Bill Text: NY S01803 | 2009-2010 | General Assembly | Amended
Bill Title: Provides that comprehensive medical insurance policies shall include coverage for regular, non-emergency out-of-network dialysis, with proper medical authorization, notice and no increase in cost to insurer; applies to individual and group policies.
Spectrum: Slight Partisan Bill (Democrat 3-1)
Status: (Passed) 2010-08-30 - SIGNED CHAP.457 [S01803 Detail]
Download: New_York-2009-S01803-Amended.html
S T A T E O F N E W Y O R K
________________________________________________________________________
1803--C
Cal. No. 561
2009-2010 Regular Sessions
I N S E N A T E
February 9, 2009
___________
Introduced by Sens. BRESLIN, ESPADA, THOMPSON -- read twice and ordered
printed, and when printed to be committed to the Committee on Insur-
ance -- committee discharged, bill amended, ordered reprinted as
amended and recommitted to said committee -- recommitted to the
Committee on Insurance in accordance with Senate Rule 6, sec. 8 --
committee discharged, bill amended, ordered reprinted as amended and
recommitted to said committee -- reported favorably from said commit-
tee and committed to the Committee on Finance -- reported favorably
from said committee, ordered to first report, amended on first report,
ordered to a second report and ordered reprinted, retaining its place
in the order of second report
AN ACT to amend the insurance law, in relation to insurance coverage for
out-of-network dialysis
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Subsection (i) of section 3216 of the insurance law is
2 amended by adding a new paragraph 27 to read as follows:
3 (27)(A) EVERY POLICY THAT INCLUDES COVERAGE FOR DIALYSIS TREATMENT
4 THAT REQUIRES SUCH SERVICES TO BE PROVIDED BY AN IN-NETWORK PROVIDER AND
5 THAT DOES NOT PROVIDE COVERAGE FOR OUT-OF-NETWORK DIALYSIS TREATMENT
6 SHALL NOT DENY COVERAGE OF SUCH SERVICES BECAUSE THE SERVICES ARE
7 PROVIDED BY AN OUT-OF-NETWORK PROVIDER, PROVIDED THAT EACH OF THE
8 FOLLOWING CONDITIONS ARE MET:
9 (I) THE OUT-OF-NETWORK PROVIDER IS DULY LICENSED TO PRACTICE AND
10 AUTHORIZED TO PROVIDE SUCH TREATMENT;
11 (II) THE OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE SERVICE AREA
12 OF THE INSURER;
13 (III) THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE INSURED FOR THE
14 CONDITION ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT IN
15 HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD00183-06-0
S. 1803--C 2
1 (IV) THE INSURED HAS NOTIFIED, IN WRITING, THE INSURER AT LEAST THIRTY
2 DAYS IN ADVANCE OF THE PROPOSED DATE OR DATES OF SUCH OUT-OF-NETWORK
3 DIALYSIS TREATMENT. THE NOTICE SHALL INCLUDE THE AUTHORIZATION REQUIRED
4 BY CLAUSE (III) OF THIS SUBPARAGRAPH. IN THE EVENT THE INSURED MUST
5 TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMERGENCY, SHORTER NOTICE
6 MAY BE PERMITTED, PROVIDED THAT THE INSURER HAS REASONABLE OPPORTUNITY
7 TO REVIEW THE TRAVEL AND TREATMENT PLANS OF THE INSURED;
8 (V) THE INSURER SHALL HAVE THE RIGHT TO PRE-APPROVE THE DIALYSIS
9 TREATMENT AND SCHEDULE; AND
10 (VI) SUCH COVERAGE IS LIMITED TO NO GREATER THAN TEN OUT-OF-NETWORK
11 TREATMENTS IN A CALENDAR YEAR.
12 (B) WHERE COVERAGE FOR OUT-OF-NETWORK DIALYSIS TREATMENT IS PROVIDED
13 PURSUANT TO SUBPARAGRAPH (A) OF THIS PARAGRAPH, NO INSURER SHALL BE
14 OBLIGATED TO REIMBURSE THE OUT-OF-NETWORK PROVIDER AT AN AMOUNT GREATER
15 THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK, INCLUD-
16 ING ALL DRUGS AND ANCILLARY SERVICES TIED TO DIALYSIS TREATMENT, AND ANY
17 AMOUNT CHARGED BY A PROVIDER IN EXCESS OF THE AMOUNT REIMBURSED BY THE
18 INSURER SHALL BE THE RESPONSIBILITY OF THE INSURED RECEIVING THE
19 OUT-OF-NETWORK SERVICES.
20 (C) SUCH COVERAGE OF OUT-OF-NETWORK DIALYSIS SERVICES REQUIRED BY
21 SUBPARAGRAPH (A) OF THIS PARAGRAPH SHALL OTHERWISE BE SUBJECT TO THE
22 LIMITATIONS, EXCLUSIONS AND TERMS OF THE POLICY, INCLUDING, BUT NOT
23 LIMITED TO, UTILIZATION REVIEW, ANNUAL DEDUCTIBLES, COPAYMENTS, AND
24 COINSURANCE, CONSISTENT WITH THOSE REQUIRED FOR OTHER SIMILAR BENEFITS
25 UNDER THE POLICY.
26 S 2. Subsection (k) of section 3221 of the insurance law is amended by
27 adding a new paragraph 16 to read as follows:
28 (16)(A) EVERY GROUP OR BLANKET POLICY THAT INCLUDES COVERAGE FOR DIAL-
29 YSIS TREATMENT THAT REQUIRES SUCH SERVICES TO BE PROVIDED BY AN IN-NET-
30 WORK PROVIDER AND THAT DOES NOT PROVIDE COVERAGE FOR OUT-OF-NETWORK
31 DIALYSIS TREATMENT SHALL NOT DENY COVERAGE OF SUCH SERVICES BECAUSE THE
32 SERVICES ARE PROVIDED BY AN OUT-OF-NETWORK PROVIDER, PROVIDED THAT EACH
33 OF THE FOLLOWING CONDITIONS ARE MET:
34 (I) THE OUT-OF-NETWORK PROVIDER IS DULY LICENSED TO PRACTICE AND
35 AUTHORIZED TO PROVIDE SUCH TREATMENT;
36 (II) THE OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE SERVICE AREA
37 OF THE INSURER;
38 (III) THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE INSURED FOR THE
39 CONDITION ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT IN
40 HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;
41 (IV) THE INSURED HAS NOTIFIED, IN WRITING, THE INSURER AT LEAST THIRTY
42 DAYS IN ADVANCE OF THE PROPOSED DATE OR DATES OF SUCH OUT-OF-NETWORK
43 DIALYSIS TREATMENT. THE NOTICE SHALL INCLUDE THE AUTHORIZATION REQUIRED
44 BY CLAUSE (III) OF THIS SUBPARAGRAPH. IN THE EVENT THE INSURED MUST
45 TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMERGENCY, SHORTER NOTICE
46 MAY BE PERMITTED, PROVIDED THAT THE INSURER HAS REASONABLE OPPORTUNITY
47 TO REVIEW THE TRAVEL AND TREATMENT PLANS OF THE INSURED;
48 (V) THE INSURER SHALL HAVE THE RIGHT TO PRE-APPROVE THE DIALYSIS
49 TREATMENT AND SCHEDULE; AND
50 (VI) SUCH COVERAGE IS LIMITED TO NO GREATER THAN TEN OUT-OF-NETWORK
51 TREATMENTS IN A CALENDAR YEAR.
52 (B) WHERE COVERAGE FOR OUT-OF-NETWORK DIALYSIS TREATMENT IS PROVIDED
53 PURSUANT TO SUBPARAGRAPH (A) OF THIS PARAGRAPH, NO INSURER SHALL BE
54 OBLIGATED TO REIMBURSE THE OUT-OF-NETWORK PROVIDER AT AN AMOUNT GREATER
55 THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK, INCLUD-
56 ING ALL DRUGS AND ANCILLARY SERVICES TIED TO DIALYSIS TREATMENT, AND ANY
S. 1803--C 3
1 AMOUNT CHARGED BY A PROVIDER IN EXCESS OF THE AMOUNT REIMBURSED BY THE
2 INSURER SHALL BE THE RESPONSIBILITY OF THE INSURED RECEIVING THE
3 OUT-OF-NETWORK SERVICES.
4 (C) SUCH COVERAGE OF OUT-OF-NETWORK DIALYSIS SERVICES REQUIRED BY
5 SUBPARAGRAPH (A) OF THIS PARAGRAPH SHALL OTHERWISE BE SUBJECT TO THE
6 LIMITATIONS, EXCLUSIONS AND TERMS OF THE POLICY, INCLUDING, BUT NOT
7 LIMITED TO, UTILIZATION REVIEW, ANNUAL DEDUCTIBLES, COPAYMENTS, AND
8 COINSURANCE, CONSISTENT WITH THOSE REQUIRED FOR OTHER SIMILAR BENEFITS
9 UNDER THE POLICY.
10 S 3. Section 4303 of the insurance law is amended by adding a new
11 subsection (gg) to read as follows:
12 (GG) (1) EVERY CONTRACT ISSUED BY A HOSPITAL SERVICE CORPORATION,
13 HEALTH SERVICE CORPORATION OR MEDICAL EXPENSE INDEMNITY CORPORATION THAT
14 INCLUDES COVERAGE FOR DIALYSIS TREATMENT THAT REQUIRES SUCH SERVICES TO
15 BE PROVIDED BY AN IN-NETWORK PROVIDER AND THAT DOES NOT PROVIDE COVERAGE
16 FOR OUT-OF-NETWORK DIALYSIS TREATMENT SHALL NOT DENY COVERAGE OF SUCH
17 SERVICES BECAUSE THE SERVICES ARE PROVIDED BY AN OUT-OF-NETWORK PROVID-
18 ER, PROVIDED THAT EACH OF THE FOLLOWING CONDITIONS ARE MET:
19 (A) THE OUT-OF-NETWORK PROVIDER IS DULY LICENSED TO PRACTICE AND
20 AUTHORIZED TO PROVIDE SUCH TREATMENT;
21 (B) THE OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE SERVICE AREA OF
22 THE INSURER;
23 (C) THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE COVERED PERSON FOR
24 THE CONDITION ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT
25 IN HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;
26 (D) THE COVERED PERSON HAS NOTIFIED, IN WRITING, THE CORPORATION AT
27 LEAST THIRTY DAYS IN ADVANCE OF THE PROPOSED DATE OR DATES OF SUCH OUT-
28 OF-NETWORK DIALYSIS TREATMENT. THE NOTICE SHALL INCLUDE THE AUTHORI-
29 ZATION REQUIRED BY SUBPARAGRAPH (C) OF THIS PARAGRAPH. IN THE EVENT THE
30 COVERED PERSON MUST TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMER-
31 GENCY, SHORTER NOTICE MAY BE PERMITTED, PROVIDED THAT THE CORPORATION
32 HAS REASONABLE OPPORTUNITY TO REVIEW THE TRAVEL AND TREATMENT PLANS OF
33 THE COVERED PERSON;
34 (E) THE CORPORATION SHALL HAVE THE RIGHT TO PRE-APPROVE THE DIALYSIS
35 TREATMENT AND SCHEDULE; AND
36 (F) SUCH COVERAGE IS LIMITED TO NO GREATER THAN TEN OUT-OF-NETWORK
37 TREATMENTS IN A CALENDAR YEAR.
38 (2) WHERE COVERAGE FOR OUT-OF-NETWORK DIALYSIS TREATMENT IS PROVIDED
39 PURSUANT TO PARAGRAPH ONE OF THIS SUBSECTION, NO CORPORATION SHALL BE
40 OBLIGATED TO REIMBURSE THE OUT-OF-NETWORK PROVIDER AT AN AMOUNT GREATER
41 THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK, INCLUD-
42 ING ALL DRUGS AND ANCILLARY SERVICES TIED TO DIALYSIS TREATMENT, AND ANY
43 AMOUNT CHARGED BY A PROVIDER IN EXCESS OF THE AMOUNT REIMBURSED BY THE
44 CORPORATION SHALL BE THE RESPONSIBILITY OF THE COVERED PERSON RECEIVING
45 THE OUT-OF-NETWORK SERVICES.
46 (3) SUCH COVERAGE OF OUT-OF-NETWORK DIALYSIS SERVICES REQUIRED BY
47 PARAGRAPH ONE OF THIS SUBSECTION SHALL OTHERWISE BE SUBJECT TO THE LIMI-
48 TATIONS, EXCLUSIONS AND TERMS OF THE POLICY, INCLUDING, BUT NOT LIMITED
49 TO, UTILIZATION REVIEW, ANNUAL DEDUCTIBLES, COPAYMENTS, AND COINSURANCE,
50 CONSISTENT WITH THOSE REQUIRED FOR OTHER SIMILAR BENEFITS UNDER THE
51 POLICY.
52 S 4. Paragraph 12 of subsection (b) of section 4322 of the insurance
53 law, as added by chapter 504 of the laws of 1995, is amended to read as
54 follows:
S. 1803--C 4
1 (12) Hemodialysis services CONSISTENT WITH THE PROVISIONS OF
2 SUBSECTION (GG) OF SECTION FOUR THOUSAND THREE HUNDRED THREE OF THIS
3 ARTICLE.
4 S 5. This act shall take effect on the first of January next succeed-
5 ing the date on which it shall have become a law and shall apply to
6 insurance policies and contracts issued, renewed, modified or altered on
7 or after such effective date.
