<STYLE><!--U {color: Green}S {color: RED} I {color: DARKBLUE; background-color:yellow} P.brk {page-break-before:always}--></STYLE> <BASEFONT SIZE=3> <PRE WIDTH="108"> <FONT SIZE=5><B> STATE OF NEW YORK</B></FONT> ________________________________________________________________________ 8052 2025-2026 Regular Sessions <FONT SIZE=5><B> IN ASSEMBLY</B></FONT> April 22, 2025 ___________ Introduced by M. of A. LAVINE, COLTON, GLICK, SAYEGH, SEAWRIGHT, TAYLOR, VANEL, STIRPE, WOERNER, SHRESTHA -- Multi-Sponsored by -- M. of A. HEVESI -- read once and referred to the Committee on Health AN ACT to amend the public health law and the insurance law, in relation to health care professional applications and terminations <B><U>The People of the State of New York, represented in Senate and Assem-</U></B> <B><U>bly, do enact as follows:</U></B> 1 Section 1. Subdivisions 2, 3, 4, 5, 6, 7, 8 and 9 of section 4406-d of 2 the public health law, as added by chapter 705 of the laws of 1996, are 3 amended to read as follows: 4 2. (a) A health care plan shall not terminate <B><U>or not renew</U></B> a contract 5 with a health care professional unless the health care plan provides to 6 the health care professional a written explanation of the reasons for 7 the proposed contract termination and an opportunity for a review or 8 hearing as hereinafter provided. This section shall not apply in cases 9 involving imminent harm to patient care, a determination of fraud, or a 10 final disciplinary action by a state licensing board or other govern- 11 mental agency that impairs the health care professional's ability to 12 practice. 13 (b) The notice of the proposed contract termination <B><U>or non-renewal</U></B> 14 provided by the health care plan to the health care professional shall 15 include: 16 (i) the reasons for the proposed action; 17 (ii) notice that the health care professional has the right to request 18 a hearing or review, at the professional's discretion, before a panel 19 [<B><S>appointed by the health care plan</S></B>] <B><U>comprised of no fewer than three</U></B> 20 <B><U>health care professionals licensed to practice in the state of New York</U></B>; 21 (iii) a time limit of not less than thirty days within which a health 22 care professional may request a hearing; and 23 (iv) a time limit for a hearing date which must be held within thirty 24 days after the date of receipt of a request for a hearing. EXPLANATION--Matter in <B><U>italics</U></B> (underscored) is new; matter in brackets [<B><S> </S></B>] is old law to be omitted. LBD03549-03-5 </PRE><P CLASS="brk"><PRE WIDTH="108"> A. 8052 2 1 (c) The hearing panel shall be comprised of three [<B><S>persons appointed</S></B> 2 <B><S>by the health care plan</S></B>] <B><U>health care professionals licensed to practice</U></B> 3 <B><U>by the state of New York in the same profession as the subject of the</U></B> 4 <B><U>review, one of whom is appointed by the health care plan, one of whom is</U></B> 5 <B><U>appointed by the health care professional who is the subject of the</U></B> 6 <B><U>hearing. The remaining member of the panel shall be chosen by the other</U></B> 7 <B><U>two panel members</U></B>. At least one person on such panel shall be a clinical 8 peer in the same discipline and the same or similar specialty as the 9 health care professional under review. The hearing panel may consist of 10 more than three persons, provided however that the number of clinical 11 peers on such panel shall constitute one-third or more of the total 12 membership of the panel <B><U>and provided further that the ratio of the</U></B> 13 <B><U>number of health care professionals appointed by the health care plan to</U></B> 14 <B><U>the number of health care professionals appointed by the subject of the</U></B> 15 <B><U>hearing to the number of health care professionals chosen by the other</U></B> 16 <B><U>panel members remains one to one to one</U></B>. 17 (d) The hearing panel shall render a decision on the proposed action 18 in a timely manner. Such decision shall include reinstatement of the 19 health care professional by the health care plan, provisional rein- 20 statement subject to conditions set forth by the health care plan or 21 termination of the health care professional. Such decision shall be 22 provided in writing to the health care professional. 23 (e) A decision by the hearing panel to terminate <B><U>or not renew</U></B> a health 24 care professional shall be effective not less than thirty days after the 25 receipt by the health care professional of the hearing panel's decision; 26 provided, however, that the provisions of paragraph (e) of subdivision 27 six of section [<B><S>four thousand four</S></B>] <B><U>forty-four</U></B> hundred three of this 28 article shall apply to such termination <B><U>or non-renewal</U></B>. 29 (f) In no event shall termination be effective earlier than sixty days 30 from the receipt of the notice of termination. 31 3. [<B><S>Either party to a contract may exercise a right of non-renewal at</S></B> 32 <B><S>the expiration of the contract period set forth therein or, for a</S></B> 33 <B><S>contract without a specific expiration date, on each January first</S></B> 34 <B><S>occurring after the contract has been in effect for at least one year,</S></B> 35 <B><S>upon sixty days notice to the other party; provided, however, that any</S></B> 36 <B><S>non-renewal shall not constitute a termination for purposes of this</S></B> 37 <B><S>section.</S></B> 38 <B><S>4.</S></B>] A health care plan shall develop and implement policies and proce- 39 dures to ensure that health care professionals are regularly informed of 40 information maintained by the health care plan to evaluate the perform- 41 ance or practice of the health care professional. The health care plan 42 shall consult with health care professionals in developing methodologies 43 to collect and analyze health care professional profiling data. Health 44 care plans shall provide any such information and profiling data and 45 analysis to health care professionals. Such information, data or analy- 46 sis shall be provided on a periodic basis appropriate to the nature and 47 amount of data and the volume and scope of services provided. Any 48 profiling data used to evaluate the performance or practice of a health 49 care professional shall be measured against stated criteria and an 50 appropriate group of health care professionals using similar treatment 51 modalities serving a comparable patient population. Upon presentation of 52 such information or data, each health care professional shall be given 53 the opportunity to discuss the unique nature of the health care profes- 54 sional's patient population which may have a bearing on the health care 55 professional's profile and to work cooperatively with the health care 56 plan to improve performance. </PRE><P CLASS="brk"><PRE WIDTH="108"> A. 8052 3 1 [<B><S>5.</S></B>] <B><U>4.</U></B> No health care plan shall terminate a contract or employment, 2 or refuse to renew a contract, solely because a health care provider 3 has: 4 (a) advocated on behalf of an enrollee; 5 (b) filed a complaint against the health care plan; 6 (c) appealed a decision of the health care plan; 7 (d) provided information or filed a report pursuant to section forty- 8 four hundred six-c of this article; or 9 (e) requested a hearing or review pursuant to this section. 10 [<B><S>6.</S></B>] <B><U>5.</U></B> Except as provided herein, no contract or agreement between a 11 health care plan and a health care professional shall contain any 12 provision which shall supersede or impair a health care professional's 13 right to notice of reasons for termination <B><U>or non-renewal</U></B> and the oppor- 14 tunity for a hearing or review concerning such termination <B><U>or non-rene-</U></B> 15 <B><U>wal</U></B>. 16 [<B><S>7.</S></B>] <B><U>6.</U></B> Any contract provision in violation of this section shall be 17 deemed to be void and unenforceable. 18 [<B><S>8.</S></B>] <B><U>7.</U></B> For purposes of this section, "health care plan" shall mean a 19 health maintenance organization licensed pursuant to article forty-three 20 of the insurance law or certified pursuant to this article or an inde- 21 pendent practice association certified or recognized pursuant to this 22 article. 23 [<B><S>9.</S></B>] <B><U>8.</U></B> For purposes of this section, "health care professional" shall 24 mean a health care professional licensed, registered or certified pursu- 25 ant to title eight of the education law. 26 § 2. Subsections (b), (c), (d), (e), (f), (g) and (h) of section 4803 27 of the insurance law, as added by chapter 705 of the laws of 1996, are 28 amended to read as follows: 29 (b) (1) An insurer shall not terminate <B><U>or not renew</U></B> a contract with a 30 health care professional for participation in the in-network benefits 31 portion of the insurer's network for a managed care product unless the 32 insurer provides to the health care professional a written explanation 33 of the reasons for the proposed contract termination and an opportunity 34 for a review or hearing as hereinafter provided. This section shall not 35 apply in cases involving imminent harm to patient care, a determination 36 of fraud, or a final disciplinary action by a state licensing board or 37 other governmental agency that impairs the health care professional's 38 ability to practice. 39 (2) The notice of the proposed contract termination <B><U>or non-renewal</U></B> 40 provided by the insurer to the health care professional shall include: 41 (i) the reasons for the proposed action; 42 (ii) notice that the health care professional has the right to request 43 a hearing or review, at the professional's discretion, before a panel 44 [<B><S>appointed by the insurer</S></B>] <B><U>comprised of no fewer than three health care</U></B> 45 <B><U>professionals licensed to practice by the state of New York</U></B>; 46 (iii) a time limit of not less than thirty days within which a health 47 care professional may request a hearing or review; and 48 (iv) a time limit for a hearing date which must be held within not 49 less than thirty days after the date of receipt of a request for a hear- 50 ing. 51 (3) The hearing panel shall be comprised of three [<B><S>persons appointed</S></B> 52 <B><S>by the insurer</S></B>] <B><U>health care professionals licensed to practice by the</U></B> 53 <B><U>state of New York in the same profession as the subject of the review,</U></B> 54 <B><U>one of whom is appointed by the insurer, one of whom is appointed by the</U></B> 55 <B><U>health care professional who is the subject of the hearing. The remain-</U></B> 56 <B><U>ing member of the panel shall be chosen by the other two panel members</U></B>. </PRE><P CLASS="brk"><PRE WIDTH="108"> A. 8052 4 1 At least one person on such panel shall be a clinical peer in the same 2 discipline and the same or similar specialty as the health care profes- 3 sional under review. The hearing panel may consist of more than three 4 persons, provided however that the number of clinical peers on such 5 panel shall constitute one-third or more of the total membership of the 6 panel <B><U>and provided further that the ratio of the number of health care</U></B> 7 <B><U>professionals appointed by the health care plan to the number of health</U></B> 8 <B><U>care professionals appointed by the subject of the hearing to the number</U></B> 9 <B><U>of health care professionals chosen by the two other panel members</U></B> 10 <B><U>remains one to one to one</U></B>. 11 (4) The hearing panel shall render a decision on the proposed action 12 in a timely manner. Such decision shall include reinstatement of the 13 health care professional by the insurer, provisional reinstatement 14 subject to conditions set forth by the insurer or termination of the 15 health care professional. Such decision shall be provided in writing to 16 the health care professional. 17 (5) A decision by the hearing panel to terminate <B><U>or not renew</U></B> a health 18 care professional shall be effective not less than thirty days after the 19 receipt by the health care professional of the hearing panel's decision; 20 provided, however, that the provisions of subsection (e) of section four 21 thousand eight hundred four <B><U>of this article</U></B> shall apply to such termi- 22 nation. 23 (6) In no event shall termination <B><U>or non-renewal</U></B> be effective earlier 24 than sixty days from the receipt of the notice of termination <B><U>or non-re-</U></B> 25 <B><U>newal</U></B>. 26 (c) [<B><S>Either party to a contract for participation in the in-network</S></B> 27 <B><S>benefits portion of an insurer's network for a managed care product may</S></B> 28 <B><S>exercise a right of non-renewal at the expiration of the contract period</S></B> 29 <B><S>set forth therein or, for a contract without a specific expiration date,</S></B> 30 <B><S>on each January first occurring after the contract has been in effect</S></B> 31 <B><S>for at least one year, upon sixty days notice to the other party;</S></B> 32 <B><S>provided, however, that any non-renewal shall not constitute a termi-</S></B> 33 <B><S>nation for purposes of this section.</S></B> 34 <B><S>(d)</S></B>] An insurer shall develop and implement policies and procedures to 35 ensure that health care providers participating in [<B><S>the</S></B>] the in-network 36 benefits portion of an insurer's network for a managed care product are 37 regularly informed of information maintained by the insurer to evaluate 38 the performance or practice of the health care professional. The insurer 39 shall consult with health care professionals in developing methodologies 40 to collect and analyze provider profiling data. Insurers shall provide 41 any such information and profiling data and analysis to these health 42 care professionals. Such information, data or analysis shall be provided 43 on a periodic basis appropriate to the nature and amount of data and the 44 volume and scope of services provided. Any profiling data used to evalu- 45 ate the performance or practice of such a health care professional shall 46 be measured against stated criteria and an appropriate group of health 47 care professionals using similar treatment modalities serving a compara- 48 ble patient population. Upon presentation of such information or data, 49 each such health care professional shall be given the opportunity to 50 discuss the unique nature of the health care professional's patient 51 population which may have a bearing on the professional's profile and to 52 work cooperatively with the insurer to improve performance. 53 [<B><S>(e)</S></B>] <B><U>(d)</U></B> No insurer shall terminate or refuse to renew a contract for 54 participation in the in-network benefits portion of an insurer's network 55 for a managed care product solely because the health care professional 56 has (1) advocated on behalf of an insured; (2) has filed a complaint </PRE><P CLASS="brk"><PRE WIDTH="108"> A. 8052 5 1 against the insurer; (3) has appealed a decision of the insurer; (4) 2 provided information or filed a report pursuant to section forty-four 3 hundred six-c of the public health law; or (5) requested a hearing or 4 review pursuant to this section. 5 [<B><S>(f)</S></B>] <B><U>(e)</U></B> Except as provided herein, no contract or agreement between 6 an insurer and a health care professional for participation in the 7 in-network benefits portion of an insurer's network for a managed care 8 product shall contain any provision which shall supersede or impair a 9 health care professional's right to notice of reasons for termination <B><U>or</U></B> 10 <B><U>non-renewal</U></B> and the opportunity for a hearing concerning such termi- 11 nation <B><U>or non-renewal</U></B>. 12 [<B><S>(g)</S></B>] <B><U>(f)</U></B> Any contract provision in violation of this section shall be 13 deemed to be void and unenforceable. 14 [<B><S>(h)</S></B>] <B><U>(g)</U></B> For purposes of this section, "health care professional" 15 shall mean a health care professional licensed, registered or certified 16 pursuant to title eight of the education law. 17 § 3. This act shall take effect immediately.