Bill Text: NY A00491 | 2021-2022 | General Assembly | Amended
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 10-0)
Status: (Introduced - Dead) 2022-01-05 - referred to insurance [A00491 Detail]
Download: New_York-2021-A00491-Amended.html
STATE OF NEW YORK ________________________________________________________________________ 491--A 2021-2022 Regular Sessions IN ASSEMBLY (Prefiled) January 6, 2021 ___________ Introduced by M. of A. L. ROSENTHAL, LAVINE, PERRY, THIELE, SANTABAR- BARA, FRONTUS -- Multi-Sponsored by -- M. of A. BARRON, COOK, CYMBROW- ITZ -- read once and referred to the Committee on Insurance -- commit- tee discharged, bill amended, ordered reprinted as amended and recommitted to said committee 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. Clause (ii) of subparagraph (A) of paragraph 20 of 2 subsection (i) of section 3216 of the insurance law, as added by chapter 3 21 of the laws of 1997, is amended and a new clause (iii) is added to 4 read as follows: 5 (ii) surgery and reconstruction of the other breast to produce a 6 symmetrical appearance; and 7 (iii) prostheses and physical complications of all stages of mastecto- 8 my, including lymphedema; 9 § 2. Subsection (i) of section 3216 of the insurance law is amended by 10 adding two new paragraphs 36 and 37 to read as follows: 11 (36) Every policy which provides hospital, surgical, medical or major 12 medical coverage shall provide coverage for the differential diagnosis 13 and treatment of lymphedema, both primary and secondary lymphedema. 14 Such coverage shall include, in addition to benefits for a course of 15 manual lymph drainage whose frequency and duration is determined by the 16 treating physician or therapist based on medical necessity and not based 17 on physical therapy and rehabilitation standards, benefits for equip- 18 ment, supplies, devices, complex decongestive therapy, and out-patient 19 self-management training and education for the treatment of lymphedema, 20 if prescribed by a health care professional legally authorized to 21 prescribe or provide such items under title eight of the education law. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD00517-02-1A. 491--A 2 1 Lymphedema therapy administered under this section shall be administered 2 only by a therapist certified to perform lymphedema treatment by the 3 Lymphology Association of North America (LANA) or certified in accord- 4 ance with standards equivalent to the certification standards of LANA. 5 Such equipment, supplies or devices shall include, but not be limited 6 to, bandages, compression garments, pads, orthotic shoes and devices, 7 with replacements when required to maintain compressive function or to 8 accommodate changes in the patient's dimensions. Coverage shall be 9 provided for follow-up treatments when medically required or to period- 10 ically validate home techniques, to monitor progress against the written 11 treatment plan and to modify the treatment plan as required. No individ- 12 ual, other than a licensed physician or surgeon competent to evaluate 13 the specific clinical issues involved in the care requested, may deny 14 requests for authorization of health care services pursuant to this 15 section. 16 (A) A policy which is a managed health care product may require such 17 health care professional be a member of such managed health care plan's 18 provider network, provided that such network includes sufficient health 19 care professionals who are qualified by specific education, experience 20 and credentials to provide the covered benefits described in this para- 21 graph. 22 (B) No insurer, corporation, or health maintenance organization shall 23 impose upon any person receiving benefits pursuant to this paragraph any 24 copayment, fee, policy year or calendar year, or durational benefit 25 limitation or maximum for benefits or services that is not equally 26 imposed upon all individuals in the same benefit category. 27 (C) This paragraph shall not apply to short-term travel, accident 28 only, limited or specified disease, or individual conversion policies or 29 contracts, nor to policies or contracts designed for issuance to persons 30 eligible for coverage under Title XVIII of the Social Security Act, 31 known as Medicare, or any other similar coverage under state or federal 32 governmental plans. 33 (D) For purposes of this paragraph, a "managed care product" shall 34 mean a policy which requires that medical or other health care services 35 covered under the policy, other than emergency care services, be 36 provided by, or pursuant to a referral from a primary care provider, and 37 that services provided pursuant to such a referral be rendered by a 38 health care provider participating in the insurer's managed care provid- 39 er network. In addition, a managed care product shall also mean the 40 in-network portion of a contract which requires that medical or other 41 health care services covered under the contract, other than emergency 42 care services, be provided by, or pursuant to a referral from a primary 43 care provider, and that services provided pursuant to such a referral be 44 rendered by a health care provider participating in the insurer's 45 managed care provider network, in order for the insured to be entitled 46 to the maximum reimbursement under the contract. 47 (37) Patients undergoing any surgery or radiotherapy procedure shall 48 be provided information on the risk of lymphedema associated with that 49 procedure, and the potential post-procedure symptoms of lymphedema. 50 Informed consent agreements for all surgeries and radiation therapies 51 shall include information on the risk of lymphedema associated with the 52 alternative procedures. 53 § 3. Clause (ii) of subparagraph (A) of paragraph 10 of subsection (k) 54 of section 3221 of the insurance law, as added by chapter 21 of the laws 55 of 1997, is amended and a new clause (iii) is added to read as follows:A. 491--A 3 1 (ii) surgery and reconstruction of the other breast to produce a 2 symmetrical appearance; and 3 (iii) prostheses and physical complications of all stages of mastecto- 4 my, including lymphedema; 5 § 4. Subsection (k) of section 3221 of the insurance law is amended by 6 adding two new paragraphs 22 and 23 to read as follows: 7 (22) Every group policy issued or issued for delivery in this state 8 which provides hospital, surgical, medical or major medical coverage 9 shall provide coverage for the differential diagnosis and treatment of 10 lymphedema, both primary and secondary lymphedema. Such coverage shall 11 include, in addition to benefits for a course of manual lymph drainage 12 whose frequency and duration is determined by the treating physician or 13 therapist based on medical necessity and not based on physical therapy 14 and rehabilitation standards, benefits for equipment, supplies, devices, 15 complex decongestive therapy, and out-patient self-management training 16 and education for the treatment of lymphedema, if prescribed by a health 17 care professional legally authorized to prescribe or provide such items 18 under title eight of the education law. Lymphedema therapy administered 19 under this section shall be administered only by a therapist certified 20 to perform lymphedema treatment by the Lymphology Association of North 21 America (LANA) or certified in accordance with standards equivalent to 22 the certification standards of LANA. Such equipment, supplies or 23 devices shall include, but not be limited to, bandages, compression 24 garments, pads, orthotic shoes and devices, with replacements when 25 required to maintain compressive function or to accommodate changes in 26 the patient's dimensions. Coverage shall be provided for follow-up 27 treatments when medically required or to periodically validate home 28 techniques, to monitor progress against the written treatment plan and 29 to modify the treatment plan as required. No individual, other than a 30 licensed physician or surgeon competent to evaluate the specific clin- 31 ical issues involved in the care requested, may deny requests for 32 authorization of health care services pursuant to this section. 33 (A) A policy which is a managed health care product may require such 34 health care professional be a member of such managed health care plan's 35 provider network, provided that such network includes sufficient health 36 care professionals who are qualified by specific education, experience 37 and credentials to provide the covered benefits described in this para- 38 graph. 39 (B) No insurer, corporation, or health maintenance organization shall 40 impose upon any person receiving benefits pursuant to this paragraph any 41 copayment, fee, policy year or calendar year, or durational benefit 42 limitation or maximum for benefits or services that is not equally 43 imposed upon all individuals in the same benefit category. 44 (C) This paragraph shall not apply to short-term travel, accident 45 only, limited or specified disease, or individual conversion policies or 46 contracts, nor to policies or contracts designed for issuance to persons 47 eligible for coverage under Title XVIII of the Social Security Act, 48 known as Medicare, or any other similar coverage under state or federal 49 governmental plans. 50 (D) For purposes of this paragraph, a "managed care product" shall 51 mean a policy which requires that medical or other health care services 52 covered under the policy, other than emergency care services, be 53 provided by, or pursuant to a referral from a primary care provider, and 54 that services provided pursuant to such a referral be rendered by a 55 health care provider participating in the insurer's managed care provid- 56 er network. In addition, a managed care product shall also mean theA. 491--A 4 1 in-network portion of a contract which requires that medical or other 2 health care services covered under the contract, other than emergency 3 care services, be provided by, or pursuant to a referral from a primary 4 care provider, and that services provided pursuant to such a referral be 5 rendered by a health care provider participating in the insurer's 6 managed care provider network, in order for the insured to be entitled 7 to the maximum reimbursement under the contract. 8 (23) Patients undergoing any surgery or radiotherapy procedure shall 9 be provided information on the risk of lymphedema associated with that 10 procedure, and the potential post-procedure symptoms of lymphedema. 11 Informed consent agreements for all surgeries and radiation therapies 12 shall include information on the risk of lymphedema associated with the 13 alternative procedures. 14 § 5. Subparagraph (B) of paragraph 1 of subsection (x) of section 4303 15 of the insurance law, as added by chapter 21 of the laws of 1997, is 16 amended and a new subparagraph (C) is added to read as follows: 17 (B) surgery and reconstruction of the other breast to produce a 18 symmetrical appearance; and 19 (C) prostheses and physical complications of all stages of mastectomy, 20 including lymphedema; 21 § 6. Section 4303 of the insurance law is amended by adding two new 22 subsections (ss) and (tt) to read as follows: 23 (ss) Every contract issued by a hospital service corporation or health 24 service corporation which provides hospital, surgical, medical or major 25 medical coverage shall provide coverage for the differential diagnosis 26 and treatment of lymphedema, both primary and secondary lymphedema. 27 Such coverage shall include, in addition to benefits for a course of 28 manual lymph drainage whose frequency and duration is determined by the 29 treating physician or therapist based on medical necessity and not based 30 on physical therapy and rehabilitation standards, benefits for equip- 31 ment, supplies, devices, complex decongestive therapy, and out-patient 32 self-management training and education for the treatment of lymphedema, 33 if prescribed by a health care professional legally authorized to 34 prescribe or provide such items under title eight of the education law. 35 Lymphedema therapy administered under this section shall be administered 36 only by a therapist certified to perform lymphedema treatment by the 37 Lymphology Association of North America (LANA) or certified in accord- 38 ance with standards equivalent to the certification standards of LANA. 39 Such equipment, supplies or devices shall include, but not be limited 40 to, bandages, compression garments, pads, orthotic shoes and devices, 41 with replacements when required to maintain compressive function or to 42 accommodate changes in the patient's dimensions. Coverage shall be 43 provided for follow-up treatments when medically required or to period- 44 ically validate home techniques, to monitor progress against the written 45 treatment plan and to modify the treatment plan as required. No individ- 46 ual, other than a licensed physician or surgeon competent to evaluate 47 the specific clinical issues involved in the care requested, may deny 48 requests for authorization of health care services pursuant to this 49 section. 50 (1) A policy which is a managed health care product may require such 51 health care professional be a member of such managed health care plan's 52 provider network, provided that such network includes sufficient health 53 care professionals who are qualified by specific education, experience 54 and credentials to provide the covered benefits described in this 55 subsection.A. 491--A 5 1 (2) No insurer, corporation, or health maintenance organization shall 2 impose upon any person receiving benefits pursuant to this subsection 3 any copayment, fee, policy year or calendar year, or durational benefit 4 limitation or maximum for benefits or services that is not equally 5 imposed upon all individuals in the same benefit category. 6 (3) This subsection shall not apply to short-term travel, accident 7 only, limited or specified disease, or individual conversion policies or 8 contracts, nor to policies or contracts designed for issuance to persons 9 eligible for coverage under Title XVIII of the Social Security Act, 10 known as Medicare, or any other similar coverage under state or federal 11 governmental plans. 12 (4) For purposes of this subsection, a "managed care product" shall 13 mean a policy which requires that medical or other health care services 14 covered under the policy, other than emergency care services, be 15 provided by, or pursuant to a referral from a primary care provider, and 16 that services provided pursuant to such a referral be rendered by a 17 health care provider participating in the insurer's managed care provid- 18 er network. In addition, a managed care product shall also mean the 19 in-network portion of a contract which requires that medical or other 20 health care services covered under the contract, other than emergency 21 care services, be provided by, or pursuant to a referral from a primary 22 care provider, and that services provided pursuant to such a referral be 23 rendered by a health care provider participating in the insurer's 24 managed care provider network, in order for the insured to be entitled 25 to the maximum reimbursement under the contract. 26 (tt) Patients undergoing any surgery or radiotherapy procedure shall 27 be provided information on the risk of lymphedema associated with that 28 procedure, and the potential post-procedure symptoms of lymphedema. 29 Informed consent agreements for all surgeries and radiation therapies 30 shall include information on the risk of lymphedema associated with the 31 alternative procedures. 32 § 7. This act shall take effect on the first of January next succeed- 33 ing the date on which it shall have become a law and shall apply to all 34 insurance policies, contracts and plans issued, renewed, modified, 35 altered or amended on or after such effective date.
