Bill Text: NY S02286 | 2023-2024 | General Assembly | Introduced
Bill Title: Enacts the "Give Kids a Chance - Carter's Law" mandating health insurance coverage for congenital anomalies including certain reconstructive services, habilitative services, and inpatient and outpatient services.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced) 2024-01-03 - REFERRED TO INSURANCE [S02286 Detail]
Download: New_York-2023-S02286-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 2286 2023-2024 Regular Sessions IN SENATE January 19, 2023 ___________ Introduced by Sen. CLEARE -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance AN ACT to amend the insurance law, in relation to enacting the "Give Kids a Chance - Carter's Law" mandating health insurance coverage for congenital anomalies The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Short title. This act shall be known and may be cited as 2 the "Give Kids a Chance - Carter's Law". 3 § 2. Subsection (a) of section 3216 of the insurance law is amended by 4 adding 5 new paragraphs 5, 6, 7, 8 and 9 to read as follows: 5 (5) "Congenital anomaly" means a medically diagnosed condition exist- 6 ing at or from birth that is a deviation from the common structure or 7 function of the body, whether caused by a hereditary or developmental 8 disability or disease. 9 (6) "Cosmetic surgery" means surgical and nonsurgical elective proce- 10 dures that enhance and reshape structures of the body to improve appear- 11 ance and confidence, but are not necessary to improve body structure or 12 function. 13 (7) "Habilitative services" means healthcare services that help an 14 individual keep, learn, or improve skills and functioning for daily 15 living. Habilitative services shall include but is not limited to phys- 16 ical and occupational therapy, speech-language pathology, and services 17 for people with disabilities in a variety of inpatient and/or outpatient 18 settings. 19 (8) "Reconstructive services" means procedures or surgery that are 20 performed to treat structures of the body affected aesthetically or 21 functionally by congenital anomalies, developmental abnormalities, trau- 22 ma, infection, tumors, or disease. Reconstructive services are intended 23 to improve function and ability, and may also be performed to achieve a 24 more typical appearance of the affected structure. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD06707-01-3S. 2286 2 1 (9) "Deviation" means an anomaly that impairs the function of the body 2 and includes but is not limited to the conditions of cleft lip, cleft 3 palate, webbed fingers or toes, supernumerary toes or fingers, craniofa- 4 cial malformations, disorders of metabolism, and other conditions that 5 are medically diagnosed to be congenital anomalies. 6 § 3. Paragraph 4 of subsection (c) of section 3216 of the insurance 7 law is amended by adding a new subparagraph (D) to read as follows: 8 (D) (1) For the purpose of this subparagraph, the term "treatment" 9 includes inpatient and outpatient care and services performed to improve 10 or restore body function, or performed to approximate a normal appear- 11 ance, as a result of a congenital anomaly and shall not include cosmetic 12 surgery. Inpatient and outpatient care and services shall include treat- 13 ment to any and all missing or abnormal body parts, including teeth, the 14 oral cavity, and their associated structures, that would otherwise be 15 provided under the plan or coverage for any other injury and sickness, 16 including: 17 (i) All inpatient and outpatient reconstructive services and proce- 18 dures; 19 (ii) All services, procedures, and adjunctive needs, including but not 20 limited to prosthetics and appliances, resulting from complications; 21 (iii) Adjunctive dental, orthodontic or prosthodontic support from 22 birth until the medical or surgical treatment of the anomaly has been 23 completed, including ongoing or subsequent treatment required to main- 24 tain function or approximate a normal appearance; 25 (iv) Procedures that do not materially restore or improve the function 26 of the body part being treated; and 27 (v) Procedures for secondary conditions and follow-up treatments. 28 (2) (i) Every policy, plan, certificate or contract shall provide 29 benefits for reconstructive services when such treatment is incidental 30 to or follows surgery resulting from injury, sickness or other diseases 31 of the involved missing or abnormal body part or when such treatment is 32 provided to a covered dependent child because of congenital disease or 33 anomaly as determined by the treating physician. 34 (ii) Every policy, plan, certificate or contract shall provide bene- 35 fits for habilitative services when such treatment is incidental to or 36 follows surgery resulting from injury, sickness or other diseases of the 37 involved missing or abnormal body part or when such treatment is 38 provided to a covered dependent child because of congenital disease or 39 anomaly as determined by the treating physician. 40 (iii) Every policy, plan, certificate or contract may be subject to 41 annual deductible, co-payment, and coinsurance provisions as may be 42 deemed appropriate and as are consistent with those established for 43 other benefits under the plan or coverage. 44 (iv) No policy, plan, certificate or contract shall: 45 a. Deny to a patient eligibility or continued eligibility, to enroll 46 or to renew, coverage under the terms of the plan, solely for the 47 purpose of avoiding the requirements of this subparagraph; or 48 b. Penalize or otherwise reduce or limit the reimbursement of a treat- 49 ing provider, or provide monetary or other incentives to a treating 50 provider to induce the provider to provide care to an individual partic- 51 ipant or beneficiary in a manner inconsistent with this subparagraph. 52 (v) Written notice of the availability of the coverage shall be deliv- 53 ered to the participant upon enrollment and annually thereafter. 54 (3) (i) In accordance with section forty-four hundred eight of the 55 public health law, an enrollee has the right to appeal any denial ofS. 2286 3 1 care that the carrier determines is not medically necessary or exper- 2 imental. 3 (ii) An internal appeal of denial filed by an enrollee or the 4 enrollee's provider to the insurance carrier regarding coverage for 5 reconstructive or habilitative services to treat a congenital anomaly 6 shall be expedited by the carrier. The health plan shall respond orally 7 with a decision within forty-eight hours, followed by a confirmation in 8 writing within seven days. 9 § 4. Subsection (f) of section 4235 of the insurance law is amended by 10 adding a new paragraph 5 to read as follows: 11 (5) (A) As used in this paragraph: 12 (i) "Congenital anomaly" means a medically diagnosed condition exist- 13 ing at or from birth that is a deviation from the common structure or 14 function of the body, whether caused by a hereditary or developmental 15 disability or disease. 16 (ii) "Cosmetic surgery" means surgical and nonsurgical elective proce- 17 dures that enhance and reshape structures of the body to improve appear- 18 ance and confidence, but are not necessary to improve body structure or 19 function. 20 (iii) "Habilitative services" means healthcare services that help an 21 individual keep, learn, or improve skills and functioning for daily 22 living. Habilitative services shall include but is not limited to phys- 23 ical and occupational therapy, speech-language pathology, and services 24 for people with disabilities in a variety of inpatient and/or outpatient 25 settings. 26 (iv) "Reconstructive services" means procedures or surgery that are 27 performed to treat structures of the body affected aesthetically or 28 functionally by congenital anomalies, developmental abnormalities, trau- 29 ma, infection, tumors, or disease. Reconstructive services are intended 30 to improve function and ability, and may also be performed to achieve a 31 more typical appearance of the affected structure. 32 (v) "Deviation" means an anomaly that impairs the function of the body 33 and includes but is not limited to the conditions of cleft lip, cleft 34 palate, webbed fingers or toes, supernumerary toes or fingers, craniofa- 35 cial malformations, disorders of metabolism, and other conditions that 36 are medically diagnosed to be congenital anomalies. 37 (B) (i) For the purpose of this paragraph, the term "treatment" 38 includes inpatient and outpatient care and services performed to improve 39 or restore body function, or performed to approximate a normal appear- 40 ance, as a result of a congenital anomaly and shall not include cosmetic 41 surgery. Inpatient and outpatient care and services shall include treat- 42 ment to any and all missing or abnormal body parts, including teeth, the 43 oral cavity, and their associated structures, that would otherwise be 44 provided under the plan or coverage for any other injury and sickness, 45 including: 46 (I) All inpatient and outpatient reconstructive services and proce- 47 dures; 48 (II) All services, procedures, and adjunctive needs, including but not 49 limited to prosthetics and appliances, resulting from complications; 50 (III) Adjunctive dental, orthodontic or prosthodontic support from 51 birth until the medical or surgical treatment of the anomaly has been 52 completed, including ongoing or subsequent treatment required to main- 53 tain function or approximate a normal appearance; 54 (IV) Procedures that do not materially restore or improve the function 55 of the body part being treated; and 56 (V) Procedures for secondary conditions and follow-up treatments.S. 2286 4 1 (ii) (I) Every policy, plan, certificate or contract shall provide 2 benefits for reconstructive services when such treatment is incidental 3 to or follows surgery resulting from injury, sickness or other diseases 4 of the involved missing or abnormal body part or when such treatment is 5 provided to a covered dependent child because of congenital disease or 6 anomaly as determined by the treating physician. 7 (II) Every policy, plan, certificate or contract shall provide bene- 8 fits for habilitative services when such treatment is incidental to or 9 follows surgery resulting from injury, sickness or other diseases of the 10 involved missing or abnormal body part or when such treatment is 11 provided to a covered dependent child because of congenital disease or 12 anomaly as determined by the treating physician. 13 (III) Every policy, plan, certificate or contract may be subject to 14 annual deductible, co-payment, and coinsurance provisions as may be 15 deemed appropriate and as are consistent with those established for 16 other benefits under the plan or coverage. 17 (IV) No policy, plan, certificate or contract shall: 18 a. Deny to a patient eligibility or continued eligibility, to enroll 19 or to renew, coverage under the terms of the plan, solely for the 20 purpose of avoiding the requirements of this paragraph; or 21 b. Penalize or otherwise reduce or limit the reimbursement of a treat- 22 ing provider, or provide monetary or other incentives to a treating 23 provider to induce the provider to provide care to an individual partic- 24 ipant or beneficiary in a manner inconsistent with this paragraph. 25 (V) Written notice of the availability of the coverage shall be deliv- 26 ered to the participant upon enrollment and annually thereafter. 27 (iii) (I) In accordance with section forty-four hundred eight of the 28 public health law, an enrollee has the right to appeal any denial of 29 care that the carrier determines is not medically necessary or exper- 30 imental. 31 (II) An internal appeal of denial filed by an enrollee or the 32 enrollee's provider to the insurance carrier regarding coverage for 33 reconstructive or habilitative services to treat a congenital anomaly 34 shall be expedited by the carrier. The health plan shall respond orally 35 with a decision within forty-eight hours, followed by a confirmation in 36 writing within seven days. 37 § 5. Paragraph 1 of subsection (d) of section 4304 of the insurance 38 law is amended by adding a new subparagraph (D) to read as follows: 39 (D) (i) As used in this paragraph: 40 1. "Congenital anomaly" means a medically diagnosed condition existing 41 at or from birth that is a deviation from the common structure or func- 42 tion of the body, whether caused by a hereditary or developmental disa- 43 bility or disease. 44 2. "Cosmetic surgery" means surgical and nonsurgical elective proce- 45 dures that enhance and reshape structures of the body to improve appear- 46 ance and confidence, but are not necessary to improve body structure or 47 function. 48 3. "Habilitative services" means healthcare services that help an 49 individual keep, learn, or improve skills and functioning for daily 50 living. Habilitative services shall include but is not limited to phys- 51 ical and occupational therapy, speech-language pathology, and services 52 for people with disabilities in a variety of inpatient and/or outpatient 53 settings. 54 4. "Reconstructive services" means procedures or surgery that are 55 performed to treat structures of the body affected aesthetically or 56 functionally by congenital anomalies, developmental abnormalities, trau-S. 2286 5 1 ma, infection, tumors, or disease. Reconstructive services are intended 2 to improve function and ability, and may also be performed to achieve a 3 more typical appearance of the affected structure. 4 5. "Deviation" means an anomaly that impairs the function of the body 5 and includes but is not limited to the conditions of cleft lip, cleft 6 palate, webbed fingers or toes, supernumerary toes or fingers, craniofa- 7 cial malformations, disorders of metabolism, and other conditions that 8 are medically diagnosed to be congenital anomalies. 9 (ii) For the purpose of this subparagraph, the term "treatment" 10 includes inpatient and outpatient care and services performed to improve 11 or restore body function, or performed to approximate a normal appear- 12 ance, as a result of a congenital anomaly and shall not include cosmetic 13 surgery. Inpatient and outpatient care and services shall include treat- 14 ment to any and all missing or abnormal body parts, including teeth, the 15 oral cavity, and their associated structures, that would otherwise be 16 provided under the plan or coverage for any other injury and sickness, 17 including: 18 1. All inpatient and outpatient reconstructive services and proce- 19 dures; 20 2. All services, procedures, and adjunctive needs, including prosthet- 21 ics and appliances, resulting from complications; 22 3. Adjunctive dental, orthodontic or prosthodontic support from birth 23 until the medical or surgical treatment of the anomaly has been 24 completed, including ongoing or subsequent treatment required to main- 25 tain function or approximate a normal appearance; 26 4. Procedures that do not materially restore or improve the function 27 of the body part being treated; and 28 5. Procedures for secondary conditions and follow-up treatments. 29 (iii) 1. Every policy, plan, certificate or contract shall provide 30 benefits for reconstructive services when such treatment is incidental 31 to or follows surgery resulting from injury, sickness or other diseases 32 of the involved missing or abnormal body part or when such treatment is 33 provided to a covered dependent child because of congenital disease or 34 anomaly as determined by the treating physician. 35 2. Every policy, plan, certificate or contract shall provide benefits 36 for habilitative services when such treatment is incidental to or 37 follows surgery resulting from injury, sickness or other diseases of the 38 involved missing or abnormal body part or when such treatment is 39 provided to a covered dependent child because of congenital disease or 40 anomaly as determined by the treating physician. 41 3. Every policy, plan, certificate or contract may be subject to annu- 42 al deductible, co-payment, and coinsurance provisions as may be deemed 43 appropriate and as are consistent with those established for other bene- 44 fits under the plan or coverage. 45 4. No policy, plan, certificate or contract shall: 46 a. Deny to a patient eligibility or continued eligibility, to enroll 47 or to renew, coverage under the terms of the plan, solely for the 48 purpose of avoiding the requirements of this subparagraph; or 49 b. Penalize or otherwise reduce or limit the reimbursement of a treat- 50 ing provider, or provide monetary or other incentives to a treating 51 provider to induce the provider to provide care to an individual partic- 52 ipant or beneficiary in a manner inconsistent with this subparagraph. 53 (iv) Written notice of the availability of the coverage shall be 54 delivered to the participant upon enrollment and annually thereafter. 55 (v) 1. In accordance with section forty-four hundred eight of the 56 public health law, an enrollee has the right to appeal any denial ofS. 2286 6 1 care that the carrier determines is not medically necessary or exper- 2 imental. 3 2. An internal appeal of denial filed by an enrollee or the enrollee's 4 provider to the insurance carrier regarding coverage for reconstructive 5 or habilitative services to treat a congenital anomaly shall be expe- 6 dited by the carrier. The health plan shall respond orally with a deci- 7 sion within forty-eight hours, followed by a confirmation in writing 8 within seven days. 9 § 6. Paragraph 1 of subsection (c) of section 4305 of the insurance 10 law is amended by adding a new subparagraph (D) to read as follows: 11 (D)(i) As used in this subparagraph: 12 1. "Congenital anomaly" means a medically diagnosed condition existing 13 at or from birth that is a deviation from the common structure or func- 14 tion of the body, whether caused by a hereditary or developmental disa- 15 bility or disease. 16 2. "Cosmetic surgery" means surgical and nonsurgical elective proce- 17 dures that enhance and reshape structures of the body to improve appear- 18 ance and confidence, but are not necessary to improve body structure or 19 function. 20 3. "Habilitative services" means healthcare services that help an 21 individual keep, learn, or improve skills and functioning for daily 22 living. Habilitative services shall include but is not limited to phys- 23 ical and occupational therapy, speech-language pathology, and services 24 for people with disabilities in a variety of inpatient and/or outpatient 25 settings. 26 4. "Reconstructive services" means procedures or surgery that are 27 performed to treat structures of the body affected aesthetically or 28 functionally by congenital anomalies, developmental abnormalities, trau- 29 ma, infection, tumors, or disease. Reconstructive services are intended 30 to improve function and ability, and may also be performed to achieve a 31 more typical appearance of the affected structure. 32 5. "Deviation" means an anomaly that impairs the function of the body 33 and includes but is not limited to the conditions of cleft lip, cleft 34 palate, webbed fingers or toes, supernumerary toes or fingers, craniofa- 35 cial malformations, disorders of metabolism, and other conditions that 36 are medically diagnosed to be congenital anomalies. 37 (ii) For the purpose of this subparagraph, the term "treatment" 38 includes inpatient and outpatient care and services performed to improve 39 or restore body function, or performed to approximate a normal appear- 40 ance, as a result of a congenital anomaly and shall not include cosmetic 41 surgery. Inpatient and outpatient care and services shall include treat- 42 ment to any and all missing or abnormal body parts, including teeth, the 43 oral cavity, and their associated structures, that would otherwise be 44 provided under the plan or coverage for any other injury and sickness, 45 including: 46 1. All inpatient and outpatient reconstructive services and proce- 47 dures; 48 2. All services, procedures, and adjunctive needs, including prosthet- 49 ics and appliances, resulting from complications; 50 3. Adjunctive dental, orthodontic or prosthodontic support from birth 51 until the medical or surgical treatment of the anomaly has been 52 completed, including ongoing or subsequent treatment required to main- 53 tain function or approximate a normal appearance; 54 4. Procedures that do not materially restore or improve the function 55 of the body part being treated; and 56 5. Procedures for secondary conditions and follow-up treatments.S. 2286 7 1 (iii) 1. Every policy, plan, certificate or contract shall provide 2 benefits for reconstructive services when such treatment is incidental 3 to or follows surgery resulting from injury, sickness or other diseases 4 of the involved missing or abnormal body part or when such treatment is 5 provided to a covered dependent child because of congenital disease or 6 anomaly as determined by the treating physician. 7 2. Every policy, plan, certificate or contract shall provide benefits 8 for habilitative services when such treatment is incidental to or 9 follows surgery resulting from injury, sickness or other diseases of the 10 involved missing or abnormal body part or when such treatment is 11 provided to a covered dependent child because of congenital disease or 12 anomaly as determined by the treating physician. 13 3. Every policy, plan, certificate or contract may be subject to annu- 14 al deductible, co-payment, and coinsurance provisions as may be deemed 15 appropriate and as are consistent with those established for other bene- 16 fits under the plan or coverage. 17 4. No policy, plan, certificate or contract shall: 18 a. Deny to a patient eligibility or continued eligibility, to enroll 19 or to renew, coverage under the terms of the plan, solely for the 20 purpose of avoiding the requirements of this subparagraph; or 21 b. Penalize or otherwise reduce or limit the reimbursement of a treat- 22 ing provider or provide monetary or other incentives to a treating 23 provider to induce the provider to provide care to an individual partic- 24 ipant or beneficiary in a manner inconsistent with this subparagraph. 25 (iv) Written notice of the availability of the coverage shall be 26 delivered to the participant upon enrollment and annually thereafter. 27 (v) 1. In accordance with section forty-four hundred eight of the 28 public health law, an enrollee has the right to appeal any denial of 29 care that the carrier determines is not medically necessary or exper- 30 imental. 31 2. An internal appeal of denial filed by an enrollee or the enrollee's 32 provider to the insurance carrier regarding coverage for reconstructive 33 or habilitative services to treat a congenital anomaly shall be expe- 34 dited by the carrier. The health plan shall respond orally with a deci- 35 sion within forty-eight hours, followed by a confirmation in writing 36 within seven days. 37 § 7. This act shall take effect on the first of January next succeed- 38 ing the date on which it shall have become a law and shall apply to all 39 policies and contracts issued, renewed, modified, altered or amended on 40 or after such date.
