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. LBD14264-03-9S. 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 forS. 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 isS. 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 incidentalS. 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.
