STATE OF NEW YORK ________________________________________________________________________ 3903 2025-2026 Regular Sessions IN ASSEMBLY January 30, 2025 ___________ Introduced by M. of A. SIMON -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law, in relation to including certain out of home services such as transition from a hospital, nursing facility or other institutional setting to the home within home care insurance coverage The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subparagraphs (C), (D) and (E) of paragraph 1 of subsection 2 (k) of section 3221 of the insurance law, subparagraphs (C) and (D) as 3 amended by chapter 557 of the laws of 2000, are amended to read as 4 follows: 5 (C) Home care means the care and treatment of a covered person who is 6 under the care of a physician [but only if] and who requires the 7 services of an agency described in subparagraph (D) of this paragraph 8 for: transition of the covered person from hospital, nursing facility or 9 other institutional setting to home; rehabilitation, recovery or medical 10 management of the covered person at home following hospitalization or 11 following care in a nursing facility or other institutional setting; or 12 medical management of a condition predisposing the covered individual to 13 hospitalization [or], confinement in a nursing facility [as defined in 14 subchapter XVIII of the federal Social Security Act, 42 U.S.C. §§ 1395 15 et seq, would otherwise have been required] or the need for other out- 16 of-home services otherwise covered under the contract if home care [was] 17 is not provided, and the plan covering the home health service is estab- 18 lished and approved in writing by such physician. 19 (D) Home care shall be provided by an agency possessing a valid 20 certificate of approval or license issued pursuant to article thirty-six 21 of the public health law and shall consist of one or more of the follow- 22 ing: EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD06580-01-5
A. 3903 2 1 (i) Part-time or intermittent home nursing care by or under the super- 2 vision of a registered professional nurse (R.N.). 3 (ii) Part-time or intermittent home health aide services which consist 4 primarily of caring for the patient. 5 (iii) Physical, occupational or speech therapy, social work, respir- 6 atory therapy and nutritional counseling, if provided by the home health 7 service or agency. 8 (iv) Medical supplies, drugs and medications prescribed by a physi- 9 cian, and laboratory services by or on behalf of a certified home health 10 agency or licensed home care services agency to the extent such items 11 would have been covered under the contract if the covered person had 12 been hospitalized or confined in a skilled nursing facility as defined 13 in subchapter XVIII of the federal Social Security Act, 42 U.S.C. §§ 14 1395 et seq. 15 (E) For the purpose of determining the benefits for home care avail- 16 able to a covered person, [each visit by a member of a home care team 17 shall be considered as one home care visit; the contract may contain a 18 limitation on the number of home care visits, but not less than forty 19 such visits in any calendar year or in any continuous period of twelve 20 months, for each person covered under the contract; four hours of home 21 health aide service shall be considered as one home care visit] nothing 22 in this paragraph shall be construed to prevent the management or utili- 23 zation review of home care benefits, including the use of preauthori- 24 zation and appropriateness criteria as to the level and intensity of 25 treatment applicable to home care, provided however that any such deter- 26 minations may be subject to appeal under article forty-nine of this 27 chapter. 28 § 2. Paragraph 3 of subsection (a) of section 4303 of the insurance 29 law, subparagraphs (A), (B) and (C) as amended by chapter 557 of the 30 laws of 2000 and subparagraph (D) as amended by chapter 21 of the laws 31 of 1990, is amended to read as follows: 32 (3) For home care to residents in this state. Such home care coverage 33 shall be included at the inception of all new contracts and, with 34 respect to all other contracts, added at any anniversary date of the 35 contract subject to evidence of insurability. Such coverage may be 36 subject to an annual deductible of not more than fifty dollars for each 37 covered person and may be subject to a coinsurance provision which 38 provides for coverage of not less than seventy-five percent of the 39 reasonable cost of services for which payment may be made. No such 40 corporation need provide such coverage to persons eligible for medicare. 41 (A) Home care shall mean the care and treatment of a covered person 42 who is under the care of a physician [but only if: 43 (i)] and who requires the services of an agency described in subpara- 44 graph (B) of this paragraph for: transition of the covered person from 45 hospital, nursing facility or other institutional setting to home; for 46 rehabilitation, recovery or medical management of the covered person at 47 home following hospitalization or following care in a nursing facility 48 or other institutional setting; or medical management of a condition 49 predisposing the covered individual to hospitalization [or], confinement 50 in a nursing facility [as defined in subchapter XVIII of the Social 51 Security Act, 42 U.S.C. § 1395 et seq, would otherwise have been 52 required] or the need for other out-of-home services otherwise covered 53 under the policy, if home care [was] is not provided, and 54 [(ii)] the plan covering the home health service is established and 55 approved in writing by such physician.
A. 3903 3 1 (B) Home care shall be provided by an agency possessing a valid 2 certificate of approval or license issued pursuant to article thirty-six 3 of the public health law. 4 (C) Home care shall consist of one or more of the following: 5 (i) part-time or intermittent home nursing care by or under the super- 6 vision of a registered professional nurse (R.N.), 7 (ii) part-time or intermittent home health aide services which consist 8 primarily of caring for the patient, 9 (iii) physical, occupational or speech therapy, social work, respir- 10 atory therapy and nutritional counseling, if provided by the home health 11 service or agency, and 12 (iv) medical supplies, drugs and medications prescribed by a physi- 13 cian, and laboratory services by or on behalf of a certified home health 14 agency or licensed home care services agency to the extent such items 15 would have been covered or provided under the contract if the covered 16 person had been hospitalized or confined in a skilled nursing facility 17 as defined in subchapter XVIII of the Social Security Act, 42 U.S.C. § 18 1395 et seq. 19 (D) For the purpose of determining the benefits for home care avail- 20 able to a covered person, [each visit by a member of a home care team 21 shall be considered as one home care visit. The contract may contain a 22 limitation on the number of home care visits, but not less than forty 23 such visits in any calendar year or in any continuous period of twelve 24 months, for each covered person. Four hours of home health aide service 25 shall be considered as one home care visit. Every contract issued by a 26 hospital service corporation or health service corporation which 27 provides coverage supplementing part A and part B of subchapter XVIII of 28 the Social Security Act, 42 U.S.C. § 1395 et seq, must make available 29 and, if requested by a subscriber holding a direct payment contract or 30 by all subscribers in a group remittance group or by the contract holder 31 in the case of group contracts issued pursuant to section four thousand 32 three hundred five of this article, provide coverage of supplemental 33 home care visits beyond those provided by part A and part B, sufficient 34 to produce an aggregate coverage of three hundred sixty-five home care 35 visits per contract year. Such coverage shall be provided pursuant to 36 regulations prescribed by the superintendent. Written notice of the 37 availability of such coverage shall be delivered to the group remitting 38 agent or group contract holder prior to inception of such contract and 39 annually thereafter, except that this notice shall not be required where 40 a policy covers two hundred or more employees or where the benefit 41 structure was the subject of collective bargaining affecting persons who 42 are employed in more than one state] nothing in this paragraph shall be 43 construed to prevent the management or utilization review of home care 44 benefits, including the use of preauthorization and appropriateness 45 criteria as to the level and intensity of treatment applicable to home 46 care, provided however that any such determinations may be subject to 47 appeal under article forty-nine of this chapter. 48 § 3. This act shall take effect on the first of January next succeed- 49 ing the date on which it shall have become a law and shall apply to all 50 policies and contracts issued, renewed, modified, altered or amended on 51 or after such date.