Provides that any copayment or coinsurance amount charged by an insurer to the insured for services rendered by a physical therapist or an occupational therapist shall not be more than twenty-five percent greater than the copayment or coinsurance amount imposed for an office visit to a licensed primary care physician or osteopath for the same or a similar diagnosed condition.
Summary
S05045 amends several provisions of New York’s insurance law to limit how much insurers may charge in copayments or coinsurance for physical therapy and occupational therapy services. Under the bill, when a policy covers these services, the patient cost-sharing for treatment provided by a licensed physical therapist or occupational therapist may not exceed 125% of the copayment or coinsurance charged for an office visit to a licensed primary care physician or osteopath for the same or a similar diagnosed condition. The bill applies this cap across multiple insurance coverage sections, including individual, group, nonprofit, and outpatient physical therapy coverage provisions.
The measure also preserves existing coverage rules requiring that therapy be within the lawful scope of practice, subject to utilization review, and generally provided pursuant to a medical order, prescription, or referral where applicable. It does not mandate new coverage for therapy services; rather, it regulates the patient cost-sharing structure when such services are already covered. The act would take effect on January 1, 2027.
Impact
The bill would amend Insurance Law sections 3216, 4235, 4301, and 4322 to standardize and cap copayments/coinsurance for physical and occupational therapy across several insurance policy types. Its practical effect is to reduce out-of-pocket costs for insured patients receiving therapy from licensed physical or occupational therapists, while limiting insurers’ ability to set higher cost-sharing for those services than for comparable primary care office visits. It would affect insurers, policyholders, and licensed therapists by creating a new parity-style cost-sharing rule in state insurance law.
Sentiment
The available legislative history suggests generally favorable sentiment toward the bill. It was introduced by a bipartisan group of senators and reported favorably from the Senate Insurance Committee, indicating committee-level support. No recorded votes or committee transcript objections are provided, so there is no evidence in the supplied materials of organized opposition or controversy at this stage.
Contention
The main policy issue is the extent to which insurers should be allowed to charge higher copayments or coinsurance for therapy services than for primary care visits. Supporters appear to favor reducing financial barriers to physical and occupational therapy and aligning patient cost-sharing more closely with primary care. Potential points of contention, though not documented in the provided record, would likely involve insurers’ concerns about premium impacts, utilization, and whether therapy services should be treated the same as physician office visits for cost-sharing purposes. The bill does not appear to change medical necessity or referral requirements, which may limit some opposition.
Same As
Provides that any copayment or coinsurance amount charged by an insurer to the insured for services rendered by a physical therapist or an occupational therapist shall not be more than twenty-five percent greater than the copayment or coinsurance amount imposed for an office visit to a licensed primary care physician or osteopath for the same or a similar diagnosed condition.
Provides that any copayment or coinsurance amount charged by an insurer to the insured for services rendered by a physical therapist or an occupational therapist shall not be more than twenty-five percent greater than the copayment or coinsurance amount imposed for an office visit to a licensed primary care physician or osteopath for the same or a similar diagnosed condition.
Limits copays, coinsurance or office deductibles for services of a physical therapist to the amount authorized for the services of a primary care physician or osteopath on or after January 1, 2027.
Limits copays, coinsurance or office deductibles for services of a physical therapist to the amount authorized for the services of a primary care physician or osteopath on or after January 1, 2026.
Limits copays, coinsurance or office deductibles for services of a physical therapist to the amount authorized for the services of a primary care physician or osteopath on or after January 1, 2026.
Limits copays, coinsurance or office deductibles for services of a physical therapist to the amount authorized for the services of a primary care physician or osteopath on or after January 1, 2027.
Provides that no policy of group accident, group health or group accident and health shall impose copayments for physical or occupational therapy greater than the copay for similar services provided by a physician.
Includes physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, respiratory therapists, respiratory therapy technicians, and recreational therapists within the existing statutory staffing standards for nursing homes.
Changes the definition of continuous supervision in relation to physical therapist assistants in both the home care setting and school setting by eliminating the joint visit requirement with the patient by the supervising licensed physical therapist and the licensed physical therapist assistant.