Bill Text: NY S07709 | 2019-2020 | 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: Slight Partisan Bill (Democrat 6-2)

Status: (Introduced - Dead) 2020-02-10 - REFERRED TO INSURANCE [S07709 Detail]

Download: New_York-2019-S07709-Introduced.html



                STATE OF NEW YORK
        ________________________________________________________________________

                                          7709

                    IN SENATE

                                    February 10, 2020
                                       ___________

        Introduced  by  Sen.  KAPLAN -- 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.
    25    (9) "Deviation" means an anomaly that impairs the function of the body
    26  and  includes  but  is not limited to the conditions of cleft lip, cleft
    27  palate, webbed fingers or toes, supernumerary toes or fingers, craniofa-

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD14264-03-9

        S. 7709                             2

     1  cial malformations, disorders of metabolism, and other  conditions  that
     2  are medically diagnosed to be congenital anomalies.
     3    §  3.  Paragraph  4 of subsection (c) of section 3216 of the insurance
     4  law is amended by adding a new subparagraph (D) to read as follows:
     5    (D) (1) For the purpose of this  subparagraph,  the  term  "treatment"
     6  includes inpatient and outpatient care and services performed to improve
     7  or  restore  body function, or performed to approximate a normal appear-
     8  ance, as a result of a congenital anomaly and shall not include cosmetic
     9  surgery. Inpatient and outpatient care and services shall include treat-
    10  ment to any and all missing or abnormal body parts, including teeth, the
    11  oral cavity, and their associated structures, that  would  otherwise  be
    12  provided  under  the plan or coverage for any other injury and sickness,
    13  including:
    14    (i) All inpatient and outpatient reconstructive  services  and  proce-
    15  dures;
    16    (ii) All services, procedures, and adjunctive needs, including but not
    17  limited to prosthetics and appliances, resulting from complications;
    18    (iii)  Adjunctive  dental,  orthodontic  or prosthodontic support from
    19  birth until the medical or surgical treatment of the  anomaly  has  been
    20  completed,  including  ongoing or subsequent treatment required to main-
    21  tain function or approximate a normal appearance;
    22    (iv) Procedures that do not materially restore or improve the function
    23  of the body part being treated; and
    24    (v) Procedures for secondary conditions and follow-up treatments.
    25    (2) (i) Every policy, plan,  certificate  or  contract  shall  provide
    26  benefits  for  reconstructive services when such treatment is incidental
    27  to or follows surgery resulting from injury, sickness or other  diseases
    28  of  the involved missing or abnormal body part or when such treatment is
    29  provided to a covered dependent child because of congenital  disease  or
    30  anomaly as determined by the treating physician.
    31    (ii)  Every  policy, plan, certificate or contract shall provide bene-
    32  fits for habilitative services when such treatment is incidental  to  or
    33  follows surgery resulting from injury, sickness or other diseases of the
    34  involved  missing  or  abnormal  body  part  or  when  such treatment is
    35  provided to a covered dependent child because of congenital  disease  or
    36  anomaly as determined by the treating physician.
    37    (iii)  Every  policy,  plan, certificate or contract may be subject to
    38  annual deductible, co-payment, and  coinsurance  provisions  as  may  be
    39  deemed  appropriate  and  as  are  consistent with those established for
    40  other benefits under the plan or coverage.
    41    (iv) No policy, plan, certificate or contract shall:
    42    a. Deny to a patient eligibility or continued eligibility,  to  enroll
    43  or  to  renew,  coverage  under  the  terms  of the plan, solely for the
    44  purpose of avoiding the requirements of this subparagraph; or
    45    b. Penalize or otherwise reduce or limit the reimbursement of a treat-
    46  ing provider, or provide monetary or  other  incentives  to  a  treating
    47  provider to induce the provider to provide care to an individual partic-
    48  ipant or beneficiary in a manner inconsistent with this subparagraph.
    49    (v) Written notice of the availability of the coverage shall be deliv-
    50  ered to the participant upon enrollment and annually thereafter.
    51    (3)  (i)  In  accordance  with section forty-four hundred eight of the
    52  public health law, an enrollee has the right to  appeal  any  denial  of
    53  care  that  the  carrier determines is not medically necessary or exper-
    54  imental.
    55    (ii) An internal  appeal  of  denial  filed  by  an  enrollee  or  the
    56  enrollee's  provider  to  the  insurance  carrier regarding coverage for

        S. 7709                             3

     1  reconstructive or habilitative services to treat  a  congenital  anomaly
     2  shall  be expedited by the carrier. The health plan shall respond orally
     3  with a decision within forty-eight hours, followed by a confirmation  in
     4  writing within seven days.
     5    § 4. Subsection (f) of section 4235 of the insurance law is amended by
     6  adding a new paragraph 5 to read as follows:
     7    (5) (A) As used in this paragraph:
     8    (i)  "Congenital anomaly" means a medically diagnosed condition exist-
     9  ing at or from birth that is a deviation from the  common  structure  or
    10  function  of  the  body, whether caused by a hereditary or developmental
    11  disability or disease.
    12    (ii) "Cosmetic surgery" means surgical and nonsurgical elective proce-
    13  dures that enhance and reshape structures of the body to improve appear-
    14  ance and confidence, but are not necessary to improve body structure  or
    15  function.
    16    (iii)  "Habilitative  services" means healthcare services that help an
    17  individual keep, learn, or improve  skills  and  functioning  for  daily
    18  living.  Habilitative services shall include but is not limited to phys-
    19  ical  and  occupational therapy, speech-language pathology, and services
    20  for people with disabilities in a variety of inpatient and/or outpatient
    21  settings.
    22    (iv) "Reconstructive services" means procedures or  surgery  that  are
    23  performed  to  treat  structures  of  the body affected aesthetically or
    24  functionally by congenital anomalies, developmental abnormalities, trau-
    25  ma, infection, tumors, or disease.  Reconstructive services are intended
    26  to improve function and ability, and may also be performed to achieve  a
    27  more typical appearance of the affected structure.
    28    (v) "Deviation" means an anomaly that impairs the function of the body
    29  and  includes  but  is not limited to the conditions of cleft lip, cleft
    30  palate, webbed fingers or toes, supernumerary toes or fingers, craniofa-
    31  cial malformations, disorders of metabolism, and other  conditions  that
    32  are medically diagnosed to be congenital anomalies.
    33    (B)  (i)  For  the  purpose  of  this  paragraph, the term "treatment"
    34  includes inpatient and outpatient care and services performed to improve
    35  or restore body function, or performed to approximate a  normal  appear-
    36  ance, as a result of a congenital anomaly and shall not include cosmetic
    37  surgery. Inpatient and outpatient care and services shall include treat-
    38  ment to any and all missing or abnormal body parts, including teeth, the
    39  oral  cavity,  and  their associated structures, that would otherwise be
    40  provided under the plan or coverage for any other injury  and  sickness,
    41  including:
    42    (I)  All  inpatient  and outpatient reconstructive services and proce-
    43  dures;
    44    (II) All services, procedures, and adjunctive needs, including but not
    45  limited to prosthetics and appliances, resulting from complications;
    46    (III) Adjunctive dental, orthodontic  or  prosthodontic  support  from
    47  birth  until  the  medical or surgical treatment of the anomaly has been
    48  completed, including ongoing or subsequent treatment required  to  main-
    49  tain function or approximate a normal appearance;
    50    (IV) Procedures that do not materially restore or improve the function
    51  of the body part being treated; and
    52    (V) Procedures for secondary conditions and follow-up treatments.
    53    (ii)  (I)  Every  policy,  plan, certificate or contract shall provide
    54  benefits for reconstructive services when such treatment  is  incidental
    55  to  or follows surgery resulting from injury, sickness or other diseases
    56  of the involved missing or abnormal body part or when such treatment  is

        S. 7709                             4

     1  provided  to  a covered dependent child because of congenital disease or
     2  anomaly as determined by the treating physician.
     3    (II)  Every  policy, plan, certificate or contract shall provide bene-
     4  fits for habilitative services when such treatment is incidental  to  or
     5  follows surgery resulting from injury, sickness or other diseases of the
     6  involved  missing  or  abnormal  body  part  or  when  such treatment is
     7  provided to a covered dependent child because of congenital  disease  or
     8  anomaly as determined by the treating physician.
     9    (III)  Every  policy,  plan, certificate or contract may be subject to
    10  annual deductible, co-payment, and  coinsurance  provisions  as  may  be
    11  deemed  appropriate  and  as  are  consistent with those established for
    12  other benefits under the plan or coverage.
    13    (IV) No policy, plan, certificate or contract shall:
    14    a. Deny to a patient eligibility or continued eligibility,  to  enroll
    15  or  to  renew,  coverage  under  the  terms  of the plan, solely for the
    16  purpose of avoiding the requirements of this paragraph; or
    17    b. Penalize or otherwise reduce or limit the reimbursement of a treat-
    18  ing provider, or provide monetary or  other  incentives  to  a  treating
    19  provider to induce the provider to provide care to an individual partic-
    20  ipant or beneficiary in a manner inconsistent with this paragraph.
    21    (V) Written notice of the availability of the coverage shall be deliv-
    22  ered to the participant upon enrollment and annually thereafter.
    23    (iii)  (I)  In accordance with section forty-four hundred eight of the
    24  public health law, an enrollee has the right to  appeal  any  denial  of
    25  care  that  the  carrier determines is not medically necessary or exper-
    26  imental.
    27    (II) An internal  appeal  of  denial  filed  by  an  enrollee  or  the
    28  enrollee's  provider  to  the  insurance  carrier regarding coverage for
    29  reconstructive or habilitative services to treat  a  congenital  anomaly
    30  shall  be expedited by the carrier. The health plan shall respond orally
    31  with a decision within forty-eight hours, followed by a confirmation  in
    32  writing within seven days.
    33    §  5.  Paragraph  1 of subsection (d) of section 4304 of the insurance
    34  law is amended by adding a new subparagraph (D) to read as follows:
    35    (D) (i) As used in this paragraph:
    36    1. "Congenital anomaly" means a medically diagnosed condition existing
    37  at or from birth that is a deviation from the common structure or  func-
    38  tion  of the body, whether caused by a hereditary or developmental disa-
    39  bility or disease.
    40    2. "Cosmetic surgery" means surgical and nonsurgical  elective  proce-
    41  dures that enhance and reshape structures of the body to improve appear-
    42  ance  and confidence, but are not necessary to improve body structure or
    43  function.
    44    3. "Habilitative services" means  healthcare  services  that  help  an
    45  individual  keep,  learn,  or  improve  skills and functioning for daily
    46  living.  Habilitative services shall include but is not limited to phys-
    47  ical and occupational therapy, speech-language pathology,  and  services
    48  for people with disabilities in a variety of inpatient and/or outpatient
    49  settings.
    50    4.  "Reconstructive  services"  means  procedures  or surgery that are
    51  performed to treat structures of  the  body  affected  aesthetically  or
    52  functionally by congenital anomalies, developmental abnormalities, trau-
    53  ma, infection, tumors, or disease.  Reconstructive services are intended
    54  to  improve function and ability, and may also be performed to achieve a
    55  more typical appearance of the affected structure.

        S. 7709                             5

     1    5. "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    (ii)  For  the  purpose  of  this  subparagraph,  the term "treatment"
     7  includes inpatient and outpatient care and services performed to improve
     8  or restore body function, or performed to approximate a  normal  appear-
     9  ance, as a result of a congenital anomaly and shall not include cosmetic
    10  surgery. Inpatient and outpatient care and services shall include treat-
    11  ment to any and all missing or abnormal body parts, including teeth, the
    12  oral  cavity,  and  their associated structures, that would otherwise be
    13  provided under the plan or coverage for any other injury  and  sickness,
    14  including:
    15    1.  All  inpatient  and  outpatient reconstructive services and proce-
    16  dures;
    17    2. All services, procedures, and adjunctive needs, including prosthet-
    18  ics and appliances, resulting from complications;
    19    3. Adjunctive dental, orthodontic or prosthodontic support from  birth
    20  until  the  medical  or  surgical  treatment  of  the  anomaly  has been
    21  completed, including ongoing or subsequent treatment required  to  main-
    22  tain function or approximate a normal appearance;
    23    4.  Procedures  that do not materially restore or improve the function
    24  of the body part being treated; and
    25    5. Procedures for secondary conditions and follow-up treatments.
    26    (iii) 1. Every policy, plan, certificate  or  contract  shall  provide
    27  benefits  for  reconstructive services when such treatment is incidental
    28  to or follows surgery resulting from injury, sickness or other  diseases
    29  of  the involved missing or abnormal body part or when such treatment is
    30  provided to a covered dependent child because of congenital  disease  or
    31  anomaly as determined by the treating physician.
    32    2.  Every policy, plan, certificate or contract shall provide benefits
    33  for habilitative services  when  such  treatment  is  incidental  to  or
    34  follows surgery resulting from injury, sickness or other diseases of the
    35  involved  missing  or  abnormal  body  part  or  when  such treatment is
    36  provided to a covered dependent child because of congenital  disease  or
    37  anomaly as determined by the treating physician.
    38    3. Every policy, plan, certificate or contract may be subject to annu-
    39  al  deductible,  co-payment, and coinsurance provisions as may be deemed
    40  appropriate and as are consistent with those established for other bene-
    41  fits under the plan or coverage.
    42    4. No policy, plan, certificate or contract shall:
    43    a. Deny to a patient eligibility or continued eligibility,  to  enroll
    44  or  to  renew,  coverage  under  the  terms  of the plan, solely for the
    45  purpose of avoiding the requirements of this subparagraph; or
    46    b. Penalize or otherwise reduce or limit the reimbursement of a treat-
    47  ing provider, or provide monetary or  other  incentives  to  a  treating
    48  provider to induce the provider to provide care to an individual partic-
    49  ipant or beneficiary in a manner inconsistent with this subparagraph.
    50    (iv)  Written  notice  of  the  availability  of the coverage shall be
    51  delivered to the participant upon enrollment and annually thereafter.
    52    (v) 1. In accordance with section  forty-four  hundred  eight  of  the
    53  public  health  law,  an  enrollee has the right to appeal any denial of
    54  care that the carrier determines is not medically  necessary  or  exper-
    55  imental.

        S. 7709                             6

     1    2. An internal appeal of denial filed by an enrollee or the enrollee's
     2  provider  to the insurance carrier regarding coverage for reconstructive
     3  or habilitative services to treat a congenital anomaly  shall  be  expe-
     4  dited  by the carrier. The health plan shall respond orally with a deci-
     5  sion  within  forty-eight  hours,  followed by a confirmation in writing
     6  within seven days.
     7    § 6. Paragraph 1 of subsection (c) of section 4305  of  the  insurance
     8  law is amended by adding a new subparagraph (D) to read as follows:
     9    (D)(i) As used in this subparagraph:
    10    1. "Congenital anomaly" means a medically diagnosed condition existing
    11  at  or from birth that is a deviation from the common structure or func-
    12  tion of the body, whether caused by a hereditary or developmental  disa-
    13  bility or disease.
    14    2.  "Cosmetic  surgery" means surgical and nonsurgical elective proce-
    15  dures that enhance and reshape structures of the body to improve appear-
    16  ance and confidence, but are not necessary to improve body structure  or
    17  function.
    18    3.  "Habilitative  services"  means  healthcare  services that help an
    19  individual keep, learn, or improve  skills  and  functioning  for  daily
    20  living.  Habilitative services shall include but is not limited to phys-
    21  ical and occupational therapy, speech-language pathology,  and  services
    22  for people with disabilities in a variety of inpatient and/or outpatient
    23  settings.
    24    4.  "Reconstructive  services"  means  procedures  or surgery that are
    25  performed to treat structures of  the  body  affected  aesthetically  or
    26  functionally by congenital anomalies, developmental abnormalities, trau-
    27  ma,  infection, tumors, or disease. Reconstructive services are intended
    28  to improve function and ability, and may also be performed to achieve  a
    29  more typical appearance of the affected structure.
    30    5.  "Deviation" means an anomaly that impairs the function of the body
    31  and includes but is not limited to the conditions of  cleft  lip,  cleft
    32  palate, webbed fingers or toes, supernumerary toes or fingers, craniofa-
    33  cial  malformations,  disorders of metabolism, and other conditions that
    34  are medically diagnosed to be congenital anomalies.
    35    (ii) For the  purpose  of  this  subparagraph,  the  term  "treatment"
    36  includes inpatient and outpatient care and services performed to improve
    37  or  restore  body function, or performed to approximate a normal appear-
    38  ance, as a result of a congenital anomaly and shall not include cosmetic
    39  surgery. Inpatient and outpatient care and services shall include treat-
    40  ment to any and all missing or abnormal body parts, including teeth, the
    41  oral cavity, and their associated structures, that  would  otherwise  be
    42  provided  under  the plan or coverage for any other injury and sickness,
    43  including:
    44    1. All inpatient and outpatient  reconstructive  services  and  proce-
    45  dures;
    46    2. All services, procedures, and adjunctive needs, including prosthet-
    47  ics and appliances, resulting from complications;
    48    3.  Adjunctive dental, orthodontic or prosthodontic support from birth
    49  until the  medical  or  surgical  treatment  of  the  anomaly  has  been
    50  completed,  including  ongoing or subsequent treatment required to main-
    51  tain function or approximate a normal appearance;
    52    4. Procedures that do not materially restore or improve  the  function
    53  of the body part being treated; and
    54    5. Procedures for secondary conditions and follow-up treatments.
    55    (iii)  1.  Every  policy,  plan, certificate or contract shall provide
    56  benefits for reconstructive services when such treatment  is  incidental

        S. 7709                             7

     1  to  or follows surgery resulting from injury, sickness or other diseases
     2  of the involved missing or abnormal body part or when such treatment  is
     3  provided  to  a covered dependent child because of congenital disease or
     4  anomaly as determined by the treating physician.
     5    2.  Every policy, plan, certificate or contract shall provide benefits
     6  for habilitative services  when  such  treatment  is  incidental  to  or
     7  follows surgery resulting from injury, sickness or other diseases of the
     8  involved  missing  or  abnormal  body  part  or  when  such treatment is
     9  provided to a covered dependent child because of congenital  disease  or
    10  anomaly as determined by the treating physician.
    11    3. Every policy, plan, certificate or contract may be subject to annu-
    12  al  deductible,  co-payment, and coinsurance provisions as may be deemed
    13  appropriate and as are consistent with those established for other bene-
    14  fits under the plan or coverage.
    15    4. No policy, plan, certificate or contract shall:
    16    a. Deny to a patient eligibility or continued eligibility,  to  enroll
    17  or  to  renew,  coverage  under  the  terms  of the plan, solely for the
    18  purpose of avoiding the requirements of this subparagraph; or
    19    b. Penalize or otherwise reduce or limit the reimbursement of a treat-
    20  ing provider or provide monetary  or  other  incentives  to  a  treating
    21  provider to induce the provider to provide care to an individual partic-
    22  ipant or beneficiary in a manner inconsistent with this subparagraph.
    23    (iv)  Written  notice  of  the  availability  of the coverage shall be
    24  delivered to the participant upon enrollment and annually thereafter.
    25    (v) 1. In accordance with section  forty-four  hundred  eight  of  the
    26  public  health  law,  an  enrollee has the right to appeal any denial of
    27  care that the carrier determines is not medically  necessary  or  exper-
    28  imental.
    29    2. An internal appeal of denial filed by an enrollee or the enrollee's
    30  provider  to the insurance carrier regarding coverage for reconstructive
    31  or habilitative services to treat a congenital anomaly  shall  be  expe-
    32  dited  by the carrier. The health plan shall respond orally with a deci-
    33  sion within forty-eight hours, followed by  a  confirmation  in  writing
    34  within seven days.
    35    §  7. This act shall take effect on the first of January next succeed-
    36  ing the date on which it shall have become a law and shall apply to  all
    37  policies  and contracts issued, renewed, modified, altered or amended on
    38  or after such date.
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