Bill Text: NY A02415 | 2017-2018 | General Assembly | Introduced
Bill Title: Mandates insurance companies to provide coverage for non-experimental infertility treatments; provides that coverage shall not be required to include the diagnosis and treatment of infertility in connection with the reversal of elective sterilizations, sex change procedures, cloning or medical or surgical services or procedures that are deemed to be experimental; provides the superintendent of financial services in consultation with the commissioner of the department of health shall determine infertility for purposes of coverage.
Spectrum: Partisan Bill (Democrat 11-0)
Status: (Introduced - Dead) 2018-06-21 - enacting clause stricken [A02415 Detail]
Download: New_York-2017-A02415-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 2415 2017-2018 Regular Sessions IN ASSEMBLY January 20, 2017 ___________ Introduced by M. of A. PAULIN, STECK, GOTTFRIED, ROSENTHAL, SIMOTAS, ZEBROWSKI -- Multi-Sponsored by -- M. of A. COOK, PERRY, TITONE, WALK- ER -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law, in relation to mandating insurance companies to provide coverage for non-experimental infertility treat- ments The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Paragraph 13 of subsection (i) of section 3216 of the 2 insurance law, as added by chapter 897 of the laws of 1990 and renum- 3 bered by chapter 131 of the laws of 1992, is amended to read as follows: 4 (13) (A) Every policy which provides coverage for hospital care shall 5 not exclude coverage for hospital care for diagnosis and treatment of 6 correctable medical conditions otherwise covered by the policy solely 7 because the medical condition results in infertility[.]; provided howev- 8 er that: 9 (i) Subject to the provisions of subparagraph (C) of this paragraph, 10 in no case shall such coverage exclude surgical or medical procedures 11 provided as part of such hospital care which would correct malformation, 12 disease or dysfunction resulting in infertility; and 13 (ii) Provided, further however, that subject to the provisions of 14 subparagraph (C) of this paragraph, in no case shall such coverage 15 exclude diagnostic tests and procedures provided as part of such hospi- 16 tal care that are necessary to determine infertility or that are neces- 17 sary in connection with any surgical or medical treatments or 18 prescription drug coverage provided pursuant to this paragraph, includ- 19 ing such diagnostic tests and procedures as hysterosalpingogram, hyster- 20 oscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post coital 21 tests, testis biopsy, semen analysis, blood tests, ultrasound, ovulation 22 induction, intrauterine insemination, in-vitro fertilization, intracyto- 23 plasmic sperm injection, uterine embryo lavage, embryo transfer, gamete EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD06452-01-7A. 2415 2 1 intra-fallopian transfer, zygote intra-fallopian transfer, low tubal 2 ovum transfer, donor eggs, and donor sperm; and 3 (iii) Provided, further however, every such policy which provides 4 coverage for prescription drugs shall include, within such coverage, 5 coverage for prescription drugs approved by the federal Food and Drug 6 Administration for use in the diagnosis and treatment of infertility in 7 accordance with subparagraph (C) of this paragraph. 8 (B) Every policy which provides coverage for surgical and medical care 9 shall not exclude coverage for surgical and medical care for diagnosis 10 and treatment of correctable medical conditions otherwise covered by the 11 policy solely because the medical condition results in infertility[.]; 12 provided, however that: 13 (i) Subject to the provisions of subparagraph (C) of this paragraph, 14 in no case shall such coverage exclude surgical or medical procedures 15 provided as part of such hospital care which would correct malformation, 16 disease or dysfunction resulting in infertility; and 17 (ii) Provided, further however, that subject to the provisions of 18 subparagraph (C) of this paragraph, in no case shall such coverage 19 exclude diagnostic tests and procedures provided as part of such hospi- 20 tal care that are necessary to determine infertility or that are neces- 21 sary in connection with any surgical or medical treatments or 22 prescription drug coverage provided pursuant to this paragraph, includ- 23 ing such diagnostic tests and procedures as hysterosalpingogram, hyster- 24 oscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post coital 25 tests, testis biopsy, semen analysis, blood tests, ultrasound, ovulation 26 induction, intrauterine insemination, in-vitro fertilization, intracyto- 27 plasmic sperm injection, uterine embryo lavage, embryo transfer, gamete 28 intra-fallopian transfer, zygote intra-fallopian transfer, low tubal 29 ovum transfer, donor eggs, and donor sperm; and 30 (iii) Provided, further however, every such policy which provides 31 coverage for prescription drugs shall include, within such coverage, 32 coverage for prescription drugs approved by the federal Food and Drug 33 Administration for use in the diagnosis and treatment of infertility in 34 accordance with subparagraph (C) of this paragraph. 35 (C) Coverage of diagnostic and treatment procedures, including 36 prescription drugs, used in the diagnosis and treatment of infertility 37 as required by subparagraphs (A) and (B) of this paragraph shall be 38 provided in accordance with the provisions of this subparagraph. 39 (i) Coverage shall be provided for persons whose ages range from twen- 40 ty-one through forty-four years of age, provided that nothing in this 41 subparagraph shall preclude the provision of coverage to persons whose 42 age is below or above such range. 43 (ii) Diagnosis and treatment of infertility shall be prescribed as 44 part of a physician's overall plan of care and consistent with the 45 guidelines for coverage as referenced in this subparagraph. 46 (iii) Coverage may be subject to co-payments, coinsurance and deduct- 47 ibles as may be deemed appropriate by the superintendent and as are 48 consistent with those established for other benefits within a given 49 policy. 50 (iv) Coverage shall be limited to those individuals who have been 51 previously covered under the policy for a period of not less than twelve 52 months, provided that for the purposes of this subparagraph "period of 53 not less than twelve months" shall be determined by calculating such 54 time from either the date the insured was first covered under the exist- 55 ing policy or from the date the insured was first covered by a previous- 56 ly in-force converted policy, whichever is earlier.A. 2415 3 1 (v) Coverage shall not be required to include the diagnosis and treat- 2 ment of infertility in connection with: 3 (I) The reversal of elective sterilizations; 4 (II) Sex change procedures; 5 (III) cloning; or 6 (IV) Medical or surgical services or procedures that are deemed to be 7 experimental in accordance with clinical guidelines referenced in clause 8 (vi) of this subparagraph. 9 (vi) The superintendent, in consultation with the commissioner of 10 health, shall promulgate regulations which shall stipulate the guide- 11 lines and standards which shall be used in carrying out the provisions 12 of this subparagraph, which shall include: 13 (I) The determination of "infertility" in accordance with the stand- 14 ards and guidelines established and adopted by the American College of 15 Obstetricians and Gynecologists and the American Society for Reproduc- 16 tive Medicine; 17 (II) The identification of experimental procedures and treatments not 18 covered for the diagnosis and treatment of infertility determined in 19 accordance with the standards and guidelines established and adopted by 20 the American College of Obstetricians and Gynecologists and the American 21 Society for Reproductive Medicine; 22 (III) The identification of the required training, experience and 23 other standards for health care providers for the provision of proce- 24 dures and treatments for the diagnosis and treatment of infertility 25 determined in accordance with the standards and guidelines established 26 and adopted by the American College of Obstetricians and Gynecologists 27 and the American Society for Reproductive Medicine; and 28 (IV) The determination of appropriate medical candidates by the treat- 29 ing physician in accordance with the standards and guidelines estab- 30 lished and adopted by the American College of Obstetricians and Gynecol- 31 ogists and/or the American Society for Reproductive Medicine. 32 (vii) A policy providing coverage under this paragraph may have the 33 following requirements and limitations: 34 (I) Limit coverage for in-vitro fertilization, gamete intra-fallopian 35 transfer, zygote intra-fallopian transfer and low tubal ovum transfer to 36 those individuals who have been unable to conceive or produce conception 37 or sustain a successful pregnancy through less expensive and medically 38 viable infertility treatment or procedures covered under such a policy; 39 (II) Nothing in this subsection shall be construed to deny the cover- 40 age required by this section to any individual who forgoes a particular 41 infertility treatment or procedure if the individual's physician deter- 42 mines that such a treatment or procedure is likely to be unsuccessful; 43 (III) Limit coverage to a lifetime cap of one hundred thousand dollars 44 for ovulation induction, intrauterine insemination, in-vitro fertiliza- 45 tion, intracytoplasmic sperm injection, uterine embryo lavage, embryo 46 transfer, gamete intra-fallopian transfer, zygote intra-fallopian trans- 47 fer, low tubal ovum transfer, donor eggs, and donor sperm; 48 (IV) Require disclosure by the individual seeking such coverage to 49 such individual's existing health insurance carrier of any previous 50 infertility treatment or procedures for which such individual received 51 coverage under a different health insurance policy. Such disclosure 52 shall be made on a form and in the manner prescribed by the commissioner 53 of the department of financial services. 54 § 2. Subparagraphs (A), (B) and (C) of paragraph 6 of subsection (k) 55 of section 3221 of the insurance law, as amended by section 1 of part K 56 of chapter 82 of the laws of 2002, are amended to read as follows:A. 2415 4 1 (A) Every group policy issued or delivered in this state which 2 provides coverage for hospital care shall not exclude coverage for 3 hospital care for diagnosis and treatment of correctable medical condi- 4 tions [otherwise covered by the policy] solely because the medical 5 condition results in infertility; provided, however that: 6 (i) subject to the provisions of subparagraph (C) of this paragraph, 7 in no case shall such coverage exclude surgical or medical procedures 8 provided as part of such hospital care which would correct malformation, 9 disease or dysfunction resulting in infertility; and 10 (ii) provided, further however, that subject to the provisions of 11 subparagraph (C) of this paragraph, in no case shall such coverage 12 exclude diagnostic tests and procedures provided as part of such hospi- 13 tal care that are necessary to determine infertility or that are neces- 14 sary in connection with any surgical or medical treatments or 15 prescription drug coverage provided pursuant to this paragraph, includ- 16 ing such diagnostic tests and procedures as hysterosalpingogram, hyster- 17 oscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post coital 18 tests, testis biopsy, semen analysis, blood tests [and], ultrasound, 19 ovulation induction, intrauterine insemination, in-vitro fertilization, 20 intracytoplasmic sperm injection, uterine embryo lavage, embryo trans- 21 fer, gamete intra-fallopian transfer, zygote intra-fallopian transfer, 22 low tubal ovum transfer, donor eggs, and donor sperm; and 23 (iii) provided, further however, every such policy which provides 24 coverage for prescription drugs shall include, within such coverage, 25 coverage for prescription drugs approved by the federal Food and Drug 26 Administration for use in the diagnosis and treatment of infertility in 27 accordance with subparagraph (C) of this paragraph. 28 (B) Every group policy issued or delivered in this state which 29 provides coverage for surgical and medical care shall not exclude cover- 30 age for surgical and medical care for diagnosis and treatment of correc- 31 table medical conditions [otherwise covered by the policy] solely 32 because the medical condition results in infertility; provided, however 33 that: 34 (i) subject to the provisions of subparagraph (C) of this paragraph, 35 in no case shall such coverage exclude surgical or medical procedures 36 which would correct malformation, disease or dysfunction resulting in 37 infertility; and 38 (ii) provided, further however, that subject to the provisions of 39 subparagraph (C) of this paragraph, in no case shall such coverage 40 exclude diagnostic tests and procedures that are necessary to determine 41 infertility or that are necessary in connection with any surgical or 42 medical treatments or prescription drug coverage provided pursuant to 43 this paragraph, including such diagnostic tests and procedures as 44 hysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy, 45 sono-hysterogram, post coital tests, testis biopsy, semen analysis, 46 blood tests [and], ultrasound, ovulation induction, intrauterine insemi- 47 nation, in-vitro fertilization, intracytoplasmic sperm injection, 48 uterine embryo lavage, embryo transfer, gamete intra-fallopian transfer, 49 zygote intra-fallopian transfer, low tubal ovum transfer, donor eggs, 50 and donor sperm; and 51 (iii) provided, further however, every such policy which provides 52 coverage for prescription drugs shall include, within such coverage, 53 coverage for prescription drugs approved by the federal Food and Drug 54 Administration for use in the diagnosis and treatment of infertility in 55 accordance with subparagraph (C) of this paragraph.A. 2415 5 1 (C) Coverage of diagnostic and treatment procedures, including 2 prescription drugs, used in the diagnosis and treatment of infertility 3 as required by subparagraphs (A) and (B) of this paragraph shall be 4 provided in accordance with the provisions of this subparagraph. 5 (i) Coverage shall be provided for persons whose ages range from twen- 6 ty-one through forty-four years, provided that nothing herein shall 7 preclude the provision of coverage to persons whose age is below or 8 above such range. 9 (ii) Diagnosis and treatment of infertility shall be prescribed as 10 part of a physician's overall plan of care and consistent with the 11 guidelines for coverage as referenced in this subparagraph. 12 (iii) Coverage may be subject to co-payments, coinsurance and deduct- 13 ibles as may be deemed appropriate by the superintendent and as are 14 consistent with those established for other benefits within a given 15 policy. 16 (iv) Coverage shall be limited to those individuals who have been 17 previously covered under the policy for a period of not less than twelve 18 months, provided that for the purposes of this subparagraph "period of 19 not less than twelve months" shall be determined by calculating such 20 time from either the date the insured was first covered under the exist- 21 ing policy or from the date the insured was first covered by a previous- 22 ly in-force converted policy, whichever is earlier. 23 (v) Coverage shall not be required to include the diagnosis and treat- 24 ment of infertility in connection with: (I) [in vitro fertilization,25gamete intrafallopian tube transfers or zygote intrafallopian tube26transfers; (II)] the reversal of elective sterilizations; [(III)] (II) 27 sex change procedures; [(IV)] (III) cloning; or [(V)] (IV) medical or 28 surgical services or procedures that are deemed to be experimental in 29 accordance with clinical guidelines referenced in clause (vi) of this 30 subparagraph. 31 (vi) The superintendent, in consultation with the commissioner of 32 health, shall promulgate regulations which shall stipulate the guide- 33 lines and standards which shall be used in carrying out the provisions 34 of this subparagraph, which shall include: 35 (I) The determination of "infertility" in accordance with the stand- 36 ards and guidelines established and adopted by the American College of 37 Obstetricians and Gynecologists and the American Society for Reproduc- 38 tive Medicine; 39 (II) The identification of experimental procedures and treatments not 40 covered for the diagnosis and treatment of infertility determined in 41 accordance with the standards and guidelines established and adopted by 42 the American College of Obstetricians and Gynecologists and the American 43 Society for Reproductive Medicine; 44 (III) The identification of the required training, experience and 45 other standards for health care providers for the provision of proce- 46 dures and treatments for the diagnosis and treatment of infertility 47 determined in accordance with the standards and guidelines established 48 and adopted by the American College of Obstetricians and Gynecologists 49 and the American Society for Reproductive Medicine; and 50 (IV) The determination of appropriate medical candidates by the treat- 51 ing physician in accordance with the standards and guidelines estab- 52 lished and adopted by the American College of Obstetricians and Gynecol- 53 ogists and/or the American Society for Reproductive Medicine. 54 (vii) A policy providing coverage under this paragraph may have the 55 following requirements and limitations:A. 2415 6 1 (I) Limit coverage for in-vitro fertilization, gamete intra-fallopian 2 transfer, zygote intra-fallopian transfer and low tubal ovum transfer to 3 those individuals who have been unable to conceive or produce conception 4 or sustain a successful pregnancy through less expensive and medically 5 viable infertility treatment or procedures covered under such a policy; 6 (II) Nothing in this subsection shall be construed to deny the cover- 7 age required by this section to any individual who forgoes a particular 8 infertility treatment or procedure if the individual's physician deter- 9 mines that such a treatment or procedure is likely to be unsuccessful; 10 (III) Limit coverage to a lifetime cap of one hundred thousand dollars 11 for ovulation induction, intrauterine insemination, in-vitro fertiliza- 12 tion, intracytoplasmic sperm injection, uterine embryo lavage, embryo 13 transfer, gamete intra-fallopian transfer, zygote intra-fallopian trans- 14 fer, low tubal ovum transfer, donor eggs, and donor sperm; 15 (IV) Require disclosure by the individual seeking such coverage to 16 such individual's existing health insurance carrier of any previous 17 infertility treatment or procedures for which such individual received 18 coverage under a different health insurance policy. Such disclosure 19 shall be made on a form and in the manner prescribed by the commissioner 20 of the department of financial services. 21 § 3. Paragraphs 1, 2 and 3 of subsection (s) of section 4303 of the 22 insurance law, as amended by section 2 of part K of chapter 82 of the 23 laws of 2002, are amended to read as follows: 24 (1) A hospital service corporation or health service corporation which 25 provides coverage for hospital care shall not exclude coverage for 26 hospital care for diagnosis and treatment of correctable medical condi- 27 tions [otherwise covered by the policy] solely because the medical 28 condition results in infertility; provided, however that: 29 (A) subject to the provisions of paragraph three of this subsection, 30 in no case shall such coverage exclude surgical or medical procedures 31 provided as part of such hospital care which would correct malformation, 32 disease or dysfunction resulting in infertility; and 33 (B) provided, further however, that subject to the provisions of para- 34 graph three of this subsection, in no case shall such coverage exclude 35 diagnostic tests and procedures provided as part of such hospital care 36 that are necessary to determine infertility or that are necessary in 37 connection with any surgical or medical treatments or prescription drug 38 coverage provided pursuant to this subsection, including such diagnostic 39 tests and procedures as hysterosalpingogram, hysteroscopy, endometrial 40 biopsy, laparoscopy, sono-hysterogram, post coital tests, testis biopsy, 41 semen analysis, blood tests [and], ultrasound, ovulation induction, 42 intrauterine insemination, in-vitro fertilization, intracytoplasmic 43 sperm injection, uterine embryo lavage, embryo transfer, gamete intra- 44 fallopian transfer, zygote intra-fallopian transfer, low tubal ovum 45 transfer, donor eggs, and donor sperm; and 46 (C) provided, further however, every such policy which provides cover- 47 age for prescription drugs shall include, within such coverage, coverage 48 for prescription drugs approved by the federal Food and Drug Adminis- 49 tration for use in the diagnosis and treatment of infertility in accord- 50 ance with paragraph three of this subsection. 51 (2) A medical expense indemnity or health service corporation which 52 provides coverage for surgical and medical care shall not exclude cover- 53 age for surgical and medical care for diagnosis and treatment of correc- 54 table medical conditions otherwise covered by the policy solely because 55 the medical condition results in infertility; provided, however that:A. 2415 7 1 (A) subject to the provisions of paragraph three of this subsection, 2 in no case shall such coverage exclude surgical or medical procedures 3 which would correct malformation, disease or dysfunction resulting in 4 infertility; and 5 (B) provided, further however, that subject to the provisions of para- 6 graph three of this subsection, in no case shall such coverage exclude 7 diagnostic tests and procedures that are necessary to determine infer- 8 tility or that are necessary in connection with any surgical or medical 9 treatments or prescription drug coverage provided pursuant to this 10 subsection, including such diagnostic tests and procedures as hystero- 11 salpingogram, hysteroscopy, endometrial biopsy, laparoscopy, sono-hyste- 12 rogram, post coital tests, testis biopsy, semen analysis, blood tests 13 [and], ultrasound, ovulation induction, intrauterine insemination, 14 in-vitro fertilization, intracytoplasmic sperm injection, uterine embryo 15 lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra- 16 fallopian transfer, low tubal ovum transfer, donor eggs, and donor 17 sperm; and 18 (C) provided, further however, every such policy which provides cover- 19 age for prescription drugs shall include, within such coverage, coverage 20 for prescription drugs approved by the federal Food and Drug Adminis- 21 tration for use in the diagnosis and treatment of infertility in accord- 22 ance with paragraph three of this subsection. 23 (3) Coverage of diagnostic and treatment procedures, including 24 prescription drugs used in the diagnosis and treatment of infertility as 25 required by paragraphs one and two of this subsection shall be provided 26 in accordance with this paragraph. 27 (A) Coverage shall be provided for persons whose ages range from twen- 28 ty-one through forty-four years, provided that nothing herein shall 29 preclude the provision of coverage to persons whose age is below or 30 above such range. 31 (B) Diagnosis and treatment of infertility shall be prescribed as part 32 of a physician's overall plan of care and consistent with the guidelines 33 for coverage as referenced in this paragraph. 34 (C) Coverage may be subject to co-payments, coinsurance and deduct- 35 ibles as may be deemed appropriate by the superintendent and as are 36 consistent with those established for other benefits within a given 37 policy. 38 (D) Coverage shall be limited to those individuals who have been 39 previously covered under the policy for a period of not less than twelve 40 months, provided that for the purposes of this paragraph "period of not 41 less than twelve months" shall be determined by calculating such time 42 from either the date the insured was first covered under the existing 43 policy or from the date the insured was first covered by a previously 44 in-force converted policy, whichever is earlier. 45 (E) Coverage shall not be required to include the diagnosis and treat- 46 ment of infertility in connection with: (i) [in vitro fertilization,47gamete intrafallopian tube transfers or zygote intrafallopian tube48transfers; (ii)] the reversal of elective sterilizations; [(iii)] (ii) 49 sex change procedures; [(iv)] (iii) cloning; or [(v)] (iv) medical or 50 surgical services or procedures that are deemed to be experimental in 51 accordance with clinical guidelines referenced in subparagraph (F) of 52 this paragraph. 53 (F) The superintendent, in consultation with the commissioner of 54 health, shall promulgate regulations which shall stipulate the guide- 55 lines and standards which shall be used in carrying out the provisions 56 of this paragraph, which shall include:A. 2415 8 1 (i) The determination of "infertility" in accordance with the stand- 2 ards and guidelines established and adopted by the American College of 3 Obstetricians and Gynecologists and the American Society for Reproduc- 4 tive Medicine; 5 (ii) The identification of experimental procedures and treatments not 6 covered for the diagnosis and treatment of infertility determined in 7 accordance with the standards and guidelines established and adopted by 8 the American College of Obstetricians and Gynecologists and the American 9 Society for Reproductive Medicine; 10 (iii) The identification of the required training, experience and 11 other standards for health care providers for the provision of proce- 12 dures and treatments for the diagnosis and treatment of infertility 13 determined in accordance with the standards and guidelines established 14 and adopted by the American College of Obstetricians and Gynecologists 15 and the American Society for Reproductive Medicine; and 16 (iv) The determination of appropriate medical candidates by the treat- 17 ing physician in accordance with the standards and guidelines estab- 18 lished and adopted by the American College of Obstetricians and Gynecol- 19 ogists and/or the American Society for Reproductive Medicine. 20 (G) A policy providing coverage under this subsection may have the 21 following requirements and limitations: 22 (I) Limit coverage for in-vitro fertilization, gamete intra-fallopian 23 transfer, zygote intra-fallopian transfer and low tubal ovum transfer to 24 those individuals who have been unable to conceive or produce conception 25 or sustain a successful pregnancy through less expensive and medically 26 viable infertility treatment or procedures covered under such a policy. 27 (II) Nothing in this subsection shall be construed to deny the cover- 28 age required by this section to any individual who forgoes a particular 29 infertility treatment or procedure if the individual's physician deter- 30 mines that such a treatment or procedure is likely to be unsuccessful; 31 (III) Limit coverage to a lifetime cap of one hundred thousand dollars 32 for ovulation induction, intrauterine insemination, in-vitro fertiliza- 33 tion, intracytoplasmic sperm injection, uterine embryo lavage, embryo 34 transfer, gamete intra-fallopian transfer, zygote intra-fallopian trans- 35 fer, low tubal ovum transfer, donor eggs, and donor sperm; 36 (IV) Require disclosure by the individual seeking such coverage to 37 such individual's existing health insurance carrier of any previous 38 infertility treatment or procedures for which such individual received 39 coverage under a different health insurance policy. Such disclosure 40 shall be made on a form and in the manner prescribed by the commissioner 41 of the department of financial services. 42 § 4. This act shall take effect immediately.