely because  a  health  care  provider
     3  has:
     4    (a) advocated on behalf of an enrollee;
     5    (b) filed a complaint against the health care plan;
     6    (c) appealed a decision of the health care plan;
     7    (d)  provided information or filed a report pursuant to section forty-
     8  four hundred six-c of this article; or
     9    (e) requested a hearing or review pursuant to this section.
    10    [6.] 5. Except as provided herein, no contract or agreement between  a
    11  health  care  plan  and  a  health  care  professional shall contain any
    12  provision which shall supersede or impair a health  care  professional's
    13  right to notice of reasons for termination or non-renewal and the oppor-
    14  tunity  for a hearing or review concerning such termination or non-rene-
    15  wal.
    16    [7.] 6. Any contract provision in violation of this section  shall  be
    17  deemed to be void and unenforceable.
    18    [8.]  7. For purposes of this section, "health care plan" shall mean a
    19  health maintenance organization licensed pursuant to article forty-three
    20  of the insurance law or certified pursuant to this article or  an  inde-
    21  pendent  practice  association  certified or recognized pursuant to this
    22  article.
    23    [9.] 8. For purposes of this section, "health care professional" shall
    24  mean a health care professional licensed, registered or certified pursu-
    25  ant to title eight of the education law.
    26    § 2. Section 4803 of the insurance law, as added by chapter 705 of the
    27  laws of 1996, subsection (a) as amended by chapter 425 of  the  laws  of
    28  2016, is amended to read as follows:
    29    §  4803.  Health care professional applications and terminations.  (a)
    30  (1) An insurer which offers a managed care product shall, upon  request,
    31  make  available and disclose to health care professionals written appli-
    32  cation procedures and minimum qualification requirements which a  health
    33  care professional must meet in order to be considered by the insurer for
    34  participation  in  the  in-network  benefits  portion  of  the insurer's
    35  network for the managed care product. The  insurer  shall  consult  with
    36  appropriately  qualified  health  care  professionals  in developing its
    37  qualification requirements for participation in the in-network  benefits
    38  portion of the insurer's network for the managed care product. An insur-
    39  er  shall  complete review of the health care professional's application
    40  to participate in the in-network portion of the insurer's  network  and,
    41  within  sixty  days  of receiving a health care professional's completed
    42  application to participate in the insurer's  network,  will  notify  the
    43  health  care  professional as to: (A) whether he or she is credentialed;
    44  or (B) whether additional time is  necessary  to  make  a  determination
    45  because  of  a  failure of a third party to provide necessary documenta-
    46  tion. In such instances where additional time is necessary because of  a
    47  lack  of  necessary documentation, an insurer shall make every effort to
    48  obtain such information as soon as  possible  and  shall  make  a  final
    49  determination within twenty-one days of receiving the necessary documen-
    50  tation.
    51    (2)  If  the  completed  application  of  a newly-licensed health care
    52  professional or a health care professional who has recently relocated to
    53  this state from another state and has not previously practiced  in  this
    54  state,  who  joins a group practice of health care professionals each of
    55  whom participates in the in-network portion of an insurer's network,  is
    56  neither  approved  nor  declined  within  sixty  days of submission of a
        A. 2704                             5
     1  completed application pursuant to paragraph one of this subsection, such
     2  health care professional shall be  deemed  "provisionally  credentialed"
     3  and  may  participate in the in-network portion of an insurer's network;
     4  provided,  however,  that a provisionally credentialed physician may not
     5  be designated as an insured's primary care physician until such time  as
     6  the physician has been fully credentialed. The network participation for
     7  a provisionally credentialed health care professional shall begin on the
     8  day  following  the sixtieth day of receipt of the completed application
     9  and shall last until the final credentialing determination  is  made  by
    10  the  insurer.  A  health  care  professional  shall only be eligible for
    11  provisional credentialing if the group practice of health  care  profes-
    12  sionals  notifies  the  insurer  in writing that, should the application
    13  ultimately be denied, the health care professional or  the  group  prac-
    14  tice:  (A)  shall refund any payments made by the insurer for in-network
    15  services provided by the provisionally credentialed health care  profes-
    16  sional  that  exceed  any  out-of-network  benefits  payable  under  the
    17  insured's contract with the insurer; and (B) shall not pursue reimburse-
    18  ment from the insured, except to collect the  copayment  or  coinsurance
    19  that otherwise would have been payable had the insured received services
    20  from  a health care professional participating in the in-network portion
    21  of an insurer's network. Interest  and  penalties  pursuant  to  section
    22  three  thousand  two  hundred twenty-four-a of this chapter shall not be
    23  assessed based on the denial of a claim submitted during the period when
    24  the health care professional was provisionally  credentialed;  provided,
    25  however,  that  nothing  herein  shall  prevent an insurer from paying a
    26  claim from a health care professional who is provisionally  credentialed
    27  upon  submission of such claim. An insurer shall not deny, after appeal,
    28  a claim for services provided by  a  provisionally  credentialed  health
    29  care  professional  solely  on  the ground that the claim was not timely
    30  filed.
    31    (b) (1) An insurer shall not terminate or not renew a contract with  a
    32  health  care  professional  for participation in the in-network benefits
    33  portion of the insurer's network for a managed care product  unless  the
    34  insurer  provides  to the health care professional a written explanation
    35  of the reasons for the proposed contract termination and an  opportunity
    36  for  a review or hearing as hereinafter provided. This section shall not
    37  apply in cases involving imminent harm to patient care, a  determination
    38  of  fraud,  or a final disciplinary action by a state licensing board or
    39  other governmental agency that impairs the  health  care  professional's
    40  ability to practice.
    41    (2)  The  notice  of  the proposed contract termination or non-renewal
    42  provided by the insurer to the health care professional shall include:
    43    (i) the reasons for the proposed action;
    44    (ii) notice that the health care professional has the right to request
    45  a hearing or review, at the professional's discretion,  before  a  panel
    46  [appointed  by the insurer] comprised of no fewer than three health care
    47  professionals licensed to practice by the state of New York;
    48    (iii) a time limit of not less than thirty days within which a  health
    49  care professional may request a hearing or review; and
    50    (iv)  a  time  limit  for a hearing date which must be held within not
    51  less than thirty days after the date of receipt of a request for a hear-
    52  ing.
    53    (3) The hearing panel shall be comprised of three  [persons  appointed
    54  by  the  insurer]  health care professionals licensed to practice by the
    55  state of New York in the same profession as the subject of  the  review,
    56  one of whom is appointed by the insurer, one of whom is appointed by the
        A. 2704                             6
     1  health  care professional who is the subject of the hearing. The remain-
     2  ing member of the panel shall be chosen by the other two panel  members.
     3  At  least  one person on such panel shall be a clinical peer in the same
     4  discipline  and the same or similar specialty as the health care profes-
     5  sional under review. The hearing panel may consist of  more  than  three
     6  persons,  provided  however  that  the  number of clinical peers on such
     7  panel shall constitute one-third or more of the total membership of  the
     8  panel  and  provided further that the ratio of the number of health care
     9  professionals appointed by the health care plan to the number of  health
    10  care professionals appointed by the subject of the hearing to the number
    11  of  health  care  professionals  chosen  by  the two other panel members
    12  remains one to one to one.
    13    (4) The hearing panel shall render a decision on the  proposed  action
    14  in  a  timely  manner.  Such decision shall include reinstatement of the
    15  health care  professional  by  the  insurer,  provisional  reinstatement
    16  subject  to  conditions  set  forth by the insurer or termination of the
    17  health care professional. Such decision shall be provided in writing  to
    18  the health care professional.
    19    (5) A decision by the hearing panel to terminate or not renew a health
    20  care professional shall be effective not less than thirty days after the
    21  receipt by the health care professional of the hearing panel's decision;
    22  provided, however, that the provisions of subsection (e) of section four
    23  thousand  eight  hundred four of this article shall apply to such termi-
    24  nation.
    25    (6) In no event shall termination or non-renewal be effective  earlier
    26  than sixty days from the receipt of the notice of termination or non-re-
    27  newal.
    28    (c)  [Either  party  to a contract for participation in the in-network
    29  benefits portion of an insurer's network for a managed care product  may
    30  exercise a right of non-renewal at the expiration of the contract period
    31  set forth therein or, for a contract without a specific expiration date,
    32  on  each  January  first occurring after the contract has been in effect
    33  for at least one year, upon  sixty  days  notice  to  the  other  party;
    34  provided,  however,  that  any non-renewal shall not constitute a termi-
    35  nation for purposes of this section.
    36    (d)] An insurer shall develop and implement policies and procedures to
    37  ensure that health care providers participating in [the] the  in-network
    38  benefits  portion of an insurer's network for a managed care product are
    39  regularly informed of information maintained by the insurer to  evaluate
    40  the performance or practice of the health care professional. The insurer
    41  shall consult with health care professionals in developing methodologies
    42  to  collect  and analyze provider profiling data. Insurers shall provide
    43  any such information and profiling data and  analysis  to  these  health
    44  care professionals. Such information, data or analysis shall be provided
    45  on a periodic basis appropriate to the nature and amount of data and the
    46  volume and scope of services provided. Any profiling data used to evalu-
    47  ate the performance or practice of such a health care professional shall
    48  be  measured  against stated criteria and an appropriate group of health
    49  care professionals using similar treatment modalities serving a compara-
    50  ble patient population. Upon presentation of such information  or  data,
    51  each  such  health  care  professional shall be given the opportunity to
    52  discuss the unique nature of  the  health  care  professional's  patient
    53  population which may have a bearing on the professional's profile and to
    54  work cooperatively with the insurer to improve performance.
    55    [(e)] (d) No insurer shall terminate or refuse to renew a contract for
    56  participation in the in-network benefits portion of an insurer's network
        A. 2704                             7
     1  for  a  managed care product solely because the health care professional
     2  has (1) advocated on behalf of an insured; (2)  has  filed  a  complaint
     3  against  the  insurer;  (3)  has appealed a decision of the insurer; (4)
     4  provided  information  or  filed a report pursuant to section forty-four
     5  hundred six-c of the public health law; or (5) requested  a  hearing  or
     6  review pursuant to this section.
     7    [(f)]  (e) Except as provided herein, no contract or agreement between
     8  an insurer and a health  care  professional  for  participation  in  the
     9  in-network  benefits  portion of an insurer's network for a managed care
    10  product shall contain any provision which shall supersede  or  impair  a
    11  health care professional's right to notice of reasons for termination or
    12  non-renewal  and  the  opportunity  for a hearing concerning such termi-
    13  nation or non-renewal.
    14    [(g)] (f) Any contract provision in violation of this section shall be
    15  deemed to be void and unenforceable.
    16    [(h)] (g) For purposes of this  section,  "health  care  professional"
    17  shall  mean a health care professional licensed, registered or certified
    18  pursuant to title eight of the education law.
    19    § 3. This act shall take effect immediately; provided that if  chapter
    20  425  of  the laws of 2016 shall not have taken effect by such date, then
    21  subdivision 1 of section 4406-d of the public  health  law,  amended  by
    22  section  one  of  this  act,  and  subsection (a) of section 4803 of the
    23  insurance law, as amended by section two of this act shall  take  effect
    24  on  the  same  date and in the same manner as chapter 425 of the laws of
    25  2016, as amended, takes effect.