Bill Text: NY A07793 | 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: Moderate Partisan Bill (Democrat 18-3)
Status: (Introduced - Dead) 2024-01-03 - referred to insurance [A07793 Detail]
Download: New_York-2023-A07793-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 7793 2023-2024 Regular Sessions IN ASSEMBLY June 15, 2023 ___________ Introduced by M. of A. SIMON, HEVESI, McDONOUGH, ZEBROWSKI, SIMPSON, JACKSON, COOK, LAVINE, CARROLL -- Multi-Sponsored by -- M. of A. BRAUNSTEIN, DeSTEFANO, EPSTEIN, FAHY, JACOBSON, LUPARDO, OTIS, L. ROSENTHAL, SAYEGH, SEAWRIGHT, STECK, STERN -- read once and referred 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- EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD06707-01-3A. 7793 2 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 (9) "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 § 3. Paragraph 4 of subsection (c) of section 3216 of the insurance 10 law is amended by adding a new subparagraph (D) to read as follows: 11 (D) (1) For the purpose of this subparagraph, the term "treatment" 12 includes inpatient and outpatient care and services performed to improve 13 or restore body function, or performed to approximate a normal appear- 14 ance, as a result of a congenital anomaly and shall not include cosmetic 15 surgery. Inpatient and outpatient care and services shall include treat- 16 ment to any and all missing or abnormal body parts, including teeth, the 17 oral cavity, and their associated structures, that would otherwise be 18 provided under the plan or coverage for any other injury and sickness, 19 including: 20 (i) All inpatient and outpatient reconstructive services and proce- 21 dures; 22 (ii) All services, procedures, and adjunctive needs, including but not 23 limited to prosthetics and appliances, resulting from complications; 24 (iii) Adjunctive dental, orthodontic or prosthodontic support from 25 birth until the medical or surgical treatment of the anomaly has been 26 completed, including ongoing or subsequent treatment required to main- 27 tain function or approximate a normal appearance; 28 (iv) Procedures that do not materially restore or improve the function 29 of the body part being treated; and 30 (v) Procedures for secondary conditions and follow-up treatments. 31 (2) (i) Every policy, plan, certificate or contract shall provide 32 benefits for reconstructive services when such treatment is incidental 33 to or follows surgery resulting from injury, sickness or other diseases 34 of the 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 (ii) Every policy, plan, certificate or contract shall provide bene- 38 fits for habilitative services when such treatment is incidental to or 39 follows surgery resulting from injury, sickness or other diseases of the 40 involved missing or abnormal body part or when such treatment is 41 provided to a covered dependent child because of congenital disease or 42 anomaly as determined by the treating physician. 43 (iii) Every policy, plan, certificate or contract may be subject to 44 annual deductible, co-payment, and coinsurance provisions as may be 45 deemed appropriate and as are consistent with those established for 46 other benefits under the plan or coverage. 47 (iv) No policy, plan, certificate or contract shall: 48 a. Deny to a patient eligibility or continued eligibility, to enroll 49 or to renew, coverage under the terms of the plan, solely for the 50 purpose of avoiding the requirements of this subparagraph; or 51 b. Penalize or otherwise reduce or limit the reimbursement of a treat- 52 ing provider, or provide monetary or other incentives to a treating 53 provider to induce the provider to provide care to an individual partic- 54 ipant or beneficiary in a manner inconsistent with this subparagraph. 55 (v) Written notice of the availability of the coverage shall be deliv- 56 ered to the participant upon enrollment and annually thereafter.A. 7793 3 1 (3) (i) In accordance with section forty-four hundred eight of the 2 public health law, an enrollee has the right to appeal any denial of 3 care that the carrier determines is not medically necessary or exper- 4 imental. 5 (ii) An internal appeal of denial filed by an enrollee or the 6 enrollee's provider to the insurance carrier regarding coverage for 7 reconstructive or habilitative services to treat a congenital anomaly 8 shall be expedited by the carrier. The health plan shall respond orally 9 with a decision within forty-eight hours, followed by a confirmation in 10 writing within seven days. 11 § 4. Subsection (f) of section 4235 of the insurance law is amended by 12 adding a new paragraph 5 to read as follows: 13 (5) (A) As used in this paragraph: 14 (i) "Congenital anomaly" means a medically diagnosed condition exist- 15 ing at or from birth that is a deviation from the common structure or 16 function of the body, whether caused by a hereditary or developmental 17 disability or disease. 18 (ii) "Cosmetic surgery" means surgical and nonsurgical elective proce- 19 dures that enhance and reshape structures of the body to improve appear- 20 ance and confidence, but are not necessary to improve body structure or 21 function. 22 (iii) "Habilitative services" means healthcare services that help an 23 individual keep, learn, or improve skills and functioning for daily 24 living. Habilitative services shall include but is not limited to phys- 25 ical and occupational therapy, speech-language pathology, and services 26 for people with disabilities in a variety of inpatient and/or outpatient 27 settings. 28 (iv) "Reconstructive services" means procedures or surgery that are 29 performed to treat structures of the body affected aesthetically or 30 functionally by congenital anomalies, developmental abnormalities, trau- 31 ma, infection, tumors, or disease. Reconstructive services are intended 32 to improve function and ability, and may also be performed to achieve a 33 more typical appearance of the affected structure. 34 (v) "Deviation" means an anomaly that impairs the function of the body 35 and includes but is not limited to the conditions of cleft lip, cleft 36 palate, webbed fingers or toes, supernumerary toes or fingers, craniofa- 37 cial malformations, disorders of metabolism, and other conditions that 38 are medically diagnosed to be congenital anomalies. 39 (B) (i) For the purpose of this paragraph, the term "treatment" 40 includes inpatient and outpatient care and services performed to improve 41 or restore body function, or performed to approximate a normal appear- 42 ance, as a result of a congenital anomaly and shall not include cosmetic 43 surgery. Inpatient and outpatient care and services shall include treat- 44 ment to any and all missing or abnormal body parts, including teeth, the 45 oral cavity, and their associated structures, that would otherwise be 46 provided under the plan or coverage for any other injury and sickness, 47 including: 48 (I) All inpatient and outpatient reconstructive services and proce- 49 dures; 50 (II) All services, procedures, and adjunctive needs, including but not 51 limited to prosthetics and appliances, resulting from complications; 52 (III) Adjunctive dental, orthodontic or prosthodontic support from 53 birth until the medical or surgical treatment of the anomaly has been 54 completed, including ongoing or subsequent treatment required to main- 55 tain function or approximate a normal appearance;A. 7793 4 1 (IV) Procedures that do not materially restore or improve the function 2 of the body part being treated; and 3 (V) Procedures for secondary conditions and follow-up treatments. 4 (ii) (I) Every policy, plan, certificate or contract shall provide 5 benefits for reconstructive services when such treatment is incidental 6 to or follows surgery resulting from injury, sickness or other diseases 7 of the involved missing or abnormal body part or when such treatment is 8 provided to a covered dependent child because of congenital disease or 9 anomaly as determined by the treating physician. 10 (II) Every policy, plan, certificate or contract shall provide bene- 11 fits for habilitative services when such treatment is incidental to or 12 follows surgery resulting from injury, sickness or other diseases of the 13 involved missing or abnormal body part or when such treatment is 14 provided to a covered dependent child because of congenital disease or 15 anomaly as determined by the treating physician. 16 (III) Every policy, plan, certificate or contract may be subject to 17 annual deductible, co-payment, and coinsurance provisions as may be 18 deemed appropriate and as are consistent with those established for 19 other benefits under the plan or coverage. 20 (IV) No policy, plan, certificate or contract shall: 21 a. Deny to a patient eligibility or continued eligibility, to enroll 22 or to renew, coverage under the terms of the plan, solely for the 23 purpose of avoiding the requirements of this paragraph; or 24 b. Penalize or otherwise reduce or limit the reimbursement of a treat- 25 ing provider, or provide monetary or other incentives to a treating 26 provider to induce the provider to provide care to an individual partic- 27 ipant or beneficiary in a manner inconsistent with this paragraph. 28 (V) Written notice of the availability of the coverage shall be deliv- 29 ered to the participant upon enrollment and annually thereafter. 30 (iii) (I) In accordance with section forty-four hundred eight of the 31 public health law, an enrollee has the right to appeal any denial of 32 care that the carrier determines is not medically necessary or exper- 33 imental. 34 (II) An internal appeal of denial filed by an enrollee or the 35 enrollee's provider to the insurance carrier regarding coverage for 36 reconstructive or habilitative services to treat a congenital anomaly 37 shall be expedited by the carrier. The health plan shall respond orally 38 with a decision within forty-eight hours, followed by a confirmation in 39 writing within seven days. 40 § 5. Paragraph 1 of subsection (d) of section 4304 of the insurance 41 law is amended by adding a new subparagraph (D) to read as follows: 42 (D) (i) As used in this paragraph: 43 1. "Congenital anomaly" means a medically diagnosed condition existing 44 at or from birth that is a deviation from the common structure or func- 45 tion of the body, whether caused by a hereditary or developmental disa- 46 bility or disease. 47 2. "Cosmetic surgery" means surgical and nonsurgical elective proce- 48 dures that enhance and reshape structures of the body to improve appear- 49 ance and confidence, but are not necessary to improve body structure or 50 function. 51 3. "Habilitative services" means healthcare services that help an 52 individual keep, learn, or improve skills and functioning for daily 53 living. Habilitative services shall include but is not limited to phys- 54 ical and occupational therapy, speech-language pathology, and services 55 for people with disabilities in a variety of inpatient and/or outpatient 56 settings.A. 7793 5 1 4. "Reconstructive services" means procedures or surgery that are 2 performed to treat structures of the body affected aesthetically or 3 functionally by congenital anomalies, developmental abnormalities, trau- 4 ma, infection, tumors, or disease. Reconstructive services are intended 5 to improve function and ability, and may also be performed to achieve a 6 more typical appearance of the affected structure. 7 5. "Deviation" means an anomaly that impairs the function of the body 8 and includes but is not limited to the conditions of cleft lip, cleft 9 palate, webbed fingers or toes, supernumerary toes or fingers, craniofa- 10 cial malformations, disorders of metabolism, and other conditions that 11 are medically diagnosed to be congenital anomalies. 12 (ii) For the purpose of this subparagraph, the term "treatment" 13 includes inpatient and outpatient care and services performed to improve 14 or restore body function, or performed to approximate a normal appear- 15 ance, as a result of a congenital anomaly and shall not include cosmetic 16 surgery. Inpatient and outpatient care and services shall include treat- 17 ment to any and all missing or abnormal body parts, including teeth, the 18 oral cavity, and their associated structures, that would otherwise be 19 provided under the plan or coverage for any other injury and sickness, 20 including: 21 1. All inpatient and outpatient reconstructive services and proce- 22 dures; 23 2. All services, procedures, and adjunctive needs, including prosthet- 24 ics and appliances, resulting from complications; 25 3. Adjunctive dental, orthodontic or prosthodontic support from birth 26 until the medical or surgical treatment of the anomaly has been 27 completed, including ongoing or subsequent treatment required to main- 28 tain function or approximate a normal appearance; 29 4. Procedures that do not materially restore or improve the function 30 of the body part being treated; and 31 5. Procedures for secondary conditions and follow-up treatments. 32 (iii) 1. Every policy, plan, certificate or contract shall provide 33 benefits for reconstructive services when such treatment is incidental 34 to or follows surgery resulting from injury, sickness or other diseases 35 of the 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 2. Every policy, plan, certificate or contract shall provide benefits 39 for habilitative services when such treatment is incidental to or 40 follows surgery resulting from injury, sickness or other diseases of the 41 involved missing or abnormal body part or when such treatment is 42 provided to a covered dependent child because of congenital disease or 43 anomaly as determined by the treating physician. 44 3. Every policy, plan, certificate or contract may be subject to annu- 45 al deductible, co-payment, and coinsurance provisions as may be deemed 46 appropriate and as are consistent with those established for other bene- 47 fits under the plan or coverage. 48 4. No policy, plan, certificate or contract shall: 49 a. Deny to a patient eligibility or continued eligibility, to enroll 50 or to renew, coverage under the terms of the plan, solely for the 51 purpose of avoiding the requirements of this subparagraph; or 52 b. Penalize or otherwise reduce or limit the reimbursement of a treat- 53 ing provider, or provide monetary or other incentives to a treating 54 provider to induce the provider to provide care to an individual partic- 55 ipant or beneficiary in a manner inconsistent with this subparagraph.A. 7793 6 1 (iv) Written notice of the availability of the coverage shall be 2 delivered to the participant upon enrollment and annually thereafter. 3 (v) 1. In accordance with section forty-four hundred eight of the 4 public health law, an enrollee has the right to appeal any denial of 5 care that the carrier determines is not medically necessary or exper- 6 imental. 7 2. An internal appeal of denial filed by an enrollee or the enrollee's 8 provider to the insurance carrier regarding coverage for reconstructive 9 or habilitative services to treat a congenital anomaly shall be expe- 10 dited by the carrier. The health plan shall respond orally with a deci- 11 sion within forty-eight hours, followed by a confirmation in writing 12 within seven days. 13 § 6. Paragraph 1 of subsection (c) of section 4305 of the insurance 14 law is amended by adding a new subparagraph (D) to read as follows: 15 (D)(i) As used in this subparagraph: 16 1. "Congenital anomaly" means a medically diagnosed condition existing 17 at or from birth that is a deviation from the common structure or func- 18 tion of the body, whether caused by a hereditary or developmental disa- 19 bility or disease. 20 2. "Cosmetic surgery" means surgical and nonsurgical elective proce- 21 dures that enhance and reshape structures of the body to improve appear- 22 ance and confidence, but are not necessary to improve body structure or 23 function. 24 3. "Habilitative services" means healthcare services that help an 25 individual keep, learn, or improve skills and functioning for daily 26 living. Habilitative services shall include but is not limited to phys- 27 ical and occupational therapy, speech-language pathology, and services 28 for people with disabilities in a variety of inpatient and/or outpatient 29 settings. 30 4. "Reconstructive services" means procedures or surgery that are 31 performed to treat structures of the body affected aesthetically or 32 functionally by congenital anomalies, developmental abnormalities, trau- 33 ma, infection, tumors, or disease. Reconstructive services are intended 34 to improve function and ability, and may also be performed to achieve a 35 more typical appearance of the affected structure. 36 5. "Deviation" means an anomaly that impairs the function of the body 37 and includes but is not limited to the conditions of cleft lip, cleft 38 palate, webbed fingers or toes, supernumerary toes or fingers, craniofa- 39 cial malformations, disorders of metabolism, and other conditions that 40 are medically diagnosed to be congenital anomalies. 41 (ii) For the purpose of this subparagraph, the term "treatment" 42 includes inpatient and outpatient care and services performed to improve 43 or restore body function, or performed to approximate a normal appear- 44 ance, as a result of a congenital anomaly and shall not include cosmetic 45 surgery. Inpatient and outpatient care and services shall include treat- 46 ment to any and all missing or abnormal body parts, including teeth, the 47 oral cavity, and their associated structures, that would otherwise be 48 provided under the plan or coverage for any other injury and sickness, 49 including: 50 1. All inpatient and outpatient reconstructive services and proce- 51 dures; 52 2. All services, procedures, and adjunctive needs, including prosthet- 53 ics and appliances, resulting from complications; 54 3. Adjunctive dental, orthodontic or prosthodontic support from birth 55 until the medical or surgical treatment of the anomaly has beenA. 7793 7 1 completed, including ongoing or subsequent treatment required to main- 2 tain function or approximate a normal appearance; 3 4. Procedures that do not materially restore or improve the function 4 of the body part being treated; and 5 5. Procedures for secondary conditions and follow-up treatments. 6 (iii) 1. Every policy, plan, certificate or contract shall provide 7 benefits for reconstructive services when such treatment is incidental 8 to or follows surgery resulting from injury, sickness or other diseases 9 of the involved missing or abnormal body part or when such treatment is 10 provided to a covered dependent child because of congenital disease or 11 anomaly as determined by the treating physician. 12 2. Every policy, plan, certificate or contract shall provide benefits 13 for habilitative services when such treatment is incidental to or 14 follows surgery resulting from injury, sickness or other diseases of the 15 involved missing or abnormal body part or when such treatment is 16 provided to a covered dependent child because of congenital disease or 17 anomaly as determined by the treating physician. 18 3. Every policy, plan, certificate or contract may be subject to annu- 19 al deductible, co-payment, and coinsurance provisions as may be deemed 20 appropriate and as are consistent with those established for other bene- 21 fits under the plan or coverage. 22 4. No policy, plan, certificate or contract shall: 23 a. Deny to a patient eligibility or continued eligibility, to enroll 24 or to renew, coverage under the terms of the plan, solely for the 25 purpose of avoiding the requirements of this subparagraph; or 26 b. Penalize or otherwise reduce or limit the reimbursement of a treat- 27 ing provider or provide monetary or other incentives to a treating 28 provider to induce the provider to provide care to an individual partic- 29 ipant or beneficiary in a manner inconsistent with this subparagraph. 30 (iv) Written notice of the availability of the coverage shall be 31 delivered to the participant upon enrollment and annually thereafter. 32 (v) 1. In accordance with section forty-four hundred eight of the 33 public health law, an enrollee has the right to appeal any denial of 34 care that the carrier determines is not medically necessary or exper- 35 imental. 36 2. An internal appeal of denial filed by an enrollee or the enrollee's 37 provider to the insurance carrier regarding coverage for reconstructive 38 or habilitative services to treat a congenital anomaly shall be expe- 39 dited by the carrier. The health plan shall respond orally with a deci- 40 sion within forty-eight hours, followed by a confirmation in writing 41 within seven days. 42 § 7. This act shall take effect on the first of January next succeed- 43 ing the date on which it shall have become a law and shall apply to all 44 policies and contracts issued, renewed, modified, altered or amended on 45 or after such date.
