S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________
                                         5074
                              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
       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,
        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD06571-02-5
       A. 5074                             2
    1  SPINOCEREBELLAR DISEASE, AND CERTAIN TYPES OF AMPUTATION,  PARALYSIS  OR
    2  PARESIS.
    3    (B)  "COMPLEX  REHABILITATION TECHNOLOGY" MEANS PRODUCTS CLASSIFIED AS
    4  DURABLE MEDICAL EQUIPMENT WITHIN THE  MEDICARE  PROGRAM  AS  OF  JANUARY
    5  FIRST,  TWO  THOUSAND FIFTEEN THAT ARE INDIVIDUALLY CONFIGURED FOR INDI-
    6  VIDUALS TO MEET THEIR SPECIFIC AND UNIQUE MEDICAL,  PHYSICAL  AND  FUNC-
    7  TIONAL NEEDS AND CAPACITIES FOR BASIC AND FUNCTIONAL ACTIVITIES OF DAILY
    8  LIVING.  SUCH  PRODUCTS  INCLUDE,  BUT  ARE NOT LIMITED TO: INDIVIDUALLY
    9  CONFIGURED MANUAL AND POWER WHEELCHAIRS AND ACCESSORIES, ADAPTIVE  SEAT-
   10  ING  AND POSITIONING ITEMS AND ACCESSORIES, AND OTHER SPECIALIZED EQUIP-
   11  MENT SUCH AS STANDING FRAMES AND GAIT TRAINERS AND ACCESSORIES.
   12    (C) "EMPLOYEE" MEANS A PERSON WHOSE TAXES ARE WITHHELD BY A  QUALIFIED
   13  COMPLEX  REHABILITATION TECHNOLOGY SUPPLIER AND REPORTED TO THE INTERNAL
   14  REVENUE SERVICE.
   15    (D) "HEALTHCARE COMMON PROCEDURE CODING SYSTEM", OR "HCPCS", MEANS THE
   16  BILLING CODES USED BY MEDICARE AND OVERSEEN BY THE FEDERAL  CENTERS  FOR
   17  MEDICARE  AND MEDICAID SERVICES THAT ARE BASED ON THE CURRENT PROCEDURAL
   18  TECHNOLOGY CODES DEVELOPED BY THE AMERICAN MEDICAL ASSOCIATION.
   19    (E) "INDIVIDUALLY CONFIGURED" MEANS A DEVICE  WITH  A  COMBINATION  OF
   20  SIZES,  FEATURES,  ADJUSTMENTS  OR  MODIFICATIONS THAT ARE CONFIGURED OR
   21  DESIGNED BY A QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLIER FOR A
   22  SPECIFIC INDIVIDUAL BY MEASURING,  FITTING,  PROGRAMMING,  ADJUSTING  OR
   23  ADAPTING  THE  DEVICE SO THAT THE DEVICE IS CONSISTENT WITH THE INDIVID-
   24  UAL'S MEDICAL CONDITION, PHYSICAL AND FUNCTIONAL NEEDS AND CAPABILITIES,
   25  BODY SIZE, PERIOD OF NEED AND INTENDED USE AS DETERMINED BY  AN  ASSESS-
   26  MENT OR EVALUATION BY A QUALIFIED HEALTH CARE PROFESSIONAL.
   27    (F)  "MIXED HPCS CODES" MEANS HEALTHCARE PROCEDURE CODING SYSTEM CODES
   28  THAT REFER TO A MIX OF COMPLEX REHABILITATION  TECHNOLOGY  PRODUCTS  AND
   29  STANDARD MOBILITY AND ACCESSORY PRODUCTS.
   30    (G)  "PURE  HPCS CODES" MEANS HEALTHCARE PROCEDURE CODING SYSTEM CODES
   31  THAT REFER EXCLUSIVELY TO COMPLEX REHABILITATION TECHNOLOGY PRODUCTS.
   32    (H) "QUALIFIED COMPLEX REHABILITATION TECHNOLOGY  PROFESSIONAL"  MEANS
   33  AN  INDIVIDUAL  WHO IS CERTIFIED AS AN ASSISTIVE TECHNOLOGY PROFESSIONAL
   34  (ATP) BY THE REHABILITATION ENGINEERING AND ASSISTIVE TECHNOLOGY SOCIETY
   35  OF NORTH AMERICA (RESNA).
   36    (I) "QUALIFIED COMPLEX REHABILITATION  TECHNOLOGY  SUPPLIER"  MEANS  A
   37  COMPANY OR ENTITY THAT:
   38    (I) IS ACCREDITED BY A RECOGNIZED ACCREDITING ORGANIZATION;
   39    (II) IS AN ENROLLED MEDICARE SUPPLIER AND MEETS THE SUPPLIER AND QUAL-
   40  ITY  STANDARDS  ESTABLISHED  FOR  DURABLE  MEDICAL  EQUIPMENT  SUPPLIERS
   41  INCLUDING THOSE FOR COMPLEX REHABILITATION TECHNOLOGY UNDER THE MEDICARE
   42  PROGRAM;
   43    (III) HAS AT LEAST ONE EMPLOYEE WHO IS A QUALIFIED  COMPLEX  REHABILI-
   44  TATION TECHNOLOGY PROFESSIONAL AVAILABLE TO ANALYZE THE NEEDS AND CAPAC-
   45  ITIES  OF COMPLEX NEEDS PATIENTS IN CONSULTATION WITH A QUALIFIED HEALTH
   46  CARE PROFESSIONAL  AND  PARTICIPATE  IN  THE  SELECTION  OF  APPROPRIATE
   47  COMPLEX REHABILITATION TECHNOLOGY AND PROVIDE TRAINING IN THE PROPER USE
   48  OF THE COMPLEX REHABILITATION TECHNOLOGY;
   49    (IV)  REQUIRES  A  QUALIFIED COMPLEX REHABILITATION TECHNOLOGY PROFES-
   50  SIONAL BE PHYSICALLY PRESENT FOR THE  EVALUATION  AND  DETERMINATION  OF
   51  APPROPRIATE   COMPLEX   REHABILITATION   TECHNOLOGY  FOR  COMPLEX  NEEDS
   52  PATIENTS;
   53    (V) HAS THE CAPABILITY TO PROVIDE  SERVICE  AND  REPAIR  BY  QUALIFIED
   54  TECHNICIANS FOR ALL COMPLEX REHABILITATION TECHNOLOGY IT SELLS;
   55    (VI) HAS AT LEAST ONE STOREFRONT LOCATION WITHIN NEW YORK STATE; AND
       A. 5074                             3
    1    (VII)  PROVIDES  WRITTEN  INFORMATION REGARDING HOW TO RECEIVE SERVICE
    2  AND REPAIR OF COMPLEX REHABILITATION TECHNOLOGY  TO  THE  COMPLEX  NEEDS
    3  PATIENT PRIOR TO THE ORDERING OF SUCH TECHNOLOGY.
    4    (J)  "QUALIFIED  HEALTH CARE PROFESSIONAL" MEANS A HEALTH CARE PROFES-
    5  SIONAL LICENSED BY THE STATE EDUCATION DEPARTMENT WHO HAS  NO  FINANCIAL
    6  RELATIONSHIP  WITH A QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLI-
    7  ER, INCLUDING BUT NOT LIMITED TO A PHYSICIAN, PHYSICAL THERAPIST,  OCCU-
    8  PATIONAL  THERAPIST,  OR  OTHER  LICENSED  HEALTH  CARE PROFESSIONAL WHO
    9  PERFORMS SPECIALTY EVALUATIONS WITHIN THE PROFESSIONAL'S SCOPE OF  PRAC-
   10  TICE.
   11    2. REIMBURSEMENT AND BILLING PROCEDURES. (A) TO THE EXTENT PERMISSIBLE
   12  UNDER  FEDERAL  LAW, THE COMMISSIONER SHALL MAINTAIN SPECIFIC REIMBURSE-
   13  MENT AND BILLING  PROCEDURES  WITHIN  THE  STATE  MEDICAID  PROGRAM  FOR
   14  COMPLEX  REHABILITATION  TECHNOLOGY PRODUCTS AND SERVICES TO ENSURE THAT
   15  MEDICAID PAYMENTS FOR SUCH PRODUCTS AND SERVICES PERMIT ADEQUATE  ACCESS
   16  TO  COMPLEX  NEEDS  PATIENTS  AND  TAKES  INTO  ACCOUNT  THE SIGNIFICANT
   17  RESOURCES, INFRASTRUCTURE, AND STAFF NEEDED TO MEET THEIR NEEDS.
   18    (B) PURSUANT TO PARAGRAPH (A) OF THIS  SUBDIVISION,  THE  COMMISSIONER
   19  SHALL,  NOT LATER THAN OCTOBER FIRST, TWO THOUSAND SEVENTEEN: (I) DESIG-
   20  NATE PRODUCTS AND SERVICES INCLUDED IN MIXED AND PURE HPCS BILLING CODES
   21  AS COMPLEX REHABILITATION TECHNOLOGY, AND AS NEEDED, CREATE NEW  BILLING
   22  CODES  OR  CODE  MODIFIERS FOR SERVICES AND PRODUCTS COVERED FOR COMPLEX
   23  NEEDS PATIENTS; (II) SET MINIMUM STANDARDS CONSISTENT WITH PARAGRAPH (I)
   24  OF SUBDIVISION ONE OF THIS SECTION IN ORDER FOR SUPPLIERS TO BE  CONSID-
   25  ERED  QUALIFIED COMPLEX REHABILITATION TECHNOLOGY SUPPLIERS ELIGIBLE FOR
   26  MEDICAID REIMBURSEMENT; (III) EXEMPT PRODUCTS OR SERVICES  BILLED  UNDER
   27  MIXED  OR  PURE  HPCS  CODES  FROM  INCLUSION  IN ANY BIDDING, SELECTIVE
   28  CONTRACTING, REQUEST FOR PROPOSAL, OR SIMILAR INITIATIVE;  (IV)  REQUIRE
   29  COMPLEX  NEEDS PATIENTS RECEIVING A COMPLEX REHABILITATION MANUAL WHEEL-
   30  CHAIR, POWER WHEELCHAIR, OR SEATING COMPONENT TO BE EVALUATED BY A QUAL-
   31  IFIED HEALTH CARE PROFESSIONAL AND A  QUALIFIED  COMPLEX  REHABILITATION
   32  TECHNOLOGY  PROFESSIONAL  TO  QUALIFY FOR REIMBURSEMENT (SUCH EVALUATION
   33  SHALL BE EXEMPT FROM ANY HEALTH CARE PROFESSIONAL CAP); (V)  MAKE  OTHER
   34  CHANGES AS NEEDED TO PROTECT ACCESS TO COMPLEX REHABILITATION TECHNOLOGY
   35  FOR  COMPLEX  NEEDS PATIENTS; AND (VI) AFFIRM THAT WITH THE EXCEPTION OF
   36  THOSE ENROLLEES COVERED UNDER A PAYMENT RATE METHODOLOGY OTHERWISE NEGO-
   37  TIATED, PAYMENTS  FOR  COMPLEX  REHABILITATION  TECHNOLOGY  PROVIDED  TO
   38  PATIENTS  ELIGIBLE  FOR MEDICAL ASSISTANCE BY ORGANIZATIONS OPERATING IN
   39  ACCORDANCE WITH THE PROVISIONS  OF  ARTICLE  FORTY-FOUR  OF  THE  PUBLIC
   40  HEALTH  LAW OR BY HEALTH MAINTENANCE ORGANIZATIONS ORGANIZED AND OPERAT-
   41  ING IN ACCORDANCE WITH ARTICLE FORTY-THREE OF THE INSURANCE  LAW,  SHALL
   42  BE  THE  RATES OF PAYMENT THAT WOULD BE PAID FOR SUCH PAYMENTS UNDER THE
   43  MEDICAL ASSISTANCE PROGRAM AS DETERMINED BY THE COMMISSIONER AND  APPLI-
   44  CABLE TO SERVICES AT THE TIME SUCH SERVICES WERE PROVIDED.
   45    S  4.  Section 3217-e of the insurance law, as added by chapter 219 of
   46  the laws of 2011, is amended to read as follows:
   47    S 3217-e. Choice of health care provider. An insurer that  is  subject
   48  to  this  article and requires or provides for designation by an insured
   49  of a participating primary care provider shall  permit  the  insured  to
   50  designate  any  participating  primary care provider who is available to
   51  accept such individual, and in the case of a  child,  shall  permit  the
   52  insured  to  designate  a  physician  (allopathic  or  osteopathic)  who
   53  specializes in pediatrics as the child's primary care provider  if  such
   54  provider participates in the network of the insurer.  EVERY POLICY WHICH
   55  PROVIDES  MEDICAL, MAJOR MEDICAL, OR SIMILAR COMPREHENSIVE TYPE COVERAGE
   56  SHALL INCLUDE ADEQUATE ACCESS TO  SERVICES  AND  EQUIPMENT  PROVIDED  BY
       A. 5074                             4
    1  QUALIFIED  COMPLEX  REHABILITATION  TECHNOLOGY  SUPPLIERS,  PURSUANT  TO
    2  SECTION THREE HUNDRED SIXTY-SEVEN-J OF  THE  SOCIAL  SERVICES  LAW,  AND
    3  ADOPT THE SUPPLIER STANDARDS CONTAINED THEREIN.
    4    S  5.  Section 4306-d of the insurance law, as added by chapter 219 of
    5  the laws of 2011, is amended to read as follows:
    6    S 4306-d. Choice of  health  care  provider.  A  corporation  that  is
    7  subject  to  the provisions of this article and requires or provides for
    8  designation by a subscriber of a  participating  primary  care  provider
    9  shall  permit the subscriber to designate any participating primary care
   10  provider who is available to accept such individual, and in the case  of
   11  a child, shall permit the subscriber to designate a physician (allopath-
   12  ic  or osteopathic) who specializes in pediatrics as the child's primary
   13  care provider if such provider participates in the network of the corpo-
   14  ration. EVERY POLICY WHICH PROVIDES MEDICAL, MAJOR MEDICAL,  OR  SIMILAR
   15  COMPREHENSIVE  TYPE  COVERAGE  SHALL INCLUDE ADEQUATE ACCESS TO SERVICES
   16  AND EQUIPMENT PROVIDED BY QUALIFIED  COMPLEX  REHABILITATION  TECHNOLOGY
   17  SUPPLIERS, PURSUANT TO SECTION THREE HUNDRED SIXTY-SEVEN-J OF THE SOCIAL
   18  SERVICES LAW, AND ADOPT THE SUPPLIER STANDARDS CONTAINED THEREIN.
   19    S  6. Section 4403 of the public health law is amended by adding a new
   20  subdivision 9 to read as follows:
   21    9. EVERY HEALTH MAINTENANCE ORGANIZATION SHALL INCLUDE ADEQUATE ACCESS
   22  TO SERVICES AND EQUIPMENT PROVIDED BY QUALIFIED  COMPLEX  REHABILITATION
   23  TECHNOLOGY SUPPLIERS, PURSUANT TO SECTION THREE HUNDRED SIXTY-SEVEN-J OF
   24  THE  SOCIAL  SERVICES  LAW,  AND  ADOPT THE SUPPLIER STANDARDS CONTAINED
   25  THEREIN.
   26    S 7. This act shall take effect on the first of January next  succeed-
   27  ing  the  date  on  which it shall have become a law, and shall apply to
   28  contracts and policies issued, renewed, modified or amended on or  after
   29  such effective date.