Amd SS3231, 3239, 4235, 4317 & 4326, Ins L; amd S4405, Pub Health L
Authorizes health insurers and health maintenance organizations, subject to the approval of the superintendent of financial services, to provide actuarially appropriate reductions in health insurance premiums or other benefits or enhancements for an enrollee's or insured's participation in a qualified wellness program.
STATE OF NEW YORK
________________________________________________________________________
5302--B
2013-2014 Regular Sessions
IN ASSEMBLY
February 22, 2013
___________
Introduced by M. of A. GJONAJ, LAVINE, JAFFEE, BROOK-KRASNY, ROBERTS,
STIRPE, BENEDETTO, COLTON, CRESPO, KEARNS, JACOBS, OTIS, ROBINSON,
RAIA, STECK, LUPARDO -- Multi-Sponsored by -- M. of A. BRAUNSTEIN,
CAMARA, GALEF, GOTTFRIED, P. LOPEZ, PEOPLES-STOKES, PERRY, RIVERA,
ROSA, SEPULVEDA, SIMANOWITZ, SKARTADOS, SWEENEY, TITONE, WEISENBERG --
read once and referred to the Committee on Insurance -- recommitted to
the Committee on Insurance in accordance with Assembly Rule 3, sec. 2
-- committee discharged, bill amended, ordered reprinted as amended
and recommitted to said committee -- again reported from said commit-
tee with amendments, ordered reprinted as amended and recommitted to
said committee
AN ACT to amend the insurance law and the public health law, in relation
to making actuarially appropriate reductions in health insurance
premiums in return for an enrollee's or insured's participation in a
qualified wellness program
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Section 3231 of the insurance law, as added by chapter 501
2 of the laws of 1992, is amended by adding a new subsection (c-1) to read
3 as follows:
4 (c-1) Subject to the approval of the superintendent, an insurer or
5 health maintenance organization issuing an individual or group health
6 insurance policy pursuant to this section may provide for an actuarially
7 appropriate reduction in premium rates or other benefits or enhancements
8 approved by the superintendent to encourage an enrollee's or insured's
9 active participation in a qualified wellness program. A qualified well-
10 ness program can be a risk management system that identifies at-risk
11 populations or any other systematic program or course of medical conduct
12 which helps to promote physical and mental fitness, health and well-be-
13 ing, helps to prevent or mitigate the conditions of acute or chronic
14 sickness, disease or pain, or which minimizes adverse health conse-
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD06713-08-4
A. 5302--B 2
1 quences due to lifestyle. Such a wellness program may have some or all
2 of the following elements to advance the physical health and mental
3 well-being of its participants:
4 (1) an education program to increase the awareness of and dissem-
5 ination of information about pursuing healthier lifestyles, and which
6 warns about risks of pursuing environmental or behavioral activities
7 that are detrimental to human health. In addition, information on the
8 availability of health screening tests to assist in the early identifi-
9 cation and treatment of diseases such as cancer, heart disease, hyper-
10 tension, diabetes, asthma, obesity or other adverse health afflictions;
11 (2) a program that encourages behavioral practices that either encour-
12 ages healthy living activities or discourages unhealthy living activ-
13 ities. Such activities or practices may include wellness programs, as
14 provided under section three thousand two hundred thirty-nine of this
15 article; and
16 (3) the monitoring of the progress of each covered person to track his
17 or her adherence to such wellness program and to provide assistance and
18 moral support to such covered person to assist him or her to attain the
19 goals of the covered person's wellness program.
20 Such wellness program shall demonstrate actuarially that it encourages
21 the general good health and well-being of the covered population. The
22 insurer or health maintenance organization shall not require specific
23 outcomes as a result of an enrollee's or insured's adherence to the
24 approved wellness program.
25 § 2. Subsections (a), (b) and (c) of section 3239 of the insurance
26 law, as added by chapter 592 of the laws of 2008, paragraphs 6 and 7 of
27 subsection (b) and subparagraphs (C) and (D) of paragraph 2 of
28 subsection (c) as amended, and paragraph 8 of subsection (b) and subpar-
29 agraphs (E) and (F) of paragraph 2 of subsection (c) as added by chapter
30 519 of the laws of 2013, are amended to read as follows:
31 (a) An insurer licensed to write accident and health insurance, a
32 corporation organized pursuant to article forty-three of this chapter, a
33 health maintenance organization certified pursuant to article forty-four
34 of the public health law and a municipal cooperative health benefits
35 plan may establish a wellness program in conjunction with its issuance
36 of a group accident and health insurance policy or group subscriber
37 contract. A "wellness program" is a program designed to promote health
38 and prevent disease that may contain rewards and incentives for partic-
39 ipation. Participation in the wellness program shall be available to
40 similarly-situated members of the group and shall be voluntary on the
41 part of the member. The specific terms of the wellness program shall be
42 set forth in the policy or contract, or in a separate document provided
43 to insureds and members which shall be consistent with the provisions of
44 this section.
45 (b) A wellness program may include, but is not limited to, the follow-
46 ing programs or services:
47 (1) the use of a health risk assessment tool;
48 (2) a smoking cessation program;
49 (3) a weight management program;
50 (4) a stress and/or hypertension management program;
51 (5) a worker injury prevention program;
52 (6) a nutrition education program;
53 (7) health or fitness incentive programs; [and]
54 (8) a coordinated weight management, nutrition, stress management and
55 physical fitness program to combat the high incidence of adult and
56 childhood obesity, asthma and other chronic respiratory conditions[.];
A. 5302--B 3
1 (9) assistance, financial or otherwise, provided to an employer for
2 health promotion and disease prevention;
3 (10) incentives for insureds or members to access preventive services,
4 such as mammography screening;
5 (11) a substance or alcohol abuse cessation program; and
6 (12) a program to manage and cope with chronic pain.
7 (c)(1) A wellness program may use rewards and incentives for partic-
8 ipation provided that where the group health insurance policy or
9 subscriber contract is required to be community-rated, the rewards and
10 incentives shall not include a discounted premium rate or a rebate or
11 refund of premium, except as provided in section three thousand two
12 hundred thirty-one of this article, or section four thousand two hundred
13 thirty-five, four thousand three hundred seventeen or four thousand
14 three hundred twenty-six of this chapter, or section forty-four hundred
15 five of the public health law.
16 (2) Permissible rewards and incentives may include:
17 (A) full or partial reimbursement of the cost of participating in
18 smoking cessation [or], weight management, stress and/or hypertension,
19 worker injury prevention, nutrition education, substance or alcohol
20 abuse cessation, or chronic pain management and coping programs;
21 (B) full or partial reimbursement of the cost of membership in a
22 health club or fitness center;
23 (C) the waiver or reduction of copayments, coinsurance and deductibles
24 for preventive services covered under the group policy or subscriber
25 contract;
26 (D) monetary rewards in the form of gift cards or gift certificates,
27 so long as the recipient of the reward is encouraged to use the reward
28 for a product or a service that promotes good health, such as healthy
29 cook books, over the counter vitamins or exercise equipment;
30 (E) full or partial reimbursement of the cost of participating in a
31 stress management program or activity; and
32 (F) full or partial reimbursement of the cost of participating in a
33 health or fitness program.
34 (3) Where the reward involves a group member's meeting a specified
35 standard based on a health condition, the wellness program must meet the
36 requirements of 45 CFR Part 146.
37 (4) A reward or incentive which involves a discounted premium rate or
38 a rebate or refund of premium shall be based on actuarial demonstration
39 that the wellness program can reasonably be expected to result in the
40 overall good health and well being of the group as provided in section
41 three thousand two hundred thirty-one of this article, sections four
42 thousand two hundred thirty-five, four thousand three hundred seventeen
43 and four thousand three hundred twenty-six of this chapter, and section
44 forty-four hundred five of the public health law.
45 § 3. Subsection (h) of section 4235 of the insurance law is amended by
46 adding a new paragraph 5 to read as follows:
47 (5) Each insurer doing business in this state, when filing with the
48 superintendent its schedules of premium rates, rules and classification
49 of risks for use in connection with the issuance of its policies of
50 group accident, group health or group accident and health insurance, may
51 provide for an actuarially appropriate reduction in premium rates or
52 other benefits or enhancements approved by the superintendent to encour-
53 age an enrollee's or insured's active participation in a qualified well-
54 ness program. A qualified wellness program can be a risk management
55 system that identifies at-risk populations or any other systematic
56 program or course of medical conduct which helps to promote physical and
A. 5302--B 4
1 mental fitness, health and well-being, helps to prevent or mitigate the
2 conditions of acute or chronic sickness, disease or pain, or which mini-
3 mizes adverse health consequences due to lifestyle. Such a wellness
4 program may have some or all of the following elements to advance the
5 physical health and mental well-being of its participants:
6 (A) an education program to increase the awareness of and dissem-
7 ination of information about pursuing healthier lifestyles, and which
8 warns about risks of pursuing environmental or behavioral activities
9 that are detrimental to human health. In addition, information on the
10 availability of health screening tests to assist in the early identifi-
11 cation and treatment of diseases such as cancer, heart disease, hyper-
12 tension, diabetes, asthma, obesity or other adverse health afflictions;
13 (B) a program that encourages behavioral practices that either encour-
14 ages healthy living activities or discourages unhealthy living activ-
15 ities. Such activities or practices may include wellness programs, as
16 provided under section three thousand two hundred thirty-nine of this
17 chapter;
18 (C) the monitoring of the progress of each covered person to track his
19 or her adherence to such wellness program and to provide assistance and
20 moral support to such covered person to assist him or her to attain the
21 goals of the covered person's wellness program.
22 Such wellness program shall demonstrate actuarially that it encourages
23 the general good health and well-being of the covered population. The
24 insurer or health maintenance organization shall not require specific
25 outcomes as a result of an enrollee's or insured's adherence to the
26 approved wellness program.
27 § 4. Section 4317 of the insurance law is amended by adding a new
28 subsection (c-1) to read as follows:
29 (c-1) Subject to the approval of the superintendent, an insurer or
30 health maintenance organization issuing an individual or group health
31 insurance contract pursuant to this section may provide for an actuari-
32 ally appropriate reduction in premium rates or other benefits or
33 enhancements approved by the superintendent to encourage an enrollee's
34 or insured's active participation in a qualified wellness program. A
35 qualified wellness program can be a risk management system that identi-
36 fies at-risk populations or any other systematic program or course of
37 medical conduct which helps to promote physical and mental fitness,
38 health and well-being, helps to prevent or mitigate the conditions of
39 acute or chronic sickness, disease or pain, or which minimizes adverse
40 health consequences due to lifestyle. Such a wellness program may have
41 some or all of the following elements to advance the physical health and
42 mental well-being of its participants:
43 (1) an education program to increase the awareness of and dissem-
44 ination of information about pursuing healthier lifestyles, and which
45 warns about risks of pursuing environmental or behavioral activities
46 that are detrimental to human health. In addition, information on the
47 availability of health screening tests to assist in the early identifi-
48 cation and treatment of diseases such as cancer, heart disease, hyper-
49 tension, diabetes, asthma, obesity or other adverse health afflictions;
50 (2) a program that encourages behavioral practices that either encour-
51 ages healthy living activities or discourages unhealthy living activ-
52 ities. Such activities or practices may include wellness programs, as
53 provided under section three thousand two hundred thirty-nine of this
54 chapter; and
55 (3) the monitoring of the progress of each covered person to track his
56 or her adherence to such wellness program and to provide assistance and
A. 5302--B 5
1 moral support to such covered person to assist him or her to attain the
2 goals of the covered person's wellness program.
3 Such wellness program shall demonstrate actuarially that it encourages
4 the general good health and well-being of the covered population. The
5 insurer or health maintenance organization shall not require specific
6 outcomes as a result of an enrollee's or insured's adherence to the
7 approved wellness program.
8 § 5. Subsection (m) of section 4326 of the insurance law is amended by
9 adding a new paragraph 4 to read as follows:
10 (4) approval of the superintendent, an insurer or health maintenance
11 organization issuing a contract for qualifying small employers or indi-
12 viduals pursuant to this section may provide for an actuarially appro-
13 priate reduction in premium rates or other benefits or enhancements
14 approved by the superintendent to encourage an enrollee's or insured's
15 active participation in a qualified wellness program. A qualified well-
16 ness program can be a risk management system that identifies at-risk
17 populations or any other systematic program or course of medical conduct
18 which helps to promote physical and mental fitness, health and well-be-
19 ing, helps to prevent or mitigate the conditions of acute or chronic
20 sickness, disease or pain, or which minimizes adverse health conse-
21 quences due to lifestyle. Such a wellness program may have some or all
22 of the following elements to advance the physical health and mental
23 well-being of its participants:
24 (1) an education program to increase the awareness of and dissem-
25 ination of information about pursuing healthier lifestyles, and which
26 warns about risks of pursuing environmental or behavioral activities
27 that are detrimental to human health. In addition, information on the
28 availability of health screening tests to assist in the early identifi-
29 cation and treatment of diseases such as cancer, heart disease, hyper-
30 tension, diabetes, asthma, obesity or other adverse health afflictions;
31 (2) a program that encourages behavioral practices that either encour-
32 ages healthy living activities or discourages unhealthy living activ-
33 ities. Such activities or practices may include wellness programs, as
34 provided under section three thousand two hundred thirty-nine of this
35 chapter; and
36 (3) the monitoring of the progress of each covered person to track his
37 or her adherence to such wellness program and to provide assistance and
38 moral support to such covered person to assist him or her to attain the
39 goals of the covered person's wellness program.
40 Such wellness program shall demonstrate actuarially that it encourages
41 the general good health and well-being of the covered population. The
42 insurer or health maintenance organization shall not require specific
43 outcomes as a result of an enrollee's or insured's adherence to the
44 approved wellness program.
45 § 6. Section 4405 of the public health law is amended by adding a new
46 subdivision 5-a to read as follows:
47 5-a. subject to the approval of the superintendent of financial
48 services, the possible providing of an actuarially appropriate reduction
49 in premium rates or other benefits or enhancements approved by the
50 superintendent of financial services to encourage an enrollee's active
51 participation in a qualified wellness program. A qualified wellness
52 program can be a risk management system that identifies at-risk popu-
53 lations or any other systematic program or course of medical conduct
54 which helps to promote physical and mental fitness, health and well-be-
55 ing, helps to prevent or mitigate the conditions of acute or chronic
56 sickness, disease or pain, or which minimizes adverse health conse-
A. 5302--B 6
1 quences due to lifestyle. Such a wellness program may have some or all
2 of the following elements to advance the physical health and mental
3 well-being of its participants:
4 (1) an education program to increase the awareness of and dissem-
5 ination of information about pursuing healthier lifestyles, and which
6 warns about risks of pursuing environmental or behavioral activities
7 that are detrimental to human health. In addition, information on the
8 availability of health screening tests to assist in the early identifi-
9 cation and treatment of diseases such as cancer, heart disease, hyper-
10 tension, diabetes, asthma, obesity or other adverse health afflictions;
11 (2) a program that encourages behavioral practices that either encour-
12 ages healthy living activities or discourages unhealthy living activ-
13 ities. Such activities or practices may include wellness programs, as
14 provided under section three thousand two hundred thirty-nine of the
15 insurance law; and
16 (3) the monitoring of the progress of each covered person to track his
17 or her adherence to such wellness program and to provide assistance and
18 moral support to such covered person to assist him or her to attain the
19 goals of the covered person's wellness program.
20 Such wellness program shall demonstrate actuarially that it encourages
21 the general good health and well-being of the covered population. The
22 health maintenance organization shall not require specific outcomes as a
23 result of an enrollee's adherence to the approved wellness program;
24 § 7. This act shall take effect on the one hundred eightieth day after
25 it shall have become a law; provided that, effective immediately any
26 rules and regulations necessary to implement the provisions of this act
27 on its effective date are authorized and directed to be added, amended
28 and/or repealed on or before such date.
