S T A T E O F N E W Y O R K
________________________________________________________________________
3651
2015-2016 Regular Sessions
I N S E N A T E
February 13, 2015
___________
Introduced by Sen. ORTT -- read twice and ordered printed, and when
printed to be committed to the Committee on Health
AN ACT to amend the social services law, the insurance law and the
public health law, in relation to preserving access to quality complex
rehabilitation technology for patients with complex medical needs
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Short title. This act shall be known and may be cited as
2 the "complex needs patient act".
3 S 2. Legislative intent. It is the intent of the legislature to:
4 1. protect access for complex needs patients to quality complex reha-
5 bilitation technology;
6 2. establish and improve standards and safeguards relating to the
7 provision of complex rehabilitation technology; and
8 3. provide quality support for complex needs patients to stay in the
9 home or community setting, prevent institutionalization, and prevent
10 hospitalizations and other costly secondary complications.
11 S 3. The social services law is amended by adding a new section 367-j
12 to read as follows:
13 S 367-J. COMPLEX NEEDS PATIENT ACT. 1. DEFINITIONS. AS USED IN THIS
14 SECTION:
15 (A) "COMPLEX NEEDS PATIENT" MEANS AN INDIVIDUAL WITH SIGNIFICANT PHYS-
16 ICAL OR FUNCTIONAL IMPAIRMENT RESULTING FROM A MEDICAL CONDITION OR
17 DISEASE INCLUDING, BUT NOT LIMITED TO: SPINAL CORD INJURY, TRAUMATIC
18 BRAIN INJURY, CEREBRAL PALSY, MUSCULAR DYSTROPHY, SPINA BIFIDA, OSTEO-
19 GENESIS IMPERFECTA, ARTHROGRYPOSIS, AMYOTROPHIC LATERAL SCLEROSIS,
20 MULTIPLE SCLEROSIS, DEMYELINATING DISEASE, MYELOPATHY, MYOPATHY,
21 PROGRESSIVE MUSCULAR ATROPHY, ANTERIOR HORN CELL DISEASE, POST-POLIO
22 SYNDROME, CEREBELLAR DEGENERATION, DYSTONIA, HUNTINGTON'S DISEASE,
23 SPINOCEREBELLAR DISEASE, AND CERTAIN TYPES OF AMPUTATION, PARALYSIS OR
24 PARESIS.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD07851-02-5
S. 3651 2
1 (B) "COMPLEX REHABILITATION TECHNOLOGY" MEANS PRODUCTS CLASSIFIED AS
2 DURABLE MEDICAL EQUIPMENT WITHIN THE MEDICARE PROGRAM AS OF JANUARY
3 FIRST, TWO THOUSAND FOURTEEN THAT ARE INDIVIDUALLY CONFIGURED FOR INDI-
4 VIDUALS TO MEET THEIR SPECIFIC AND UNIQUE MEDICAL, PHYSICAL AND FUNC-
5 TIONAL NEEDS AND CAPACITIES FOR BASIC AND FUNCTIONAL ACTIVITIES OF DAILY
6 LIVING. SUCH PRODUCTS INCLUDE, BUT ARE NOT LIMITED TO: MANUAL AND POWER
7 WHEELCHAIRS AND ACCESSORIES, ADAPTIVE SEATING AND POSITIONING ITEMS AND
8 ACCESSORIES, AND OTHER SPECIALIZED EQUIPMENT SUCH AS STANDING FRAMES AND
9 GAIT TRAINERS AND ACCESSORIES.
10 (C) "EMPLOYEE" MEANS A PERSON WHOSE TAXES ARE WITHHELD BY A QUALIFIED
11 COMPLEX REHABILITATION TECHNOLOGY SUPPLIER AND REPORTED TO THE INTERNAL
12 REVENUE SERVICE.
13 (D) "HEALTHCARE COMMON PROCEDURE CODING SYSTEM", OR "HCPCS", MEANS THE
14 BILLING CODES USED BY MEDICARE AND OVERSEEN BY THE FEDERAL CENTERS FOR
15 MEDICARE AND MEDICAID SERVICES THAT ARE BASED ON THE CURRENT PROCEDURAL
16 TECHNOLOGY CODES DEVELOPED BY THE AMERICAN MEDICAL ASSOCIATION.
17 (E) "INDIVIDUALLY CONFIGURED" MEANS A DEVICE WITH A COMBINATION OF
18 SIZES, FEATURES, ADJUSTMENTS OR MODIFICATIONS THAT IS CUSTOMIZED BY A
19 QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLIER FOR A SPECIFIC
20 INDIVIDUAL BY MEASURING, FITTING, PROGRAMMING, ADJUSTING OR ADAPTING THE
21 DEVICE SO THAT THE DEVICE IS CONSISTENT WITH THE INDIVIDUAL'S MEDICAL
22 CONDITION, PHYSICAL AND FUNCTIONAL NEEDS AND CAPABILITIES, BODY SIZE,
23 PERIOD OF NEED AND INTENDED USE AS DETERMINED BY AN ASSESSMENT OR EVALU-
24 ATION BY A QUALIFIED HEALTH CARE PROFESSIONAL.
25 (F) "MIXED HCPCS CODES" MEANS CODES THAT REFER TO A MIX OF COMPLEX
26 REHABILITATION TECHNOLOGY PRODUCTS AND STANDARD MOBILITY AND ACCESSORY
27 PRODUCTS.
28 (G) "PURE HCPCS CODES" MEANS CODES THAT REFER EXCLUSIVELY TO COMPLEX
29 REHABILITATION TECHNOLOGY PRODUCTS.
30 (H) "QUALIFIED COMPLEX REHABILITATION TECHNOLOGY PROFESSIONAL" MEANS
31 AN INDIVIDUAL WHO IS CERTIFIED AS AN ASSISTIVE TECHNOLOGY PROFESSIONAL
32 (ATP) BY THE REHABILITATION ENGINEERING AND ASSISTIVE TECHNOLOGY SOCIETY
33 OF NORTH AMERICA.
34 (I) "QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLIER" MEANS A
35 COMPANY OR ENTITY THAT:
36 (I) IS ACCREDITED BY A RECOGNIZED ACCREDITING ORGANIZATION;
37 (II) IS AN ENROLLED MEDICARE SUPPLIER AND MEETS THE SUPPLIER AND QUAL-
38 ITY STANDARDS ESTABLISHED FOR DURABLE MEDICAL EQUIPMENT SUPPLIERS
39 INCLUDING THOSE FOR COMPLEX REHABILITATION TECHNOLOGY UNDER THE MEDICARE
40 PROGRAM;
41 (III) HAS AT LEAST ONE EMPLOYEE WHO IS A QUALIFIED COMPLEX REHABILI-
42 TATION TECHNOLOGY PROFESSIONAL AVAILABLE TO ANALYZE THE NEEDS AND CAPAC-
43 ITIES OF COMPLEX NEEDS PATIENTS IN CONSULTATION WITH A QUALIFIED HEALTH
44 CARE PROFESSIONAL AND PARTICIPATE IN THE SELECTION OF APPROPRIATE
45 COMPLEX REHABILITATION TECHNOLOGY AND PROVIDE TRAINING IN THE PROPER USE
46 OF THE COMPLEX REHABILITATION TECHNOLOGY;
47 (IV) REQUIRES A QUALIFIED COMPLEX REHABILITATION TECHNOLOGY PROFES-
48 SIONAL BE PHYSICALLY PRESENT FOR THE EVALUATION AND DETERMINATION OF
49 APPROPRIATE COMPLEX REHABILITATION TECHNOLOGY FOR COMPLEX NEEDS
50 PATIENTS;
51 (V) HAS THE CAPABILITY TO PROVIDE SERVICE AND REPAIR BY QUALIFIED
52 TECHNICIANS FOR ALL COMPLEX REHABILITATION TECHNOLOGY IT SELLS;
53 (VI) HAS AT LEAST ONE STOREFRONT LOCATION WITHIN NEW YORK STATE; AND
54 (VII) PROVIDES WRITTEN INFORMATION REGARDING HOW TO RECEIVE SERVICE
55 AND REPAIR OF COMPLEX REHABILITATION TECHNOLOGY TO THE COMPLEX NEEDS
56 PATIENT AT THE TIME SUCH TECHNOLOGY IS DELIVERED.
S. 3651 3
1 (J) "QUALIFIED HEALTH CARE PROFESSIONAL" MEANS A HEALTH CARE PROFES-
2 SIONAL LICENSED BY THE STATE EDUCATION DEPARTMENT WHO HAS NO FINANCIAL
3 RELATIONSHIP WITH A QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLI-
4 ER, INCLUDING BUT NOT LIMITED TO A PHYSICIAN, PHYSICAL THERAPIST, OCCU-
5 PATIONAL THERAPIST, OR OTHER LICENSED HEALTH CARE PROFESSIONAL WHO
6 PERFORMS SPECIALTY EVALUATIONS WITHIN THE PROFESSIONAL'S SCOPE OF PRAC-
7 TICE.
8 2. REIMBURSEMENT AND BILLING PROCEDURES. (A) TO THE EXTENT PERMISSIBLE
9 UNDER FEDERAL LAW, THE COMMISSIONER SHALL ESTABLISH SPECIFIC REIMBURSE-
10 MENT AND BILLING PROCEDURES WITHIN THE STATE MEDICAID PROGRAM FOR
11 COMPLEX REHABILITATION TECHNOLOGY PRODUCTS AND SERVICES TO ENSURE THAT
12 MEDICAID PAYMENTS FOR SUCH PRODUCTS AND SERVICES PERMIT ADEQUATE ACCESS
13 TO COMPLEX NEEDS PATIENTS AND TAKES INTO ACCOUNT THE SIGNIFICANT
14 RESOURCES, INFRASTRUCTURE, AND STAFF NEEDED TO MEET THEIR NEEDS.
15 (B) WHEN ESTABLISHING REIMBURSEMENT AND BILLING PROCEDURES PURSUANT TO
16 PARAGRAPH (A) OF THIS SUBDIVISION, THE COMMISSIONER SHALL, NOT LATER
17 THAN OCTOBER FIRST, TWO THOUSAND SIXTEEN: (I) DESIGNATE PRODUCTS AND
18 SERVICES INCLUDED IN MIXED AND PURE HCPCS BILLING CODES AS COMPLEX REHA-
19 BILITATION TECHNOLOGY, AND AS NEEDED, CREATE NEW BILLING CODES OR CODE
20 MODIFIERS FOR SERVICES AND PRODUCTS COVERED FOR COMPLEX NEEDS PATIENTS;
21 (II) SET MINIMUM STANDARDS CONSISTENT WITH PARAGRAPH (I) OF SUBDIVISION
22 ONE OF THIS SECTION IN ORDER FOR SUPPLIERS TO BE CONSIDERED QUALIFIED
23 COMPLEX REHABILITATION TECHNOLOGY SUPPLIERS ELIGIBLE FOR MEDICAID
24 REIMBURSEMENT; (III) EXEMPT PRODUCTS OR SERVICES BILLED UNDER MIXED OR
25 PURE HCPCS CODES FROM INCLUSION IN ANY BIDDING, SELECTIVE CONTRACTING,
26 REQUEST FOR PROPOSAL, OR SIMILAR INITIATIVE; (IV) REQUIRE COMPLEX NEEDS
27 PATIENTS RECEIVING A COMPLEX REHABILITATION MANUAL WHEELCHAIR, POWER
28 WHEELCHAIR, OR SEATING COMPONENT TO BE EVALUATED BY A QUALIFIED HEALTH
29 CARE PROFESSIONAL AND A QUALIFIED COMPLEX REHABILITATION TECHNOLOGY
30 PROFESSIONAL TO QUALIFY FOR REIMBURSEMENT; (V) MAKE OTHER CHANGES AS
31 NEEDED TO PROTECT ACCESS TO COMPLEX REHABILITATION TECHNOLOGY FOR
32 COMPLEX NEEDS PATIENTS; AND (VI) AFFIRM THAT WITH THE EXCEPTION OF THOSE
33 ENROLLEES COVERED UNDER A PAYMENT RATE METHODOLOGY OTHERWISE NEGOTIATED,
34 PAYMENTS FOR COMPLEX REHABILITATION TECHNOLOGY PROVIDED TO PATIENTS
35 ELIGIBLE FOR MEDICAL ASSISTANCE BY ORGANIZATIONS OPERATING IN ACCORDANCE
36 WITH THE PROVISIONS OF ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW OR BY
37 HEALTH MAINTENANCE ORGANIZATIONS ORGANIZED AND OPERATING IN ACCORDANCE
38 WITH ARTICLE FORTY-THREE OF THE INSURANCE LAW, SHALL BE THE RATES OF
39 PAYMENT THAT WOULD BE PAID FOR SUCH PAYMENTS UNDER THE MEDICAL ASSIST-
40 ANCE PROGRAM AS DETERMINED BY THE COMMISSIONER AND APPLICABLE TO
41 SERVICES AT THE TIME SUCH SERVICES WERE PROVIDED.
42 S 4. Section 3217-e of the insurance law, as added by chapter 219 of
43 the laws of 2011, is amended to read as follows:
44 S 3217-e. Choice of health care provider. An insurer that is subject
45 to this article and requires or provides for designation by an insured
46 of a participating primary care provider shall permit the insured to
47 designate any participating primary care provider who is available to
48 accept such individual, and in the case of a child, shall permit the
49 insured to designate a physician (allopathic or osteopathic) who
50 specializes in pediatrics as the child's primary care provider if such
51 provider participates in the network of the insurer. EVERY POLICY WHICH
52 PROVIDES MEDICAL, MAJOR MEDICAL, OR SIMILAR COMPREHENSIVE TYPE COVERAGE
53 SHALL INCLUDE ADEQUATE ACCESS TO SERVICES AND EQUIPMENT PROVIDED BY
54 QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLIERS, PURSUANT TO
55 SECTION THREE HUNDRED SIXTY-SEVEN-J OF THE SOCIAL SERVICES LAW, AND
56 ADOPT THE SUPPLIER STANDARDS CONTAINED THEREIN.
S. 3651 4
1 S 5. Section 4306-d of the insurance law, as added by chapter 219 of
2 the laws of 2011, is amended to read as follows:
3 S 4306-d. Choice of health care provider. A corporation that is
4 subject to the provisions of this article and requires or provides for
5 designation by a subscriber of a participating primary care provider
6 shall permit the subscriber to designate any participating primary care
7 provider who is available to accept such individual, and in the case of
8 a child, shall permit the subscriber to designate a physician (allopath-
9 ic or osteopathic) who specializes in pediatrics as the child's primary
10 care provider if such provider participates in the network of the corpo-
11 ration. EVERY POLICY WHICH PROVIDES MEDICAL, MAJOR MEDICAL, OR SIMILAR
12 COMPREHENSIVE TYPE COVERAGE SHALL INCLUDE ADEQUATE ACCESS TO SERVICES
13 AND EQUIPMENT PROVIDED BY QUALIFIED COMPLEX REHABILITATION TECHNOLOGY
14 SUPPLIERS, PURSUANT TO SECTION THREE HUNDRED SIXTY-SEVEN-J OF THE SOCIAL
15 SERVICES LAW, AND ADOPT THE SUPPLIER STANDARDS CONTAINED THEREIN.
16 S 6. Section 4403 of the public health law is amended by adding a new
17 subdivision 9 to read as follows:
18 9. EVERY HEALTH MAINTENANCE ORGANIZATION SHALL INCLUDE ADEQUATE ACCESS
19 TO SERVICES AND EQUIPMENT PROVIDED BY QUALIFIED COMPLEX REHABILITATION
20 TECHNOLOGY SUPPLIERS, PURSUANT TO SECTION THREE HUNDRED SIXTY-SEVEN-J OF
21 THE SOCIAL SERVICES LAW, AND ADOPT THE SUPPLIER STANDARDS CONTAINED
22 THEREIN.
23 S 7. This act shall take effect on the first of January next succeed-
24 ing the date on which it shall have become a law, and shall apply to
25 contracts and policies issued, renewed, modified or amended on or after
26 such effective date.