Bill Text: NY A05476 | 2019-2020 | General Assembly | Introduced
Bill Title: Expands coverage for eating disorders; requires comparable coverage for adults and children with eating disorders; defines eating disorder.
Spectrum: Partisan Bill (Democrat 21-0)
Status: (Introduced - Dead) 2020-01-08 - referred to insurance [A05476 Detail]
Download: New_York-2019-A05476-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 5476 2019-2020 Regular Sessions IN ASSEMBLY February 12, 2019 ___________ Introduced by M. of A. ORTIZ -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law, in relation to coverage for eating disorders The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subsection (i) of section 3216 of the insurance law is 2 amended by adding a new paragraph 35 to read as follows: 3 (35) (A) Every policy which provides medical coverage that includes 4 coverage for physician services in a physician's office and every policy 5 which provides major medical or similar comprehensive-type coverage 6 shall include coverage for inpatient hospitalization, partial hospitali- 7 zation, residential care, intensive outpatient treatment, follow up 8 outpatient care and counseling for adults and children with eating 9 disorders. Such coverage shall be provided under the terms and condi- 10 tions otherwise applicable under the policy, including network limita- 11 tions or variations, exclusions, co-pays, coinsurance, deductibles or 12 other specific cost sharing mechanisms. Provided further, where a policy 13 provides both in-network and out-of-network benefits, the out-of-network 14 benefits may have different coinsurance, co-pays, or deductibles, than 15 the in-network benefits, regardless of whether the policy is written 16 under one license or two licenses. 17 (B) Coverage for treatment of an eating disorder provided under this 18 paragraph is limited to medically necessary treatment that is provided 19 by a licensed treating physician, psychiatrist, psychologist, mental 20 health counselor, clinical social worker, or licensed marriage and fami- 21 ly therapist, in accordance with a treatment plan. Such treatment plan, 22 upon request by the insurer, shall include all elements necessary for 23 such insurer to pay claims. Such elements include, but are not limited 24 to, a diagnosis, proposed treatment by type, frequency and duration of 25 treatment, and goals. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD08518-02-9A. 5476 2 1 (C) Medical necessity determinations and care management for the 2 treatment of eating disorders shall consider the overall medical and 3 mental health needs of the individual with an eating disorder, shall not 4 be based solely on weight, and shall take into consideration the most 5 recent Practice Guideline for the Treatment of Patients with Eating 6 Disorders adopted by the American Psychiatric Association in addition to 7 current standards based upon the medical literature generally recognized 8 as authoritative in the medical community. 9 (D) For purposes of this paragraph, the term "eating disorder" means 10 pica, rumination disorder, avoidant/restrictive food intake disorder, 11 anorexia nervosa, bulimia nervosa, binge eating disorder, other speci- 12 fied feeding or eating disorder, and any other eating disorder contained 13 in the most recent version of the Diagnostic and Statistical Manual of 14 Mental Disorders published by the American Psychiatric Association. 15 § 2. Subparagraph (B) of paragraph 5 of subsection (l) of section 3221 16 of the insurance law, as amended by chapter 502 of the laws of 2007, is 17 amended to read as follows: 18 (B) (i) Every insurer delivering a group or school blanket policy or 19 issuing a group or school blanket policy for delivery, in this state, 20 which provides coverage for inpatient hospital care or coverage for 21 physician services, shall provide comparable coverage for adults and 22 children with biologically based mental illness. Such group policies 23 issued or delivered in this state shall also provide such comparable 24 coverage for children with serious emotional disturbances. Such coverage 25 shall be provided under the terms and conditions otherwise applicable 26 under the policy, including network limitations or variations, exclu- 27 sions, co-pays, coinsurance, deductibles or other specific cost sharing 28 mechanisms. Provided further, where a policy provides both in-network 29 and out-of-network benefits, the out-of-network benefits may have 30 different coinsurance, co-pays, or deductibles, than the in-network 31 benefits, regardless of whether the policy is written under one license 32 or two licenses. 33 (ii) For purposes of this paragraph, the term "biologically based 34 mental illness" means a mental, nervous, or emotional condition that is 35 caused by a biological disorder of the brain and results in a clinically 36 significant, psychological syndrome or pattern that substantially limits 37 the functioning of the person with the illness. Such biologically based 38 mental illnesses are defined as schizophrenia/psychotic disorders, major 39 depression, bipolar disorder, delusional disorders, panic disorder, 40 obsessive compulsive disorders[, bulimia, and anorexia] or an eating 41 disorder. 42 (iii) (I) For purposes of this subsection, the term "eating disorder" 43 means pica, rumination disorder, avoidant/restrictive food intake disor- 44 der, anorexia nervosa, bulimia nervosa, binge eating disorder, other 45 specified feeding or eating disorder, and any other eating disorder 46 contained in the most recent version of the Diagnostic and Statistical 47 Manual of Mental Disorders published by the American Psychiatric Associ- 48 ation. 49 (II) Notwithstanding any provision of this section to the contrary, 50 coverage for treatment of an eating disorder provided under this 51 subsection shall include inpatient hospitalization, partial hospitaliza- 52 tion, residential care, intensive outpatient treatment, follow up outpa- 53 tient care and counseling, provided, however, such treatment is limited 54 to medically necessary treatment that is provided by a licensed treating 55 physician, psychiatrist, psychologist, mental health counselor, clinical 56 social worker, or licensed marriage and family therapist, in accordanceA. 5476 3 1 with a treatment plan. Such treatment plan, upon request by the medical 2 expense indemnity corporation or health service corporation, shall 3 include all elements necessary for such corporation to pay claims. Such 4 elements include, but are not limited to, a diagnosis, proposed treat- 5 ment by type, frequency and duration of treatment, and goals. 6 (III) Medical necessity determinations and care management for the 7 treatment of eating disorders shall consider the overall medical and 8 mental health needs of the individual with an eating disorder, shall not 9 be based solely on weight, and shall take into consideration the most 10 recent Practice Guideline for the Treatment of Patients with Eating 11 Disorders adopted by the American Psychiatric Association in addition to 12 current standards based upon the medical literature generally recognized 13 as authoritative in the medical community. 14 § 3. Paragraph 2 of subsection (g) of section 4303 of the insurance 15 law, as amended by chapter 502 of the laws of 2007, is amended to read 16 as follows: 17 (2) (A) A hospital service corporation or a health service corpo- 18 ration, which provides group, group remittance or school blanket cover- 19 age for inpatient hospital care, shall provide comparable coverage for 20 adults and children with biologically based mental illness. Such hospi- 21 tal service corporation or health service corporation shall also provide 22 such comparable coverage for children with serious emotional disturb- 23 ances. Such coverage shall be provided under the terms and conditions 24 otherwise applicable under the contract, including network limitations 25 or variations, exclusions, co-pays, coinsurance, deductibles or other 26 specific cost sharing mechanisms. Provided further, where a contract 27 provides both in-network and out-of-network benefits, the out-of-network 28 benefits may have different coinsurance, co-pays, or deductibles, than 29 the in-network benefits, regardless of whether the contract is written 30 under one license or two licenses. 31 (B) For purposes of this subsection, the term "biologically based 32 mental illness" means a mental, nervous, or emotional condition that is 33 caused by a biological disorder of the brain and results in a clinically 34 significant, psychological syndrome or pattern that substantially limits 35 the functioning of the person with the illness. Such biologically based 36 mental illnesses are defined as schizophrenia/psychotic disorders, major 37 depression, bipolar disorder, delusional disorders, panic disorder, 38 obsessive compulsive disorders[, anorexia, and bulimia] or an eating 39 disorder. 40 (C) (i) For purposes of this subsection, the term "eating disorder" 41 means pica, rumination disorder, avoidant/restrictive food intake disor- 42 der, anorexia nervosa, bulimia nervosa, binge eating disorder, other 43 specified feeding or eating disorder, and any other eating disorder 44 contained in the most recent version of the Diagnostic and Statistical 45 Manual of Mental Disorders published by the American Psychiatric Associ- 46 ation. 47 (ii) Notwithstanding any provision of this section to the contrary, 48 coverage for treatment of an eating disorder provided under this 49 subsection shall include inpatient hospitalization, partial hospitaliza- 50 tion, residential care, intensive outpatient treatment, follow up outpa- 51 tient care and counseling, provided, however, such treatment is limited 52 to medically necessary treatment that is provided by a licensed treating 53 physician, psychiatrist, psychologist, mental health counselor, clinical 54 social worker, or licensed marriage and family therapist, in accordance 55 with a treatment plan. Such treatment plan, upon request by the medical 56 expense indemnity corporation or health service corporation, shallA. 5476 4 1 include all elements necessary for such corporation to pay claims. Such 2 elements include, but are not limited to, a diagnosis, proposed treat- 3 ment by type, frequency and duration of treatment, and goals. 4 (iii) Medical necessity determinations and care management for the 5 treatment of eating disorders shall consider the overall medical and 6 mental health needs of the individual with an eating disorder, shall not 7 be based solely on weight, and shall take into consideration the most 8 recent Practice Guideline for the Treatment of Patients with Eating 9 Disorders adopted by the American Psychiatric Association in addition to 10 current standards based upon the medical literature generally recognized 11 as authoritative in the medical community. 12 § 4. Paragraph 2 of subsection (h) of section 4303 of the insurance 13 law, as amended by chapter 502 of the laws of 2007, is amended to read 14 as follows: 15 (2) (A) A medical expense indemnity corporation or a health service 16 corporation, which provides group, group remittance or school blanket 17 coverage for physician services, shall provide comparable coverage for 18 adults and children with biologically based mental illness. Such medical 19 expense indemnity corporation or health service corporation shall also 20 provide such comparable coverage for children with serious emotional 21 disturbances. Such coverage shall be provided under the terms and condi- 22 tions otherwise applicable under the contract, including network limita- 23 tions or variations, exclusions, co-pays, coinsurance, deductibles or 24 other specific cost sharing mechanisms. Provided further, where a 25 contract provides both in-network and out-of-network benefits, the out- 26 of-network benefits may have different coinsurance, co-pays, or deduct- 27 ibles, than the in-network benefits, regardless of whether the contract 28 is written under one license or two licenses. 29 (B) For purposes of this subsection, the term "biologically based 30 mental illness" means a mental, nervous, or emotional condition that is 31 caused by a biological disorder of the brain and results in a clinically 32 significant, psychological syndrome or pattern that substantially limits 33 the functioning of the person with the illness. Such biologically based 34 mental illnesses are defined as schizophrenia/psychotic disorders, major 35 depression, bipolar disorder, delusional disorders, panic disorder, 36 obsessive compulsive disorder[, anorexia, and bulimia] or an eating 37 disorder. 38 (C) (i) For purposes of this subsection, the term "eating disorder" 39 means pica, rumination disorder, avoidant/restrictive food intake disor- 40 der, anorexia nervosa, bulimia nervosa, binge eating disorder, other 41 specified feeding or eating disorder, and any other eating disorder 42 contained in the most recent version of the Diagnostic and Statistical 43 Manual of Mental Disorders published by the American Psychiatric Associ- 44 ation. 45 (ii) Notwithstanding any provision of this section to the contrary, 46 coverage for treatment of an eating disorder provided under this 47 subsection shall include inpatient hospitalization, partial hospitaliza- 48 tion, residential care, intensive outpatient treatment, follow up outpa- 49 tient care and counseling, provided, however, such treatment is limited 50 to medically necessary treatment that is provided by a licensed treating 51 physician, psychiatrist, psychologist, mental health counselor, clinical 52 social worker, or licensed marriage and family therapist, in accordance 53 with a treatment plan. Such treatment plan, upon request by the medical 54 expense indemnity corporation or health service corporation, shall 55 include all elements necessary for such corporation to pay claims. SuchA. 5476 5 1 elements include, but are not limited to, a diagnosis, proposed treat- 2 ment by type, frequency and duration of treatment, and goals. 3 (iii) Medical necessity determinations and care management for the 4 treatment of eating disorders shall consider the overall medical and 5 mental health needs of the individual with an eating disorder, shall not 6 be based solely on weight, and shall take into consideration the most 7 recent Practice Guideline for the Treatment of Patients with Eating 8 Disorders adopted by the American Psychiatric Association in addition to 9 current standards based upon the medical literature generally recognized 10 as authoritative in the medical community. 11 § 5. This act shall take effect on the ninetieth day after it shall 12 have become a law; provided, however, that the provisions of this act 13 shall apply to policies and contracts issued, renewed, modified, altered 14 or amended on or after such effective date.
