S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________
                                        5074--A
                              2015-2016 Regular Sessions
                                 I N  A S S E M B L Y
                                   February 12, 2015
                                      ___________
       Introduced  by  M.  of  A. McDONALD, LAVINE, MONTESANO, MILLER, GUNTHER,
         LIFTON -- Multi-Sponsored by -- M. of A. DUPREY, HOOPER, SIMANOWITZ --
         read once and referred to the Committee  on  Health  --  reported  and
         referred  to  the Committee on Ways and Means -- committee discharged,
         bill amended, ordered reprinted as amended  and  recommitted  to  said
         committee
       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,
        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD06571-03-5
       A. 5074--A                          2
    1  PROGRESSIVE  MUSCULAR  ATROPHY,  ANTERIOR  HORN CELL DISEASE, POST-POLIO
    2  SYNDROME,  CEREBELLAR  DEGENERATION,  DYSTONIA,  HUNTINGTON'S   DISEASE,
    3  SPINOCEREBELLAR  DISEASE,  AND CERTAIN TYPES OF AMPUTATION, PARALYSIS OR
    4  PARESIS.
    5    (B)  "COMPLEX  REHABILITATION TECHNOLOGY" MEANS PRODUCTS CLASSIFIED AS
    6  DURABLE MEDICAL EQUIPMENT WITHIN THE  MEDICARE  PROGRAM  AS  OF  JANUARY
    7  FIRST,  TWO  THOUSAND FIFTEEN THAT ARE INDIVIDUALLY CONFIGURED FOR INDI-
    8  VIDUALS TO MEET THEIR SPECIFIC AND UNIQUE MEDICAL,  PHYSICAL  AND  FUNC-
    9  TIONAL NEEDS AND CAPACITIES FOR BASIC AND FUNCTIONAL ACTIVITIES OF DAILY
   10  LIVING.  SUCH  PRODUCTS  INCLUDE,  BUT  ARE NOT LIMITED TO: INDIVIDUALLY
   11  CONFIGURED MANUAL AND POWER WHEELCHAIRS AND ACCESSORIES, ADAPTIVE  SEAT-
   12  ING  AND POSITIONING ITEMS AND ACCESSORIES, AND OTHER SPECIALIZED EQUIP-
   13  MENT SUCH AS STANDING FRAMES AND GAIT TRAINERS AND ACCESSORIES.
   14    (C) "EMPLOYEE" MEANS A PERSON WHOSE TAXES ARE WITHHELD BY A  QUALIFIED
   15  COMPLEX  REHABILITATION TECHNOLOGY SUPPLIER AND REPORTED TO THE INTERNAL
   16  REVENUE SERVICE.
   17    (D) "HEALTHCARE COMMON PROCEDURE CODING SYSTEM", OR "HCPCS", MEANS THE
   18  BILLING CODES USED BY MEDICARE AND OVERSEEN BY THE FEDERAL  CENTERS  FOR
   19  MEDICARE  AND MEDICAID SERVICES THAT ARE BASED ON THE CURRENT PROCEDURAL
   20  TECHNOLOGY CODES DEVELOPED BY THE AMERICAN MEDICAL ASSOCIATION.
   21    (E) "INDIVIDUALLY CONFIGURED" MEANS A DEVICE  WITH  A  COMBINATION  OF
   22  SIZES,  FEATURES,  ADJUSTMENTS  OR  MODIFICATIONS THAT ARE CONFIGURED OR
   23  DESIGNED BY A QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLIER FOR A
   24  SPECIFIC INDIVIDUAL BY MEASURING,  FITTING,  PROGRAMMING,  ADJUSTING  OR
   25  ADAPTING  THE  DEVICE SO THAT THE DEVICE IS CONSISTENT WITH THE INDIVID-
   26  UAL'S MEDICAL CONDITION, PHYSICAL AND FUNCTIONAL NEEDS AND CAPABILITIES,
   27  BODY SIZE, PERIOD OF NEED AND INTENDED USE AS DETERMINED BY  AN  ASSESS-
   28  MENT OR EVALUATION BY A QUALIFIED HEALTH CARE PROFESSIONAL.
   29    (F)  "MIXED  HCPCS  CODES"  MEANS  HEALTHCARE  COMMON PROCEDURE CODING
   30  SYSTEM CODES THAT REFER TO A MIX OF  COMPLEX  REHABILITATION  TECHNOLOGY
   31  PRODUCTS AND STANDARD MOBILITY AND ACCESSORY PRODUCTS.
   32    (G) "PURE HCPCS CODES" MEANS HEALTHCARE COMMON PROCEDURE CODING SYSTEM
   33  CODES  THAT  REFER  EXCLUSIVELY  TO  COMPLEX  REHABILITATION  TECHNOLOGY
   34  PRODUCTS.
   35    (H) "QUALIFIED COMPLEX REHABILITATION TECHNOLOGY  PROFESSIONAL"  MEANS
   36  AN  INDIVIDUAL  WHO IS CERTIFIED AS AN ASSISTIVE TECHNOLOGY PROFESSIONAL
   37  (ATP) BY THE REHABILITATION ENGINEERING AND ASSISTIVE TECHNOLOGY SOCIETY
   38  OF NORTH AMERICA (RESNA).
   39    (I) "QUALIFIED COMPLEX REHABILITATION  TECHNOLOGY  SUPPLIER"  MEANS  A
   40  COMPANY OR ENTITY THAT:
   41    (I) IS ACCREDITED BY A RECOGNIZED ACCREDITING ORGANIZATION;
   42    (II) IS AN ENROLLED MEDICARE SUPPLIER AND MEETS THE SUPPLIER AND QUAL-
   43  ITY  STANDARDS  ESTABLISHED  FOR  DURABLE  MEDICAL  EQUIPMENT  SUPPLIERS
   44  INCLUDING THOSE FOR COMPLEX REHABILITATION TECHNOLOGY UNDER THE MEDICARE
   45  PROGRAM;
   46    (III) HAS AT LEAST ONE EMPLOYEE WHO IS A QUALIFIED  COMPLEX  REHABILI-
   47  TATION TECHNOLOGY PROFESSIONAL AVAILABLE TO ANALYZE THE NEEDS AND CAPAC-
   48  ITIES  OF COMPLEX NEEDS PATIENTS IN CONSULTATION WITH A QUALIFIED HEALTH
   49  CARE PROFESSIONAL  AND  PARTICIPATE  IN  THE  SELECTION  OF  APPROPRIATE
   50  COMPLEX REHABILITATION TECHNOLOGY AND PROVIDE TRAINING IN THE PROPER USE
   51  OF THE COMPLEX REHABILITATION TECHNOLOGY;
   52    (IV)  REQUIRES  A  QUALIFIED COMPLEX REHABILITATION TECHNOLOGY PROFES-
   53  SIONAL BE PHYSICALLY PRESENT FOR THE  EVALUATION  AND  DETERMINATION  OF
   54  APPROPRIATE   COMPLEX   REHABILITATION   TECHNOLOGY  FOR  COMPLEX  NEEDS
   55  PATIENTS;
       A. 5074--A                          3
    1    (V) HAS THE CAPABILITY TO PROVIDE  SERVICE  AND  REPAIR  BY  QUALIFIED
    2  TECHNICIANS FOR ALL COMPLEX REHABILITATION TECHNOLOGY IT SELLS;
    3    (VI) HAS AT LEAST ONE STOREFRONT LOCATION WITHIN NEW YORK STATE; AND
    4    (VII)  PROVIDES  WRITTEN  INFORMATION REGARDING HOW TO RECEIVE SERVICE
    5  AND REPAIR OF COMPLEX REHABILITATION TECHNOLOGY  TO  THE  COMPLEX  NEEDS
    6  PATIENT PRIOR TO THE ORDERING OF SUCH TECHNOLOGY.
    7    (J)  "QUALIFIED  HEALTH CARE PROFESSIONAL" MEANS A HEALTH CARE PROFES-
    8  SIONAL LICENSED BY THE STATE EDUCATION DEPARTMENT WHO HAS  NO  FINANCIAL
    9  RELATIONSHIP  WITH A QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLI-
   10  ER, INCLUDING BUT NOT LIMITED TO A PHYSICIAN, PHYSICAL THERAPIST,  OCCU-
   11  PATIONAL  THERAPIST,  OR  OTHER  LICENSED  HEALTH  CARE PROFESSIONAL WHO
   12  PERFORMS SPECIALTY EVALUATIONS WITHIN THE PROFESSIONAL'S SCOPE OF  PRAC-
   13  TICE.
   14    2. REIMBURSEMENT AND BILLING PROCEDURES. (A) TO THE EXTENT PERMISSIBLE
   15  UNDER  FEDERAL  LAW, THE COMMISSIONER SHALL MAINTAIN SPECIFIC REIMBURSE-
   16  MENT AND BILLING  PROCEDURES  WITHIN  THE  STATE  MEDICAID  PROGRAM  FOR
   17  COMPLEX  REHABILITATION  TECHNOLOGY PRODUCTS AND SERVICES TO ENSURE THAT
   18  MEDICAID PAYMENTS FOR SUCH PRODUCTS AND SERVICES PERMIT ADEQUATE  ACCESS
   19  TO  COMPLEX  NEEDS  PATIENTS  AND  TAKES  INTO  ACCOUNT  THE SIGNIFICANT
   20  RESOURCES, INFRASTRUCTURE, AND STAFF NEEDED TO MEET THEIR NEEDS.
   21    (B) PURSUANT TO PARAGRAPH (A) OF THIS  SUBDIVISION,  THE  COMMISSIONER
   22  SHALL,  NOT LATER THAN OCTOBER FIRST, TWO THOUSAND SEVENTEEN: (I) DESIG-
   23  NATE PRODUCTS AND SERVICES INCLUDED IN  MIXED  AND  PURE  HCPCS  BILLING
   24  CODES  AS  COMPLEX  REHABILITATION TECHNOLOGY, AND AS NEEDED, CREATE NEW
   25  BILLING CODES OR CODE MODIFIERS FOR SERVICES AND  PRODUCTS  COVERED  FOR
   26  COMPLEX NEEDS PATIENTS; (II) SET MINIMUM STANDARDS CONSISTENT WITH PARA-
   27  GRAPH  (I)  OF SUBDIVISION ONE OF THIS SECTION IN ORDER FOR SUPPLIERS TO
   28  BE CONSIDERED  QUALIFIED  COMPLEX  REHABILITATION  TECHNOLOGY  SUPPLIERS
   29  ELIGIBLE  FOR  MEDICAID REIMBURSEMENT; (III) EXEMPT PRODUCTS OR SERVICES
   30  BILLED UNDER MIXED OR PURE HCPCS CODES FROM INCLUSION  IN  ANY  BIDDING,
   31  SELECTIVE CONTRACTING, REQUEST FOR PROPOSAL, OR SIMILAR INITIATIVE; (IV)
   32  REQUIRE COMPLEX NEEDS PATIENTS RECEIVING A COMPLEX REHABILITATION MANUAL
   33  WHEELCHAIR,  POWER WHEELCHAIR, OR SEATING COMPONENT TO BE EVALUATED BY A
   34  QUALIFIED HEALTH CARE PROFESSIONAL AND  A  QUALIFIED  COMPLEX  REHABILI-
   35  TATION TECHNOLOGY PROFESSIONAL TO QUALIFY FOR REIMBURSEMENT (SUCH EVALU-
   36  ATION  SHALL  BE EXEMPT FROM ANY HEALTH CARE PROFESSIONAL CAP); (V) MAKE
   37  OTHER CHANGES AS NEEDED TO  PROTECT  ACCESS  TO  COMPLEX  REHABILITATION
   38  TECHNOLOGY  FOR  COMPLEX  NEEDS  PATIENTS; AND (VI) AFFIRM THAT WITH THE
   39  EXCEPTION OF THOSE ENROLLEES COVERED UNDER A  PAYMENT  RATE  METHODOLOGY
   40  OTHERWISE  NEGOTIATED,  PAYMENTS  FOR  COMPLEX REHABILITATION TECHNOLOGY
   41  PROVIDED TO PATIENTS ELIGIBLE FOR MEDICAL  ASSISTANCE  BY  ORGANIZATIONS
   42  OPERATING IN ACCORDANCE WITH THE PROVISIONS OF ARTICLE FORTY-FOUR OF THE
   43  PUBLIC  HEALTH  LAW OR BY HEALTH MAINTENANCE ORGANIZATIONS ORGANIZED AND
   44  OPERATING IN ACCORDANCE WITH ARTICLE FORTY-THREE OF THE  INSURANCE  LAW,
   45  SHALL BE THE RATES OF PAYMENT THAT WOULD BE PAID FOR SUCH PAYMENTS UNDER
   46  THE  MEDICAL  ASSISTANCE  PROGRAM  AS DETERMINED BY THE COMMISSIONER AND
   47  APPLICABLE TO SERVICES AT THE TIME SUCH SERVICES WERE PROVIDED.
   48    S 4. Section 3217-e of the insurance law, as added by chapter  219  of
   49  the laws of 2011, is amended to read as follows:
   50    S  3217-e.  Choice of health care provider. An insurer that is subject
   51  to this article and requires or provides for designation by  an  insured
   52  of  a  participating  primary  care provider shall permit the insured to
   53  designate any participating primary care provider who  is  available  to
   54  accept  such  individual,  and  in the case of a child, shall permit the
   55  insured  to  designate  a  physician  (allopathic  or  osteopathic)  who
   56  specializes  in  pediatrics as the child's primary care provider if such
       A. 5074--A                          4
    1  provider participates in the network of the insurer.  EVERY POLICY WHICH
    2  PROVIDES MEDICAL, MAJOR MEDICAL, OR SIMILAR COMPREHENSIVE TYPE  COVERAGE
    3  SHALL  INCLUDE  ADEQUATE  ACCESS  TO  SERVICES AND EQUIPMENT PROVIDED BY
    4  QUALIFIED  COMPLEX  REHABILITATION  TECHNOLOGY  SUPPLIERS,  PURSUANT  TO
    5  SECTION THREE HUNDRED SIXTY-SEVEN-J OF  THE  SOCIAL  SERVICES  LAW,  AND
    6  ADOPT THE SUPPLIER STANDARDS CONTAINED THEREIN.
    7    S  5.  Section 4306-d of the insurance law, as added by chapter 219 of
    8  the laws of 2011, is amended to read as follows:
    9    S 4306-d. Choice of  health  care  provider.  A  corporation  that  is
   10  subject  to  the provisions of this article and requires or provides for
   11  designation by a subscriber of a  participating  primary  care  provider
   12  shall  permit the subscriber to designate any participating primary care
   13  provider who is available to accept such individual, and in the case  of
   14  a child, shall permit the subscriber to designate a physician (allopath-
   15  ic  or osteopathic) who specializes in pediatrics as the child's primary
   16  care provider if such provider participates in the network of the corpo-
   17  ration. EVERY POLICY WHICH PROVIDES MEDICAL, MAJOR MEDICAL,  OR  SIMILAR
   18  COMPREHENSIVE  TYPE  COVERAGE  SHALL INCLUDE ADEQUATE ACCESS TO SERVICES
   19  AND EQUIPMENT PROVIDED BY QUALIFIED  COMPLEX  REHABILITATION  TECHNOLOGY
   20  SUPPLIERS, PURSUANT TO SECTION THREE HUNDRED SIXTY-SEVEN-J OF THE SOCIAL
   21  SERVICES LAW, AND ADOPT THE SUPPLIER STANDARDS CONTAINED THEREIN.
   22    S  6. Section 4403 of the public health law is amended by adding a new
   23  subdivision 9 to read as follows:
   24    9. EVERY HEALTH MAINTENANCE ORGANIZATION SHALL INCLUDE ADEQUATE ACCESS
   25  TO SERVICES AND EQUIPMENT PROVIDED BY QUALIFIED  COMPLEX  REHABILITATION
   26  TECHNOLOGY SUPPLIERS, PURSUANT TO SECTION THREE HUNDRED SIXTY-SEVEN-J OF
   27  THE  SOCIAL  SERVICES  LAW,  AND  ADOPT THE SUPPLIER STANDARDS CONTAINED
   28  THEREIN.
   29    S 7. This act shall take effect on the first of January next  succeed-
   30  ing  the  date  on  which it shall have become a law, and shall apply to
   31  contracts and policies issued, renewed, modified or amended on or  after
   32  such effective date.