•  Summary 
  •  
  •  Actions 
  •  
  •  Committee Votes 
  •  
  •  Floor Votes 
  •  
  •  Memo 
  •  
  •  Text 
  •  
  •  LFIN 
  •  
  •  Chamber Video/Transcript 

AB7793 Summary:

BILL NOA07793
 
SAME ASSAME AS S02286
 
SPONSORSimon (MS)
 
COSPNSRHevesi, McDonough, Zebrowski, Simpson, Jackson, Cook, Lavine, Carroll
 
MLTSPNSRBraunstein, DeStefano, Epstein, Fahy, Jacobson, Lupardo, Otis, Rosenthal L, Sayegh, Seawright, Steck, Stern
 
Amd §§3216, 4235, 4304 & 4305, Ins L
 
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.
Go to top    

AB7793 Actions:

BILL NOA07793
 
06/15/2023referred to insurance
01/03/2024referred to insurance
Go to top

AB7793 Memo:

NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A7793
 
SPONSOR: Simon (MS)
  TITLE OF BILL: 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   PURPOSE: To require coverage for medical and dental treatments as well as rehabi- litative therapies (physical, speech, occupational, etc.) to address conditions or illness related to or developed as a result of a congen- ital anomaly.   SUMMARY OF PROVISIONS: Section 1. Adds 5 new paragraphs 5, 6, 7, 8 and 9 to subsection (a) of 3216 of the insurance law to require every policy that provides coverage for hospital, surgical, or medical care to provide coverage for the assessment, evaluation, treatment, management, and follow-up care of congenital abnormalities. Such.,coverage shall not be denied on the grounds that it is for cosmetic purposes or is not for -a functional defect or impairment. Section 2. Paragraph 4 of Subsection (C) of section § 3216 of the insur- ance law is amended by adding a new subparagraph (D). Section 3. Adds a new paragraph 5 to subsection (F) of § 4235 of the insurance law to require every group or blanket policy that provides coverage for hospital, surgical or medical care to provide coverage for hospital, surgical, or medical care to provide coverage for the assess- ment, evaluation, treatment, management, and follow-up care of congen- ital abnormalities. Such coverage shall not be denied on the grounds that it is for cosmetic purposes or is not for a functional defect or impairment. Section 4. Adds a new subsection (d) to § 4304 of the insurance law to require every medical expense indemnity corporation, hospital service corporation or health service corporation that provides coverage for hospital, surgical or medical care to provide coverage for the assess- ment, evaluation, treatment, management, and follow-up care of congen- ital abnormalities. Such coverage shall not be denied on the grounds that it is for cosmetic purposes or is not for a functional defect or impaiLwent. Section 5. Paragraph 1 of subsection (c) of section § 4305 is amended by adding a new subparagraph (d) Section 6. Sets forth the effective date.   JUSTIFICATION: For every 38 babies born in New York State one is diagnosed with a congenital anomaly. There are a variety of different congenital anoma- lies New York's children are born with, ranging from atrial septal defect with 11,316 cases annually to trisomy 21 with 2,790 cases annual- ly. Two of the most commonly recognized congenital anomalies are cleft lip and cleft palate. A child would be:diagnosed with cleft lip and/or cleft palate where the child is born with 'an Unclosed lip and/or with an unclosed roof of the mouth. Basically, there is a gap in facial struc- ture due to incomplete fusion of skin, muscle and bone. This defect occurs during fetal development. Uncorrected, the defect causes severe eating, breathing, speaking and hearing difficulties and presents gross facial deformities. With appropriate surgical treatment, bone grafts, orthodontic, prostho- dontic and dental treatment as well as,Speech, physical and occupational therapies, individuals can gain nearly full function and approximate normal facial appearance. There is currently no New York State require- ment for full coverage (medical, dental and related therapies) for cleft lip, cleft palate or any other congenital anomaly. Currently, health insurance coverage varies by insurer both as to what is offered and as to how coverage is applied when covering costs related to congenital anomalies. While initial surgeries to close the structural gap for cleft lip and/or cleft palate are often covered, subsequent surgeries, bone grafts, follow up treatment and orthodontic, prosthodontic and related care are often not covered at all, are severely restricted in coverage or are subject to individual negotiation or confrontation with insurers. This lack of coverage consistency is the same when dealing with other congenital anomalies. For example, .a,6 month old male with sagittal craniosynostosis (premature closing, of a baby's skull) who had to wear a prescribed helmet to protect post-operative treatment was denied coverage for a second helmet as he continued to grow. New York law should be clear, comprehensive and consistent. This is a matter of fairness to the citizens of New York. Children should be covered for all procedures and therapies from infancy until they are no longer eligible to be covered on their parents' health "insurance. Correcting this gap in insurance coverage would provide a prudent investment in our most important resource: our children. Passage of the bill would also provide equity to insurers who are now forced to compete with each other on a field Where they are forced to guess how their competitors will apply coverage for congenital anomalies. Other states currently mandate comprehensive coverage for all congenital defects diagnosed by a doctor among them, Louisiana, Colorado, New Hamp- shire, Indiana, and North Carolina have laws specifically requiring comprehensive coverage for any Congenital anomaly. New York should join these states and make sure everyone receives comprehensive coverage.   LEGISLATIVE HISTORY: 2021-22: A1943 Simon S24 Kaplan -referred to insurance 2020: A.8890 Simon S.7709 Kaplan -referred to insurance   FISCAL IMPLICATIONS: None   LOCAL FISCAL IMPLICATIONS: None   EFFECTIVE DATE: this act shall take effect on the first of January next succeeding the date on which it shall have become a law and shall apply to all policies and contracts issued, renewed, modified, altered, or amended on or after such date.
Go to top

AB7793 Text:



 
                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.
                                                                   LBD06707-01-3

        A. 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  been

        A. 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.
Go to top