Defines the term "genetic predisposition" for purposes of individual and small group health insurance policies; requires that genetic predisposition be disregarded in community rating; provides that no pre-existing condition exclusion in such a policy shall exclude coverage on the basis of any genetic predisposition.
STATE OF NEW YORK
________________________________________________________________________
S. 3726 A. 5858
2011-2012 Regular Sessions
SENATE - ASSEMBLY
March 2, 2011
___________
IN SENATE -- Introduced by Sen. KRUGER -- read twice and ordered print-
ed, and when printed to be committed to the Committee on Insurance
IN ASSEMBLY -- Introduced by M. of A. KAVANAGH -- read once and referred
to the Committee on Insurance
AN ACT to amend the insurance law, in relation to genetic predisposition
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subsection (a) of section 107 of the insurance law is
2 amended by adding a new paragraph 54 to read as follows:
3 (54) "Genetic predisposition" shall mean the presence of a variation
4 in the composition of the genes of an individual or an individual's
5 family member which is scientifically or medically identifiable and
6 which is determined to be associated with an increased statistical risk
7 of being expressed as either a physical or mental disease or disability
8 in the individual or having offspring with a genetically influenced
9 disease, but which has not resulted in any symptoms of such disease or
10 disorder.
11 § 2. Subsection (a) of section 3231 of the insurance law, as amended
12 by chapter 661 of the laws of 1997, is amended to read as follows:
13 (a) No individual health insurance policy and no group health insur-
14 ance policy covering between two and fifty employees or members of the
15 group exclusive of spouses and dependents, hereinafter referred to as a
16 small group, providing hospital and/or medical benefits, including medi-
17 care supplemental insurance, shall be issued in this state unless such
18 policy is community rated and, notwithstanding any other provisions of
19 law, the underwriting of such policy involves no more than the imposi-
20 tion of a pre-existing condition limitation as permitted by this arti-
21 cle. Any individual, and dependents of such individual, and any small
22 group, including all employees or group members and dependents of
23 employees or members, applying for individual health insurance coverage,
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD07054-01-1
S. 3726 2 A. 5858
1 including medicare supplemental coverage, or small group health insur-
2 ance coverage, including medicare supplemental insurance, must be
3 accepted at all times throughout the year for any hospital and/or
4 medical coverage offered by the insurer to individuals or small groups
5 in this state. Once accepted for coverage, an individual or small group
6 cannot be terminated by the insurer due to claims experience. Termi-
7 nation of an individual or small group shall be based only on one or
8 more of the reasons set forth in subsection (g) of section three thou-
9 sand two hundred sixteen or subsection (p) of section three thousand two
10 hundred twenty-one of this article. Group hospital and/or medical cover-
11 age, including medicare supplemental insurance, obtained through an
12 out-of-state trust covering a group of fifty or fewer employees or
13 participating persons who are residents of this state must be community
14 rated regardless of the situs of delivery of the policy. Notwithstanding
15 any other provisions of law, the underwriting of such policy may involve
16 no more than the imposition of a pre-existing condition limitation as
17 permitted by this article, and once accepted for coverage, an individual
18 or small group cannot be terminated due to claims experience. Termi-
19 nation of an individual or small group shall be based only on one or
20 more of the reasons set forth in subsection (p) of section three thou-
21 sand two hundred twenty-one of this article. For the purposes of this
22 section, "community rated" means a rating methodology in which the
23 premium for all persons covered by a policy or contract form is the same
24 based on the experience of the entire pool of risks covered by that
25 policy or contract form without regard to age, sex, health status,
26 including any genetic predisposition, or occupation.
27 § 3. The opening paragraph of subsection (b) of section 3232 of the
28 insurance law, as amended by chapter 661 of the laws of 1997, is amended
29 to read as follows:
30 No pre-existing condition provision shall exclude coverage for a peri-
31 od in excess of twelve months following the enrollment date of coverage
32 for the covered person and may only relate to a condition (whether phys-
33 ical or mental), regardless of the cause of the condition, for which
34 medical advice, diagnosis, care or treatment was recommended or received
35 within the six-month period ending on the enrollment date. No pre-ex-
36 isting condition provision shall exclude coverage on the basis of any
37 genetic predisposition. For purposes of this section "enrollment date"
38 means the first day of coverage of the individual under the policy or,
39 if earlier, the first day of the waiting period that must pass with
40 respect to an individual before such individual is eligible to be
41 covered for benefits. If an individual seeks and obtains coverage in the
42 individual market, any period after the date the individual files a
43 substantially complete application for coverage and before the first day
44 of coverage is a waiting period. For purposes of this section genetic
45 information shall not be treated as a pre-existing condition in the
46 absence of a diagnosis of the condition related to such information. No
47 pre-existing condition limitation provision shall exclude coverage in
48 the case of:
49 § 4. Subsection (a) of section 4317 of the insurance law, as amended
50 by chapter 661 of the laws of 1997, is amended to read as follows:
51 (a) No individual health insurance contract and no group health insur-
52 ance contract covering between two and fifty employees or members of the
53 group exclusive of spouses and dependents, including contracts for which
54 the premiums are paid by a remitting agent for a group, hereinafter
55 referred to as a small group, providing hospital and/or medical bene-
56 fits, including Medicare supplemental insurance, shall be issued in this
S. 3726 3 A. 5858
1 state unless such contract is community rated and, notwithstanding any
2 other provisions of law, the underwriting of such contract involves no
3 more than the imposition of a pre-existing condition limitation as
4 permitted by this article. Any individual, and dependents of such indi-
5 vidual, and any small group, including all employees or group members
6 and dependents of employees or members, applying for individual or small
7 group health insurance coverage must be accepted at all times throughout
8 the year for any hospital and/or medical coverage, including Medicare
9 supplemental insurance, offered by the corporation to individuals or
10 small groups in this state. Once accepted for coverage, an individual or
11 small group cannot be terminated by the insurer due to claims experi-
12 ence. Termination of coverage for individuals or small groups may be
13 based only on one or more of the reasons set forth in subsection (c) of
14 section four thousand three hundred four or subsection (j) of section
15 four thousand three hundred five of this article. For the purposes of
16 this section, "community rated" means a rating methodology in which the
17 premium for all persons covered by a policy or contract form is the
18 same, based on the experience of the entire pool of risks covered by
19 that policy or contract form without regard to age, sex, health status,
20 including any genetic predisposition, or occupation.
21 § 5. The opening paragraph of subsection (b) of section 4318 of the
22 insurance law, as amended by chapter 661 of the laws of 1997, is amended
23 to read as follows:
24 No pre-existing condition provision shall exclude coverage for a peri-
25 od in excess of twelve months following the enrollment date for the
26 covered person and may only relate to a condition (whether physical or
27 mental), regardless of the cause of the condition for which medical
28 advice, diagnosis, care or treatment was recommended or received within
29 the six month period ending on the enrollment date. For purposes of
30 this section "enrollment date" means the first day of coverage of the
31 individual under the contract or, if earlier, the first day of the wait-
32 ing period that must pass with respect to an individual before the indi-
33 vidual is eligible to be covered for benefits. If an individual seeks
34 and obtains coverage in the individual market, any period after the date
35 the individual files a substantially complete application for coverage
36 and before the first day of coverage is a waiting period. For purposes
37 of this section, genetic information shall not be treated as a pre-ex-
38 isting condition in the absence of a diagnosis of the condition related
39 to such information. No pre-existing condition provision shall exclude
40 coverage on the basis of any genetic predisposition. No pre-existing
41 condition provision shall exclude coverage in the case of:
42 § 6. This act shall take effect on the sixtieth day after it shall
43 have become a law and shall apply to all policies issued, renewed,
44 altered or modified on or after such date.