Bill Text: NY A01876 | 2023-2024 | General Assembly | Introduced
Bill Title: Requires health insurance policies and contracts shall provide coverage for the diagnosis and treatment of lymphedema, both primary and secondary lymphedema; requires such coverage shall include benefits for equipment, supplies, devices, complex decongestive therapy and out-patient self-management training and education for the treatment of lymphedema, both primary and secondary lymphedema.
Spectrum: Partisan Bill (Democrat 7-0)
Status: (Introduced) 2024-01-03 - referred to insurance [A01876 Detail]
Download: New_York-2023-A01876-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 1876 2023-2024 Regular Sessions IN ASSEMBLY January 23, 2023 ___________ Introduced by M. of A. L. ROSENTHAL, LAVINE, THIELE, SANTABARBARA, STECK -- Multi-Sponsored by -- M. of A. COOK -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law, in relation to requiring certain health insurance coverage for lymphedema The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Clauses (i) and (ii) of subparagraph (A) of paragraph 20 of 2 subsection (i) of section 3216 of the insurance law, as amended by chap- 3 ter 571 of the laws of 2022, are amended and a new clause (iii) is added 4 to read as follows: 5 (i) all stages of reconstruction of the breast or chest wall on which 6 the mastectomy or partial mastectomy has been performed; [and] 7 (ii) surgery and reconstruction of the other breast or chest wall to 8 produce a symmetrical appearance; 9 in the manner determined by the attending physician and the patient to 10 be appropriate. Chest wall reconstruction surgery shall include aesthet- 11 ic flat closure as such term is defined by the National Cancer Insti- 12 tute. Such coverage may be subject to annual deductibles and coinsurance 13 provisions as may be deemed appropriate by the superintendent and as are 14 consistent with those established for other benefits within a given 15 policy. Written notice of the availability of such coverage shall be 16 delivered to the policyholder prior to inception of such policy and 17 annually thereafter[.]; and 18 (iii) prostheses and physical complications of all stages of mastecto- 19 my, including lymphedema; 20 § 2. Subsection (i) of section 3216 of the insurance law is amended by 21 adding two new paragraphs 39 and 40 to read as follows: 22 (39) Every policy which provides hospital, surgical, medical or major 23 medical coverage shall provide coverage for the differential diagnosis 24 and treatment of lymphedema, both primary and secondary lymphedema. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD06690-01-3A. 1876 2 1 Such coverage shall include, in addition to benefits for a course of 2 manual lymph drainage whose frequency and duration is determined by the 3 treating physician or therapist based on medical necessity and not based 4 on physical therapy and rehabilitation standards, benefits for equip- 5 ment, supplies, devices, complex decongestive therapy, and out-patient 6 self-management training and education for the treatment of lymphedema, 7 if prescribed by a health care professional legally authorized to 8 prescribe or provide such items under title eight of the education law. 9 Lymphedema therapy administered under this section shall be administered 10 only by a therapist certified to perform lymphedema treatment by the 11 Lymphology Association of North America (LANA) or certified in accord- 12 ance with standards equivalent to the certification standards of LANA. 13 Such equipment, supplies or devices shall include, but not be limited 14 to, bandages, compression garments, pads, orthotic shoes and devices, 15 with replacements when required to maintain compressive function or to 16 accommodate changes in the patient's dimensions. Coverage shall be 17 provided for follow-up treatments when medically required or to period- 18 ically validate home techniques, to monitor progress against the written 19 treatment plan and to modify the treatment plan as required. No individ- 20 ual, other than a licensed physician or surgeon competent to evaluate 21 the specific clinical issues involved in the care requested, may deny 22 requests for authorization of health care services pursuant to this 23 section. 24 (A) A policy which is a managed health care product may require such 25 health care professional be a member of such managed health care plan's 26 provider network, provided that such network includes sufficient health 27 care professionals who are qualified by specific education, experience 28 and credentials to provide the covered benefits described in this para- 29 graph. 30 (B) No insurer, corporation, or health maintenance organization shall 31 impose upon any person receiving benefits pursuant to this paragraph any 32 copayment, fee, policy year or calendar year, or durational benefit 33 limitation or maximum for benefits or services that is not equally 34 imposed upon all individuals in the same benefit category. 35 (C) This paragraph shall not apply to short-term travel, accident 36 only, limited or specified disease, or individual conversion policies or 37 contracts, nor to policies or contracts designed for issuance to persons 38 eligible for coverage under Title XVIII of the Social Security Act, 39 known as Medicare, or any other similar coverage under state or federal 40 governmental plans. 41 (D) For purposes of this paragraph, a "managed care product" shall 42 mean a policy which requires that medical or other health care services 43 covered under the policy, other than emergency care services, be 44 provided by, or pursuant to a referral from a primary care provider, and 45 that services provided pursuant to such a referral be rendered by a 46 health care provider participating in the insurer's managed care provid- 47 er network. In addition, a managed care product shall also mean the 48 in-network portion of a contract which requires that medical or other 49 health care services covered under the contract, other than emergency 50 care services, be provided by, or pursuant to a referral from a primary 51 care provider, and that services provided pursuant to such a referral be 52 rendered by a health care provider participating in the insurer's 53 managed care provider network, in order for the insured to be entitled 54 to the maximum reimbursement under the contract. 55 (40) Patients undergoing any surgery or radiotherapy procedure shall 56 be provided information on the risk of lymphedema associated with thatA. 1876 3 1 procedure, and the potential post-procedure symptoms of lymphedema. 2 Informed consent agreements for all surgeries and radiation therapies 3 shall include information on the risk of lymphedema associated with the 4 alternative procedures. 5 § 3. Clauses (i) and (ii) of subparagraph (A) of paragraph 10 of 6 subsection (k) of section 3221 of the insurance law, as amended by chap- 7 ter 571 of the laws of 2022, are amended and a new clause (iii) is added 8 to read as follows: 9 (i) all stages of reconstruction of the breast or chest wall on which 10 the mastectomy or partial mastectomy has been performed; [and] 11 (ii) surgery and reconstruction of the other breast or chest wall to 12 produce a symmetrical appearance; 13 in the manner determined by the attending physician and the patient to 14 be appropriate. Chest wall reconstruction surgery shall include aesthet- 15 ic flat closure as such term is defined by the National Cancer Insti- 16 tute. Such coverage may be subject to annual deductibles and coinsurance 17 provisions as may be deemed appropriate by the superintendent and as are 18 consistent with those established for other benefits within a given 19 policy. Written notice of the availability of such coverage shall be 20 delivered to the policyholder prior to inception of such policy and 21 annually thereafter[.]; and 22 (iii) prostheses and physical complications of all stages of mastecto- 23 my, including lymphedema; 24 § 4. Subsection (k) of section 3221 of the insurance law is amended by 25 adding two new paragraphs 23 and 24 to read as follows: 26 (23) Every group policy issued or issued for delivery in this state 27 which provides hospital, surgical, medical or major medical coverage 28 shall provide coverage for the differential diagnosis and treatment of 29 lymphedema, both primary and secondary lymphedema. Such coverage shall 30 include, in addition to benefits for a course of manual lymph drainage 31 whose frequency and duration is determined by the treating physician or 32 therapist based on medical necessity and not based on physical therapy 33 and rehabilitation standards, benefits for equipment, supplies, devices, 34 complex decongestive therapy, and out-patient self-management training 35 and education for the treatment of lymphedema, if prescribed by a health 36 care professional legally authorized to prescribe or provide such items 37 under title eight of the education law. Lymphedema therapy administered 38 under this section shall be administered only by a therapist certified 39 to perform lymphedema treatment by the Lymphology Association of North 40 America (LANA) or certified in accordance with standards equivalent to 41 the certification standards of LANA. Such equipment, supplies or 42 devices shall include, but not be limited to, bandages, compression 43 garments, pads, orthotic shoes and devices, with replacements when 44 required to maintain compressive function or to accommodate changes in 45 the patient's dimensions. Coverage shall be provided for follow-up 46 treatments when medically required or to periodically validate home 47 techniques, to monitor progress against the written treatment plan and 48 to modify the treatment plan as required. No individual, other than a 49 licensed physician or surgeon competent to evaluate the specific clin- 50 ical issues involved in the care requested, may deny requests for 51 authorization of health care services pursuant to this section. 52 (A) A policy which is a managed health care product may require such 53 health care professional be a member of such managed health care plan's 54 provider network, provided that such network includes sufficient health 55 care professionals who are qualified by specific education, experienceA. 1876 4 1 and credentials to provide the covered benefits described in this para- 2 graph. 3 (B) No insurer, corporation, or health maintenance organization shall 4 impose upon any person receiving benefits pursuant to this paragraph any 5 copayment, fee, policy year or calendar year, or durational benefit 6 limitation or maximum for benefits or services that is not equally 7 imposed upon all individuals in the same benefit category. 8 (C) This paragraph shall not apply to short-term travel, accident 9 only, limited or specified disease, or individual conversion policies or 10 contracts, nor to policies or contracts designed for issuance to persons 11 eligible for coverage under Title XVIII of the Social Security Act, 12 known as Medicare, or any other similar coverage under state or federal 13 governmental plans. 14 (D) For purposes of this paragraph, a "managed care product" shall 15 mean a policy which requires that medical or other health care services 16 covered under the policy, other than emergency care services, be 17 provided by, or pursuant to a referral from a primary care provider, and 18 that services provided pursuant to such a referral be rendered by a 19 health care provider participating in the insurer's managed care provid- 20 er network. In addition, a managed care product shall also mean the 21 in-network portion of a contract which requires that medical or other 22 health care services covered under the contract, other than emergency 23 care services, be provided by, or pursuant to a referral from a primary 24 care provider, and that services provided pursuant to such a referral be 25 rendered by a health care provider participating in the insurer's 26 managed care provider network, in order for the insured to be entitled 27 to the maximum reimbursement under the contract. 28 (24) Patients undergoing any surgery or radiotherapy procedure shall 29 be provided information on the risk of lymphedema associated with that 30 procedure, and the potential post-procedure symptoms of lymphedema. 31 Informed consent agreements for all surgeries and radiation therapies 32 shall include information on the risk of lymphedema associated with the 33 alternative procedures. 34 § 5. Subparagraphs (A) and (B) of paragraph 1 of subsection (x) of 35 section 4303 of the insurance law, as amended by chapter 571 of the laws 36 of 2022, are amended and a new subparagraph (C) is added to read as 37 follows: 38 (A) all stages of reconstruction of the breast or chest wall on which 39 the mastectomy or partial mastectomy has been performed; [and] 40 (B) surgery and reconstruction of the other breast or chest wall to 41 produce a symmetrical appearance; and 42 (C) prostheses and physical complications of all stages of mastectomy, 43 including lymphedema; 44 in the manner determined by the attending physician and the patient to 45 be appropriate. Chest wall reconstruction surgery shall include aesthet- 46 ic flat closure as such term is defined by the National Cancer insti- 47 tute. Such coverage may be subject to annual deductibles or coinsurance 48 provisions as may be deemed appropriate by the superintendent and as are 49 consistent with those established for other benefits within a given 50 policy. Written notice of the availability of such coverage shall be 51 delivered to the group remitting agent or group contract holder prior to 52 the inception of such contract and annually thereafter. 53 § 6. Section 4303 of the insurance law is amended by adding two new 54 subsections (uu) and (vv) to read as follows: 55 (uu) Every contract issued by a hospital service corporation or health 56 service corporation which provides hospital, surgical, medical or majorA. 1876 5 1 medical coverage shall provide coverage for the differential diagnosis 2 and treatment of lymphedema, both primary and secondary lymphedema. 3 Such coverage shall include, in addition to benefits for a course of 4 manual lymph drainage whose frequency and duration is determined by the 5 treating physician or therapist based on medical necessity and not based 6 on physical therapy and rehabilitation standards, benefits for equip- 7 ment, supplies, devices, complex decongestive therapy, and out-patient 8 self-management training and education for the treatment of lymphedema, 9 if prescribed by a health care professional legally authorized to 10 prescribe or provide such items under title eight of the education law. 11 Lymphedema therapy administered under this section shall be administered 12 only by a therapist certified to perform lymphedema treatment by the 13 Lymphology Association of North America (LANA) or certified in accord- 14 ance with standards equivalent to the certification standards of LANA. 15 Such equipment, supplies or devices shall include, but not be limited 16 to, bandages, compression garments, pads, orthotic shoes and devices, 17 with replacements when required to maintain compressive function or to 18 accommodate changes in the patient's dimensions. Coverage shall be 19 provided for follow-up treatments when medically required or to period- 20 ically validate home techniques, to monitor progress against the written 21 treatment plan and to modify the treatment plan as required. No individ- 22 ual, other than a licensed physician or surgeon competent to evaluate 23 the specific clinical issues involved in the care requested, may deny 24 requests for authorization of health care services pursuant to this 25 section. 26 (1) A policy which is a managed health care product may require such 27 health care professional be a member of such managed health care plan's 28 provider network, provided that such network includes sufficient health 29 care professionals who are qualified by specific education, experience 30 and credentials to provide the covered benefits described in this 31 subsection. 32 (2) No insurer, corporation, or health maintenance organization shall 33 impose upon any person receiving benefits pursuant to this subsection 34 any copayment, fee, policy year or calendar year, or durational benefit 35 limitation or maximum for benefits or services that is not equally 36 imposed upon all individuals in the same benefit category. 37 (3) This subsection shall not apply to short-term travel, accident 38 only, limited or specified disease, or individual conversion policies or 39 contracts, nor to policies or contracts designed for issuance to persons 40 eligible for coverage under Title XVIII of the Social Security Act, 41 known as Medicare, or any other similar coverage under state or federal 42 governmental plans. 43 (4) For purposes of this subsection, a "managed care product" shall 44 mean a policy which requires that medical or other health care services 45 covered under the policy, other than emergency care services, be 46 provided by, or pursuant to a referral from a primary care provider, and 47 that services provided pursuant to such a referral be rendered by a 48 health care provider participating in the insurer's managed care provid- 49 er network. In addition, a managed care product shall also mean the 50 in-network portion of a contract which requires that medical or other 51 health care services covered under the contract, other than emergency 52 care services, be provided by, or pursuant to a referral from a primary 53 care provider, and that services provided pursuant to such a referral be 54 rendered by a health care provider participating in the insurer's 55 managed care provider network, in order for the insured to be entitled 56 to the maximum reimbursement under the contract.A. 1876 6 1 (vv) Patients undergoing any surgery or radiotherapy procedure shall 2 be provided information on the risk of lymphedema associated with that 3 procedure, and the potential post-procedure symptoms of lymphedema. 4 Informed consent agreements for all surgeries and radiation therapies 5 shall include information on the risk of lymphedema associated with the 6 alternative procedures. 7 § 7. This act shall take effect on the first of January next succeed- 8 ing the date on which it shall have become a law and shall apply to all 9 insurance policies, contracts and plans issued, renewed, modified, 10 altered or amended on or after such effective date.
