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Insurance Reform
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OT and PT Insurance Reform

A.298 by Assembly member Gunther and S.2134 by Senator Young, amends the insurance laws in New York. The proposed legislation provides that no policy of group accident or group health can impose co-payments in excess of twenty percent of total reimbursement for occupational therapy and physical therapy services. The bill adds occupational therapy as a covered service under not-for-profit insurance plans.

The bill creates an exceptions process for out-patient visit limits. The bill also reforms utilization review procedures by prohibiting health care plans from compensating utilization review agents on a percentage basis or other method which would provide a financial incentive to deny claims; prohibit a health plan from terminating or refusing to renew a contract on the basis that a provider offered or rendered medically necessary care; require utilization review agents to provide adverse determinations to both the provider and the enrollee; require utilization review agents to report to the Department of Health and Department of Insurance respectively the clinical review criteria and standards and the definition of medical necessity used under the utilization plan; require utilization review agents to report any amendments to their utilization review plan within thirty days of such amendment; allow a health care provider to request clinical review criteria and other clinical information which the health care plan might consider in its utilization review.

NYSOTA is currently seeking sponsors for this proposed legislation.

What you can do: Contact your local Assembly member or Senator and speak out in support of this proposed legislation.

Click here to find your NYS representatives.

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