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See Summary
S T A T E O F N E W Y O R K
________________________________________________________________________
213--B
Cal. No. 7
2009-2010 Regular Sessions
I N A S S E M B L Y
(PREFILED)
January 7, 2009
___________
Introduced by M. of A. MARKEY, REILLY, ABBATE, COLTON, GUNTHER, JAFFEE,
SPANO, PHEFFER, MILLMAN, BARRON, GALEF, ORTIZ, ZEBROWSKI, DenDEKKER,
CARROZZA, PEOPLES-STOKES -- Multi-Sponsored by -- M. of A. ALFANO,
AMEDORE, BRENNAN, BURLING, CALHOUN, CHRISTENSEN, CONTE, CROUCH,
DelMONTE, ERRIGO, FINCH, GLICK, GOTTFRIED, HYER-SPENCER, KOON, LUPAR-
DO, MAYERSOHN, McDONOUGH, McENENY, MENG, PERRY, RAIA, RUSSELL, SCAR-
BOROUGH, SCHIMEL, SWEENEY, THIELE, TOBACCO, WEISENBERG -- read once
and referred to the Committee on Insurance -- amended on the special
order of third reading, ordered reprinted as amended, retaining its
place on the special order of third reading -- reported from commit-
tee, advanced to a third reading, amended and ordered reprinted,
retaining its place on the order of third reading
AN ACT to amend the insurance law, in relation to insurance coverage for
out-of-network dialysis
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 27 to read as follows:
3 (27)(A) EVERY POLICY THAT INCLUDES COVERAGE FOR DIALYSIS TREATMENT
4 THAT REQUIRES SUCH SERVICES TO BE PROVIDED BY AN IN-NETWORK PROVIDER
5 SHALL NOT DENY COVERAGE OF SUCH SERVICES BECAUSE THE SERVICES ARE
6 PROVIDED BY AN OUT-OF-NETWORK PROVIDER, PROVIDED THAT EACH OF THE
7 FOLLOWING CONDITIONS ARE MET:
8 (I) THE OUT-OF-NETWORK PROVIDER IS DULY LICENSED TO PRACTICE AND
9 AUTHORIZED TO PROVIDE SUCH TREATMENT;
10 (II) THE OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE SERVICE AREA
11 OF THE INSURER;
12 (III) THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE INSURED FOR THE
13 CONDITION ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT IN
14 HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD00183-04-0
A. 213--B 2
1 (IV) THE INSURED HAS NOTIFIED, IN WRITING, THE INSURER AT LEAST THIRTY
2 DAYS IN ADVANCE OF THE PROPOSED DATE OR DATES OF SUCH OUT-OF-NETWORK
3 DIALYSIS TREATMENT. THE NOTICE SHALL INCLUDE THE AUTHORIZATION REQUIRED
4 BY CLAUSE (III) OF THIS SUBPARAGRAPH. IN THE EVENT THE INSURED MUST
5 TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMERGENCY, SHORTER NOTICE
6 MAY BE PERMITTED, PROVIDED THAT THE INSURER HAS REASONABLE OPPORTUNITY
7 TO REVIEW THE TRAVEL AND TREATMENT PLANS OF THE INSURED;
8 (V) THE INSURER SHALL HAVE THE RIGHT TO PRE-APPROVE THE DIALYSIS
9 TREATMENT AND SCHEDULE; AND
10 (VI) SUCH COVERAGE IS LIMITED TO NO GREATER THAN TEN OUT-OF-NETWORK
11 TREATMENTS IN A CALENDAR YEAR.
12 (B) THE OUT-OF-NETWORK PROVIDER SHALL BE BOUND BY THE TERMS AND CONDI-
13 TIONS OF THE INSURERS PROVIDER NETWORK CONTRACT AND NO INSURER SHALL BE
14 OBLIGATED TO REIMBURSE THE OUT-OF-NETWORK PROVIDER AT AN AMOUNT GREATER
15 THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK, INCLUD-
16 ING ALL DRUGS AND ANCILLARY SERVICES TIED TO DIALYSIS TREATMENT, AND ANY
17 AMOUNT CHARGED BY A PROVIDER IN EXCESS OF THE AMOUNT REIMBURSED BY THE
18 INSURER SHALL BE THE RESPONSIBILITY OF THE INSURED RECEIVING THE
19 OUT-OF-NETWORK SERVICES.
20 (C) SUCH COVERAGE OF OUT-OF-NETWORK DIALYSIS SERVICES REQUIRED BY
21 SUBPARAGRAPH (A) OF THIS PARAGRAPH SHALL OTHERWISE BE SUBJECT TO THE
22 LIMITATIONS, EXCLUSIONS AND TERMS OF THE POLICY, INCLUDING, BUT NOT
23 LIMITED TO, UTILIZATION REVIEW, ANNUAL DEDUCTIBLES, COPAYMENTS, AND
24 COINSURANCE, CONSISTENT WITH THOSE REQUIRED FOR OTHER SIMILAR BENEFITS
25 UNDER THE POLICY.
26 S 2. Subsection (k) of section 3221 of the insurance law is amended by
27 adding a new paragraph 16 to read as follows:
28 (16)(A) EVERY GROUP OR BLANKET POLICY THAT INCLUDES COVERAGE FOR DIAL-
29 YSIS TREATMENT THAT REQUIRES SUCH SERVICES TO BE PROVIDED BY AN IN-NET-
30 WORK PROVIDER SHALL NOT DENY COVERAGE OF SUCH SERVICES BECAUSE THE
31 SERVICES ARE PROVIDED BY AN OUT-OF-NETWORK PROVIDER, PROVIDED THAT EACH
32 OF THE FOLLOWING CONDITIONS ARE MET:
33 (I) THE OUT-OF-NETWORK PROVIDER IS DULY LICENSED TO PRACTICE AND
34 AUTHORIZED TO PROVIDE SUCH TREATMENT;
35 (II) THE OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE SERVICE AREA
36 OF THE INSURER;
37 (III) THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE INSURED FOR THE
38 CONDITION ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT IN
39 HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;
40 (IV) THE INSURED HAS NOTIFIED, IN WRITING, THE INSURER AT LEAST THIRTY
41 DAYS IN ADVANCE OF THE PROPOSED DATE OR DATES OF SUCH OUT-OF-NETWORK
42 DIALYSIS TREATMENT. THE NOTICE SHALL INCLUDE THE AUTHORIZATION REQUIRED
43 BY CLAUSE (III) OF THIS SUBPARAGRAPH. IN THE EVENT THE INSURED MUST
44 TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMERGENCY, SHORTER NOTICE
45 MAY BE PERMITTED, PROVIDED THAT THE INSURER HAS REASONABLE OPPORTUNITY
46 TO REVIEW THE TRAVEL AND TREATMENT PLANS OF THE INSURED;
47 (V) THE INSURER SHALL HAVE THE RIGHT TO PRE-APPROVE THE DIALYSIS
48 TREATMENT AND SCHEDULE; AND
49 (VI) SUCH COVERAGE IS LIMITED TO NO GREATER THAN TEN OUT-OF-NETWORK
50 TREATMENTS IN A CALENDAR YEAR.
51 (B) THE OUT-OF-NETWORK PROVIDER SHALL BE BOUND BY THE TERMS AND CONDI-
52 TIONS OF THE INSURERS PROVIDER NETWORK CONTRACT AND NO INSURER SHALL BE
53 OBLIGATED TO REIMBURSE THE OUT-OF-NETWORK PROVIDER AT AN AMOUNT GREATER
54 THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK, INCLUD-
55 ING ALL DRUGS AND ANCILLARY SERVICES TIED TO DIALYSIS TREATMENT, AND ANY
56 AMOUNT CHARGED BY A PROVIDER IN EXCESS OF THE AMOUNT REIMBURSED BY THE
A. 213--B 3
1 INSURER SHALL BE THE RESPONSIBILITY OF THE INSURED RECEIVING THE
2 OUT-OF-NETWORK SERVICES.
3 (C) SUCH COVERAGE OF OUT-OF-NETWORK DIALYSIS SERVICES REQUIRED BY
4 SUBPARAGRAPH (A) OF THIS PARAGRAPH SHALL OTHERWISE BE SUBJECT TO THE
5 LIMITATIONS, EXCLUSIONS AND TERMS OF THE POLICY, INCLUDING, BUT NOT
6 LIMITED TO, UTILIZATION REVIEW, ANNUAL DEDUCTIBLES, COPAYMENTS, AND
7 COINSURANCE, CONSISTENT WITH THOSE REQUIRED FOR OTHER SIMILAR BENEFITS
8 UNDER THE POLICY.
9 S 3. Section 4303 of the insurance law is amended by adding a new
10 subsection (gg) to read as follows:
11 (GG) (1) EVERY CONTRACT ISSUED BY A HOSPITAL SERVICE CORPORATION,
12 HEALTH SERVICE CORPORATION OR MEDICAL EXPENSE INDEMNITY CORPORATION THAT
13 INCLUDES COVERAGE FOR DIALYSIS TREATMENT THAT REQUIRES SUCH SERVICES TO
14 BE PROVIDED BY AN IN-NETWORK PROVIDER SHALL NOT DENY COVERAGE OF SUCH
15 SERVICES BECAUSE THE SERVICES ARE PROVIDED BY AN OUT-OF-NETWORK PROVID-
16 ER, PROVIDED THAT EACH OF THE FOLLOWING CONDITIONS ARE MET:
17 (A) THE OUT-OF-NETWORK PROVIDER IS DULY LICENSED TO PRACTICE AND
18 AUTHORIZED TO PROVIDE SUCH TREATMENT;
19 (B) THE OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE SERVICE AREA OF
20 THE INSURER;
21 (C) THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE COVERED PERSON FOR
22 THE CONDITION ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT
23 IN HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;
24 (D) THE COVERED PERSON HAS NOTIFIED, IN WRITING, THE CORPORATION AT
25 LEAST THIRTY DAYS IN ADVANCE OF THE PROPOSED DATE OR DATES OF SUCH OUT-
26 OF-NETWORK DIALYSIS TREATMENT. THE NOTICE SHALL INCLUDE THE AUTHORI-
27 ZATION REQUIRED BY SUBPARAGRAPH (C) OF THIS PARAGRAPH. IN THE EVENT THE
28 COVERED PERSON MUST TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMER-
29 GENCY, SHORTER NOTICE MAY BE PERMITTED, PROVIDED THAT THE CORPORATION
30 HAS REASONABLE OPPORTUNITY TO REVIEW THE TRAVEL AND TREATMENT PLANS OF
31 THE COVERED PERSON;
32 (E) THE CORPORATION SHALL HAVE THE RIGHT TO PRE-APPROVE THE DIALYSIS
33 TREATMENT AND SCHEDULE; AND
34 (F) SUCH COVERAGE IS LIMITED TO NO GREATER THAN TEN OUT-OF-NETWORK
35 TREATMENTS IN A CALENDAR YEAR.
36 (2) THE OUT-OF-NETWORK PROVIDER SHALL BE BOUND BY THE TERMS AND CONDI-
37 TIONS OF THE INSURERS PROVIDER NETWORK CONTRACT AND NO CORPORATION SHALL
38 BE OBLIGATED TO REIMBURSE THE OUT-OF-NETWORK PROVIDER AT AN AMOUNT
39 GREATER THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK,
40 INCLUDING ALL DRUGS AND ANCILLARY SERVICES TIED TO DIALYSIS TREATMENT,
41 AND ANY AMOUNT CHARGED BY A PROVIDER IN EXCESS OF THE AMOUNT REIMBURSED
42 BY THE CORPORATION SHALL BE THE RESPONSIBILITY OF THE COVERED PERSON
43 RECEIVING THE OUT-OF-NETWORK SERVICES.
44 (3) SUCH COVERAGE OF OUT-OF-NETWORK DIALYSIS SERVICES REQUIRED BY
45 PARAGRAPH ONE OF THIS SUBSECTION SHALL OTHERWISE BE SUBJECT TO THE LIMI-
46 TATIONS, EXCLUSIONS AND TERMS OF THE POLICY, INCLUDING, BUT NOT LIMITED
47 TO, UTILIZATION REVIEW, ANNUAL DEDUCTIBLES, COPAYMENTS, AND COINSURANCE,
48 CONSISTENT WITH THOSE REQUIRED FOR OTHER SIMILAR BENEFITS UNDER THE
49 POLICY.
50 S 4. Paragraph 12 of subsection (b) of section 4322 of the insurance
51 law, as added by chapter 504 of the laws of 1995, is amended to read as
52 follows:
53 (12) Hemodialysis services CONSISTENT WITH THE PROVISIONS OF
54 SUBSECTION (GG) OF SECTION FOUR THOUSAND THREE HUNDRED THREE OF THIS
55 ARTICLE.
A. 213--B 4
1 S 5. This act shall take effect on the first of January next succeed-
2 ing the date on which it shall have become a law and shall apply to
3 insurance policies and contracts issued, renewed, modified or altered on
4 or after such effective date.
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