Bill Text: NY A05782 | 2019-2020 | General Assembly | Introduced
Bill Title: Provides health insurance coverage for New Yorkers if the federal Affordable Care Act is repealed.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2020-01-08 - referred to insurance [A05782 Detail]
Download: New_York-2019-A05782-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 5782 2019-2020 Regular Sessions IN ASSEMBLY February 19, 2019 ___________ Introduced by M. of A. ROZIC -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law, in relation to providing health insurance protection to New Yorkers in the event that the federal Affordable Care Act is repealed The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. The insurance law is amended by adding a new section 3217-i 2 to read as follows: 3 § 3217-i. Essential health benefits package. (a) Coverage required. 4 No insurer subject to this article shall decline to provide an essential 5 health benefits package as required by this section. 6 (b) Definition. The term "essential health benefits package" means, 7 with respect to any health plan, coverage that provides for the essen- 8 tial health benefits as defined by the superintendent under subsection 9 (c) of this section; limits cost-sharing for such coverage in accordance 10 with subsection (d) of this section; and subject to subsection (d) of 11 this section, provides either bronze, silver, gold or platinum level of 12 coverage as described in subsection (e) of this section. 13 (c) Superintendent's powers and duties with respect to essential 14 health benefits. (1) Subject to paragraph two of this subsection, the 15 superintendent shall define the essential health benefits, except that 16 such benefits shall include at least the following general categories 17 and the items and services covered within such categories: (i) ambulato- 18 ry patient services, (ii) emergency services, (iii) hospitalization, 19 (iv) maternity and newborn care, (v) mental health and substance use 20 disorder services, including behavioral health treatment, (vi) 21 prescription drugs, (vii) rehabilitative and habilitative services and 22 devices, (viii) laboratory services, (ix) preventive and wellness 23 services and chronic disease management, and (x) pediatric services, 24 including oral and vision care. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD00844-01-9A. 5782 2 1 (2) The superintendent shall ensure that the scope of the essential 2 health benefits under paragraph one of this subsection is equal to the 3 scope of benefits provided under a typical employer plan, as determined 4 by the superintendent. In defining the essential health benefits under 5 paragraph one of this subsection, the superintendent shall: 6 (A) ensure that such essential health benefits reflect an appropriate 7 balance among the categories described in paragraph one of this 8 subsection so that benefits are not unduly weighted toward any category; 9 (B) not make coverage decisions, determine reimbursement rates, estab- 10 lish incentive programs, or design benefits in ways that discriminate 11 against individuals because of their age, disability, or expected length 12 of life; 13 (C) take into account the health care needs of diverse segments of the 14 population, including women, children, persons with disabilities, and 15 other groups; 16 (D) ensure that health benefits established as essential not be 17 subject to denial to individuals against their wishes on the basis of 18 the individuals' age or expected length of life or of the individuals' 19 present or predicted disability, degree of medical dependency, or quali- 20 ty of life; 21 (E) provide that a qualified health plan shall not be treated as 22 providing coverage for the essential health benefits described in para- 23 graph one of this subsection unless the plan provides that: 24 (i) coverage for emergency department services will be provided with- 25 out imposing any requirement under the plan for prior authorization of 26 services or any limitation on coverage where the provider of services 27 does not have a contractual relationship with the plan for the providing 28 of services that is more restrictive than the requirements or limita- 29 tions that apply to emergency department services received from provid- 30 ers who do have such a contractual relationship with the plan; and 31 (ii) if such services are provided out-of-network, the cost-sharing 32 requirement, expressed as a copayment amount or coinsurance rate, is the 33 same requirement that would apply if such services were provided in-net- 34 work; 35 (F) provide that if a stand-alone dental benefits plan is offered 36 through an exchange, another health plan offered through such exchange 37 shall not fail to be treated as a qualified health plan solely because 38 the plan does not offer coverage of benefits offered through the stand- 39 alone plan that are otherwise required under subparagraph (G) of this 40 paragraph; and 41 (G) periodically update the essential health benefits under paragraph 42 one of this subsection to address any gaps in access to coverage. 43 (d) Cost-sharing requirements. (1) There shall be an annual limitation 44 on cost-sharing. (A) The cost-sharing incurred under a health plan with 45 respect to self-only coverage or coverage other than self-only coverage 46 for a plan year beginning in two thousand fourteen shall not exceed the 47 dollar amounts in effect for self-only and family coverage, respective- 48 ly, for taxable years beginning in two thousand fourteen. 49 (B) In the case of any plan year beginning in a calendar year after 50 two thousand fourteen, the limitation under this paragraph shall: 51 (i) in the case of self-only coverage, be equal to the dollar amount 52 under subparagraph (A) of this paragraph for self-only coverage for plan 53 years beginning in two thousand fourteen, increased by an amount equal 54 to the product of that amount and the premium adjustment percentage 55 under paragraph three of this subsection for the calendar year; andA. 5782 3 1 (ii) in the case of other coverage, twice the amount in effect under 2 clause (i) of this subparagraph. If the amount of any increase under 3 clause (i) of this subparagraph is not a multiple of fifty dollars, such 4 increase shall be rounded to the next lowest multiple of fifty dollars. 5 (2) (A) The term "cost-sharing" shall include: 6 (i) deductibles, coinsurance, copayments, or similar charges; and 7 (ii) any other expenditure required of an insured individual which is 8 a qualified medical expense with respect to essential health benefits 9 covered under the plan. 10 (B) Such term does not include premiums, balance billing amounts for 11 non-network providers, or spending for non-covered services. 12 (3) For purposes of clause (i) of subparagraph (B) of paragraph one of 13 this subsection, the premium adjustment percentage for any calendar year 14 is the percentage, if any, by which the average per capita premium for 15 health insurance coverage in the United States for the preceding calen- 16 dar year exceeds such average per capita premium for the year two thou- 17 sand thirteen. 18 (e) Levels of coverage. (1) Levels of coverage described in this 19 subsection are as follows: 20 (A) Bronze level. A plan in the bronze level shall provide a level of 21 coverage that is designed to provide benefits that are actuarially 22 equivalent to sixty percent of the full actuarial value of the benefits 23 provided under the plan. 24 (B) Silver level. A plan in the silver level shall provide a level of 25 coverage that is designed to provide benefits that are actuarially 26 equivalent to seventy percent of the full actuarial value of the bene- 27 fits provided under the plan. 28 (C) Gold level. A plan in the gold level shall provide a level of 29 coverage that is designed to provide benefits that are actuarially 30 equivalent to eighty percent of the full actuarial value of the benefits 31 provided under the plan. 32 (D) Platinum level. A plan in the platinum level shall provide a level 33 of coverage that is designed to provide benefits that are actuarially 34 equivalent to ninety percent of the full actuarial value of the benefits 35 provided under the plan. 36 (2) (A) Actuarial value. Under regulations issued by the superinten- 37 dent, the level of coverage of a plan shall be determined on the basis 38 that the essential health benefits described in subsection (c) of this 39 section shall be provided to a standard population and without regard to 40 the population the plan may actually provide benefits to. 41 (B) Employer contributions. The superintendent shall issue regulations 42 under which employer contributions to a health savings account may be 43 taken into account. 44 § 2. The insurance law is amended by adding a new section 4306-h to 45 read as follows: 46 § 4306-h. Essential health benefits package. (a) Coverage required. No 47 corporation subject to this article shall decline to provide an essen- 48 tial health benefits package as required by this section. 49 (b) Definition. The term "essential health benefits package" means, 50 with respect to any health plan, coverage that provides for the essen- 51 tial health benefits as defined by the superintendent under subsection 52 (c) of this section; limits cost-sharing for such coverage in accordance 53 with subsection (d) of this section; and subject to subsection (d) of 54 this section, provides either bronze, silver, gold or platinum level of 55 coverage as described in subsection (e) of this section.A. 5782 4 1 (c) Superintendent's powers and duties with respect to essential 2 health benefits. (1) Subject to paragraph two of this subsection, the 3 superintendent shall define the essential health benefits, except that 4 such benefits shall include at least the following general categories 5 and the items and services covered within such categories: (i) ambulato- 6 ry patient services, (ii) emergency services, (iii) hospitalization, 7 (iv) maternity and newborn care, (v) mental health and substance use 8 disorder services, including behavioral health treatment, (vi) 9 prescription drugs, (vii) rehabilitative and habilitative services and 10 devices, (viii) laboratory services, (ix) preventive and wellness 11 services and chronic disease management, and (x) pediatric services, 12 including oral and vision care. 13 (2) The superintendent shall ensure that the scope of the essential 14 health benefits under paragraph one of this subsection is equal to the 15 scope of benefits provided under a typical employer plan, as determined 16 by the superintendent. In defining the essential health benefits under 17 paragraph one of this subsection, the superintendent shall: 18 (A) ensure that such essential health benefits reflect an appropriate 19 balance among the categories described in paragraph one of this 20 subsection so that benefits are not unduly weighted toward any category; 21 (B) not make coverage decisions, determine reimbursement rates, estab- 22 lish incentive programs, or design benefits in ways that discriminate 23 against individuals because of their age, disability, or expected length 24 of life; 25 (C) take into account the health care needs of diverse segments of the 26 population, including women, children, persons with disabilities, and 27 other groups; 28 (D) ensure that health benefits established as essential not be 29 subject to denial to individuals against their wishes on the basis of 30 the individuals' age or expected length of life or of the individuals' 31 present or predicted disability, degree of medical dependency, or quali- 32 ty of life; 33 (E) provide that a qualified health plan shall not be treated as 34 providing coverage for the essential health benefits described in para- 35 graph one of this subsection unless the plan provides that: 36 (i) coverage for emergency department services will be provided with- 37 out imposing any requirement under the plan for prior authorization of 38 services or any limitation on coverage where the provider of services 39 does not have a contractual relationship with the plan for the providing 40 of services that is more restrictive than the requirements or limita- 41 tions that apply to emergency department services received from provid- 42 ers who do have such a contractual relationship with the plan; and 43 (ii) if such services are provided out-of-network, the cost-sharing 44 requirement, expressed as a copayment amount or coinsurance rate, is the 45 same requirement that would apply if such services were provided in-net- 46 work; 47 (F) provide that if a stand-alone dental benefits plan is offered 48 through an exchange, another health plan offered through such exchange 49 shall not fail to be treated as a qualified health plan solely because 50 the plan does not offer coverage of benefits offered through the stand- 51 alone plan that are otherwise required under subparagraph (G) of this 52 paragraph; and 53 (G) periodically update the essential health benefits under paragraph 54 one of this subsection to address any gaps in access to coverage. 55 (d) Cost-sharing requirements. (1) There shall be an annual limitation 56 on cost-sharing. (A) The cost-sharing incurred under a health plan withA. 5782 5 1 respect to self-only coverage or coverage other than self-only coverage 2 for a plan year beginning in two thousand fourteen shall not exceed the 3 dollar amounts in effect for self-only and family coverage, respective- 4 ly, for taxable years beginning in two thousand fourteen. 5 (B) In the case of any plan year beginning in a calendar year after 6 two thousand fourteen, the limitation under this paragraph shall: 7 (i) in the case of self-only coverage, be equal to the dollar amount 8 under subparagraph (A) of this paragraph for self-only coverage for plan 9 years beginning in two thousand fourteen, increased by an amount equal 10 to the product of that amount and the premium adjustment percentage 11 under paragraph three of this subsection for the calendar year; and 12 (ii) in the case of other coverage, twice the amount in effect under 13 clause (i) of this subparagraph. If the amount of any increase under 14 clause (i) of this subparagraph is not a multiple of fifty dollars, such 15 increase shall be rounded to the next lowest multiple of fifty dollars. 16 (2) (A) The term "cost-sharing" shall include: 17 (i) deductibles, coinsurance, copayments, or similar charges; and 18 (ii) any other expenditure required of an insured individual which is 19 a qualified medical expense with respect to essential health benefits 20 covered under the plan. 21 (B) Such term does not include premiums, balance billing amounts for 22 non-network providers, or spending for non-covered services. 23 (3) For purposes of clause (i) of subparagraph (B) of paragraph one of 24 this subsection, the premium adjustment percentage for any calendar year 25 is the percentage, if any, by which the average per capita premium for 26 health insurance coverage in the United States for the preceding calen- 27 dar year exceeds such average per capita premium for the year two thou- 28 sand thirteen. 29 (e) Levels of coverage. (1) Levels of coverage described in this 30 subsection are as follows: 31 (A) Bronze level. A plan in the bronze level shall provide a level of 32 coverage that is designed to provide benefits that are actuarially 33 equivalent to sixty percent of the full actuarial value of the benefits 34 provided under the plan. 35 (B) Silver level. A plan in the silver level shall provide a level of 36 coverage that is designed to provide benefits that are actuarially 37 equivalent to seventy percent of the full actuarial value of the bene- 38 fits provided under the plan. 39 (C) Gold level. A plan in the gold level shall provide a level of 40 coverage that is designed to provide benefits that are actuarially 41 equivalent to eighty percent of the full actuarial value of the benefits 42 provided under the plan. 43 (D) Platinum level. A plan in the platinum level shall provide a level 44 of coverage that is designed to provide benefits that are actuarially 45 equivalent to ninety percent of the full actuarial value of the benefits 46 provided under the plan. 47 (2) (A) Actuarial value. Under regulations issued by the superinten- 48 dent, the level of coverage of a plan shall be determined on the basis 49 that the essential health benefits described in subsection (c) of this 50 section shall be provided to a standard population and without regard to 51 the population the plan may actually provide benefits to. 52 (B) Employer contributions. The superintendent shall issue regulations 53 under which employer contributions to a health savings account may be 54 taken into account. 55 § 3. Subsection (e) of section 3217-f of the insurance law, as added 56 by chapter 219 of the laws of 2011, is amended to read as follows:A. 5782 6 1 (e) For purposes of this section, "essential health benefits" shall 2 have the same meaning [ascribed by section 1302(b) of the Affordable3Care Act, 42 U.S.C. § 18022(b)] as subsection (c) of section three thou- 4 sand two hundred seventeen-i of this article. 5 § 4. Subsection (h) and paragraph 19 of subsection (k) of section 3221 6 of the insurance law, subsection (h) as added by section 54 of part D of 7 chapter 56 of the laws of 2013 and paragraph 19 of subsection (k) as 8 amended by chapter 377 of the laws of 2014, are amended to read as 9 follows: 10 (h) Every small group policy or association group policy delivered or 11 issued for delivery in this state that provides coverage for hospital, 12 medical or surgical expense insurance and is not a grandfathered health 13 plan shall provide coverage for the essential health benefit package as 14 required in section [2707(a) of the public health service act, 42 U.S.C.15§ 300gg-6(a)] three thousand two hundred seventeen-i of this article. 16 For purposes of this subsection: 17 (1) "essential health benefits package" shall have the meaning set 18 forth in [section 1302(a) of the affordable care act, 42 U.S.C. §1918022(a)] subsection (c) of section three thousand two hundred seven- 20 teen-i of this article; 21 (2) "grandfathered health plan" means coverage provided by an insurer 22 in which an individual was enrolled on March twenty-third, two thousand 23 ten for as long as the coverage maintains grandfathered status [in24accordance with section 1251(e) of the affordable care act, 42 U.S.C. §2518011(e)]; 26 (3) "small group" means a group of fifty or fewer employees or members 27 exclusive of spouses and dependents; provided, however, that beginning 28 January first, two thousand sixteen, "small group" means a group of one 29 hundred or fewer employees or members exclusive of spouses and depen- 30 dents; and 31 (4) "association group" means a group defined in subparagraphs (B), 32 (D), (H), (K), (L) or (M) of paragraph one of subsection (c) of section 33 four thousand two hundred thirty-five of this chapter, provided that: 34 (A) the group includes one or more individual members; or 35 (B) the group includes one or more member employers or other member 36 groups that are small groups. 37 (19) Every group or blanket accident and health insurance policy 38 delivered or issued for delivery in this state which provides medical 39 coverage that includes coverage for physician services in a physician's 40 office and every policy which provides major medical or similar compre- 41 hensive-type coverage shall include coverage for equipment and supplies 42 used for the treatment of ostomies, if prescribed by a physician or 43 other licensed health care provider legally authorized to prescribe 44 under title eight of the education law. Such coverage shall be subject 45 to annual deductibles and coinsurance as deemed appropriate by the 46 superintendent. The coverage required by this paragraph shall be identi- 47 cal to, and shall not enhance or increase the coverage required as part 48 of essential health benefits [as required pursuant to section 2707 (a)49of the public health services act 42 U.S.C. 300 gg-6(a)] set forth in 50 section three thousand two hundred seventeen-i of this article. 51 § 5. Subsection (d) of section 3240 of the insurance law, as added by 52 section 41 of part D of chapter 56 of the laws of 2013, is amended to 53 read as follows: 54 (d) A student accident and health insurance policy or contract shall 55 provide coverage for essential health benefits as defined in [sectionA. 5782 7 11302(b) of the affordable care act, 42 U.S.C. § 18022(b)] subsection (c) 2 of section three thousand two hundred seventeen-i of this article. 3 § 6. Subsection (u-1) of section 4303 of the insurance law, as amended 4 by chapter 377 of the laws of 2014, is amended to read as follows: 5 (u-1) A medical expense indemnity corporation or a health service 6 corporation which provides medical coverage that includes coverage for 7 physician services in a physician's office and every policy which 8 provides major medical or similar comprehensive-type coverage shall 9 include coverage for equipment and supplies used for the treatment of 10 ostomies, if prescribed by a physician or other licensed health care 11 provider legally authorized to prescribe under title eight of the educa- 12 tion law. Such coverage shall be subject to annual deductibles and coin- 13 surance as deemed appropriate by the superintendent. The coverage 14 required by this subsection shall be identical to, and shall not enhance 15 or increase the coverage required as part of essential health benefits 16 as required pursuant to section [2707(a) of the public health services17act 42 U.S.C. 300 gg-6(a)] four thousand three hundred six-h of this 18 article. 19 § 7. Subsection (e) of section 4306-e of the insurance law, as added 20 by chapter 219 of the laws of 2011, is amended to read as follows: 21 (e) For purposes of this section, "essential health benefits" shall 22 have the meaning ascribed by [section 1302(b) of the Affordable Care23Act, 42 U.S.C. § 18022(b)] subsection (c) of section four thousand three 24 hundred six-h of this article. 25 § 8. Subsections (d) and (e) of section 4326 of the insurance law, as 26 amended by section 56 of part D of chapter 56 of the laws of 2013, are 27 amended to read as follows: 28 (d) A qualifying group health insurance contract shall provide cover- 29 age for the essential health benefit package as required [in section302707(a) of the public health service act, 42 U.S.C. § 300gg-6(a)] by 31 section four thousand three hundred six-h of this article. For purposes 32 of this subsection "essential health benefits package" shall have the 33 meaning set forth in [section 1302(a) of the affordable care act, 4234U.S.C. § 18022(a)] subsection (c) of section four thousand three hundred 35 six-h of this article. 36 (e) A qualifying group health insurance contract issued to a qualify- 37 ing small employer prior to January first, two thousand fourteen that 38 does not include all essential health benefits required pursuant to 39 section [2707(a) of the public health service act, 42 U.S.C. §40300gg-6(a)] four thousand three hundred six-h of this article, shall be 41 discontinued, including grandfathered health plans. For the purposes of 42 this paragraph, "grandfathered health plans" means coverage provided by 43 a corporation to individuals who were enrolled on March twenty-third, 44 two thousand ten for as long as the coverage maintains grandfathered 45 status [in accordance with section 1251(e) of the affordable care act,4642 U.S.C. § 18011(e)]. A qualifying small employer shall be transitioned 47 to a plan that provides: (1) a level of coverage that is designed to 48 provide benefits that are actuarially equivalent to eighty percent of 49 the full actuarial value of the benefits provided under the plan; and 50 (2) coverage for the essential health benefit package as required in 51 section [2707(a) of the public health service act, 42 U.S.C. §52300gg-6(a)] four thousand three hundred six-h of this article. The 53 superintendent shall standardize the benefit package and cost sharing 54 requirements of qualified group health insurance contracts consistent 55 with coverage offered through the health benefit exchange [established56pursuant to section 1311 of the affordable care act, 42 U.S.C. § 18031].A. 5782 8 1 § 9. Paragraph 1 of subsection (b) of section 4328 of the insurance 2 law, as added by section 46 of part D of chapter 56 of the laws of 2013, 3 is amended to read as follows: 4 (1) The individual enrollee direct payment contract offered pursuant 5 to this section shall provide coverage for the essential health benefit 6 package as required in section [2707(a) of the public health service7act, 42 U.S.C. § 300gg-6(a)] four thousand three hundred six-h of this 8 article. For purposes of this paragraph, "essential health benefits 9 package" shall have the meaning set forth in [section 1302(a) of the10affordable care act, 42 U.S.C. § 18022(a)] subsection (c) of section 11 four thousand three hundred six-h of this article. 12 § 10. Subsections (f) and (g) of section 3232 of the insurance law, as 13 added by chapter 219 of the laws of 2011, are amended and a new 14 subsection (j) is added to read as follows: 15 (f) With respect to an individual under age nineteen, an insurer may 16 not impose any pre-existing condition exclusion in an individual or 17 group policy of hospital, medical, surgical or prescription drug expense 18 insurance [pursuant to the requirements of section 2704 of the Public19Health Service Act, 42 U.S.C. § 300gg-3, as made effective by section201255(2) of the Affordable Care Act,] except for an individual under age 21 nineteen covered under an individual policy of hospital, medical, surgi- 22 cal or prescription drug expense insurance that is a grandfathered 23 health plan. 24 (g) Beginning January first, two thousand fourteen[, pursuant to25section 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3,] an 26 insurer may not impose any pre-existing condition exclusion in an indi- 27 vidual or group policy of hospital, medical, surgical or prescription 28 drug expense insurance except in an individual policy that is a grandfa- 29 thered health plan. 30 (j) For purposes of subsections (f) and (g) of this section, "pre-ex- 31 isting condition" shall mean a limitation or exclusion of benefits 32 relating to a condition based on the fact that the condition was present 33 before the date of enrollment for such coverage, whether or not any 34 medical advice, diagnosis, care, or treatment was recommended or 35 received before such date. 36 § 11. Subsections (f) and (g) of section 4318 of the insurance law, as 37 added by chapter 219 of the laws of 2011, are amended and a new 38 subsection (j) is added to read as follows: 39 (f) With respect to an individual under age nineteen, a corporation 40 may not impose any pre-existing condition exclusion in an individual or 41 group contract of hospital, medical, surgical or prescription drug 42 expense insurance pursuant to the requirements of section [2704 of the43Public Health Service Act, 42 U.S.C. § 300gg-3, as made effective by44section 1255(2) of the Affordable Care Act] four thousand three hundred 45 six-h of this article, except for an individual under age nineteen 46 covered under an individual contract of hospital, medical, surgical or 47 prescription drug expense insurance that is a grandfathered health plan. 48 (g) Beginning January first, two thousand fourteen, pursuant to 49 section [2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3] 50 four thousand three hundred six-h of this article, a corporation may not 51 impose any pre-existing condition exclusion in an individual or group 52 contract of hospital, medical, surgical or prescription drug expense 53 insurance except in an individual contract that is a grandfathered 54 health plan. 55 (j) For purposes of subsections (f) and (g) of this section, "pre-ex- 56 isting exclusion" shall mean a limitation or exclusion of benefitsA. 5782 9 1 relating to a condition based on the fact that the condition was present 2 before the date of enrollment for such coverage, whether or not any 3 medical advice, diagnosis, care, or treatment was recommended or 4 received before such date. 5 § 12. This act shall take effect on such date as the affordable care 6 act is fully repealed and at such time as the provisions of such act are 7 no longer in force and effect; provided that the superintendent of 8 financial services shall notify the legislative bill drafting commission 9 upon the occurrence of the repeal of the federal Affordable Care Act in 10 order that the commission may maintain an accurate and timely effective 11 data base of the official text of the laws of the state of New York in 12 furtherance of effectuating the provisions of section 44 of the legisla- 13 tive law and section 70-b of the public officers law.
