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S01803 Summary:

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S01803 Floor Votes:

S01803 Text:

 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         1803--C
            Cal. No. 561
 
                               2009-2010 Regular Sessions
 
                    IN SENATE
 
                                    February 9, 2009
                                       ___________
 
        Introduced  by Sens. BRESLIN, ESPADA, THOMPSON -- read twice and ordered
          printed, and when printed to be committed to the Committee  on  Insur-
          ance  --  committee  discharged,  bill  amended,  ordered reprinted as
          amended and recommitted  to  said  committee  --  recommitted  to  the

          Committee  on  Insurance  in  accordance with Senate Rule 6, sec. 8 --
          committee discharged, bill amended, ordered reprinted as  amended  and
          recommitted  to said committee -- reported favorably from said commit-
          tee and committed to the Committee on Finance  --  reported  favorably
          from said committee, ordered to first report, amended on first report,
          ordered  to a second report and ordered reprinted, retaining its place
          in the order of second report
 
        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 and
     5  that  does  not  provide  coverage for out-of-network dialysis treatment
     6  shall not deny coverage  of  such  services  because  the  services  are
     7  provided  by  an  out-of-network  provider,  provided  that  each of the
     8  following conditions are met:
     9    (i) The out-of-network provider  is  duly  licensed  to  practice  and
    10  authorized to provide such treatment;
    11    (ii)  The  out-of-network provider is located outside the service area
    12  of the insurer;
    13    (iii) The in-network healthcare provider treating the insured for  the

    14  condition  issues a written order for dialysis treatment stating that in
    15  his or her opinion such treatment is necessary;
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD00183-06-0
        S. 1803--C                          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) Where coverage for out-of-network dialysis treatment  is  provided
    13  pursuant  to  subparagraph  (A)  of  this paragraph, 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 out-of-
    19  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    § 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 and that does  not  provide  coverage  for  out-of-network
    31  dialysis  treatment shall not deny coverage of such services because the
    32  services are provided by an out-of-network provider, provided that  each
    33  of the following conditions are met:
    34    (i)  The  out-of-network  provider  is  duly  licensed to practice and
    35  authorized to provide such treatment;
    36    (ii) The out-of-network provider is located outside the  service  area
    37  of the insurer;
    38    (iii)  The in-network healthcare provider treating the insured for the
    39  condition issues a written order for dialysis treatment stating that  in
    40  his or her opinion such treatment is necessary;

    41    (iv) The insured has notified, in writing, the insurer at least thirty
    42  days  in  advance  of  the proposed date or dates of such out-of-network
    43  dialysis treatment.  The notice shall include the authorization required
    44  by clause (iii) of this subparagraph. In  the  event  the  insured  must
    45  travel on sudden notice due to family or other emergency, shorter notice
    46  may  be  permitted, provided that the insurer has reasonable opportunity
    47  to review the travel and treatment plans of the insured;
    48    (v) The insurer shall have  the  right  to  pre-approve  the  dialysis
    49  treatment and schedule; and
    50    (vi)  Such  coverage  is limited to no greater than ten out-of-network
    51  treatments in a calendar year.

    52    (B) Where coverage for out-of-network dialysis treatment  is  provided
    53  pursuant  to  subparagraph  (A)  of  this paragraph, no insurer shall be
    54  obligated to reimburse the out-of-network provider at an amount  greater
    55  than it would have paid for the same treatment within a network, includ-
    56  ing all drugs and ancillary services tied to dialysis treatment, and any
        S. 1803--C                          3
 
     1  amount  charged  by a provider in excess of the amount reimbursed by the
     2  insurer shall be the responsibility of the insured receiving the out-of-
     3  network services.
     4    (C)  Such  coverage  of  out-of-network  dialysis services required by
     5  subparagraph (A) of this paragraph shall otherwise  be  subject  to  the

     6  limitations,  exclusions  and  terms  of  the policy, including, but not
     7  limited to, utilization  review,  annual  deductibles,  copayments,  and
     8  coinsurance,  consistent  with those required for other similar benefits
     9  under the policy.
    10    § 3. Section 4303 of the insurance law is  amended  by  adding  a  new
    11  subsection (gg) to read as follows:
    12    (gg)  (1)  Every  contract  issued  by a hospital service corporation,
    13  health service corporation or medical expense indemnity corporation that
    14  includes coverage for dialysis treatment that requires such services  to
    15  be provided by an in-network provider and that does not provide coverage
    16  for  out-of-network  dialysis  treatment shall not deny coverage of such

    17  services because the services are provided by an out-of-network  provid-
    18  er, provided that each of the following conditions are met:
    19    (A)  The  out-of-network  provider  is  duly  licensed to practice and
    20  authorized to provide such treatment;
    21    (B) The out-of-network provider is located outside the service area of
    22  the insurer;
    23    (C) The in-network healthcare provider treating the covered person for
    24  the condition issues a written order for dialysis treatment stating that
    25  in his or her opinion such treatment is necessary;
    26    (D) The covered person has notified, in writing,  the  corporation  at
    27  least  thirty days in advance of the proposed date or dates of such out-

    28  of-network dialysis treatment.  The notice shall  include  the  authori-
    29  zation  required by subparagraph (C) of this paragraph. In the event the
    30  covered person must travel on sudden notice due to family or other emer-
    31  gency, shorter notice may be permitted, provided  that  the  corporation
    32  has  reasonable  opportunity to review the travel and treatment plans of
    33  the covered person;
    34    (E) The corporation shall have the right to pre-approve  the  dialysis
    35  treatment and schedule; and
    36    (F)  Such  coverage  is  limited to no greater than ten out-of-network
    37  treatments in a calendar year.
    38    (2) Where coverage for out-of-network dialysis treatment  is  provided
    39  pursuant  to  paragraph  one of this subsection, no corporation shall be

    40  obligated to reimburse the out-of-network provider at an amount  greater
    41  than it would have paid for the same treatment within a network, includ-
    42  ing all drugs and ancillary services tied to dialysis treatment, and any
    43  amount  charged  by a provider in excess of the amount reimbursed by the
    44  corporation shall be the responsibility of the covered person  receiving
    45  the out-of-network services.
    46    (3)  Such  coverage  of  out-of-network  dialysis services required by
    47  paragraph one of this subsection shall otherwise be subject to the limi-
    48  tations, exclusions and terms of the policy, including, but not  limited
    49  to, utilization review, annual deductibles, copayments, and coinsurance,

    50  consistent  with  those  required  for  other similar benefits under the
    51  policy.
    52    § 4. Paragraph 12 of subsection (b) of section 4322 of  the  insurance
    53  law,  as added by chapter 504 of the laws of 1995, is amended to read as
    54  follows:
        S. 1803--C                          4
 
     1    (12)  Hemodialysis  services  consistent  with   the   provisions   of
     2  subsection  (gg)  of  section  four thousand three hundred three of this
     3  article.
     4    §  5. This act shall take effect on the first of January next succeed-
     5  ing the date on which it shall have become a  law  and  shall  apply  to
     6  insurance policies and contracts issued, renewed, modified or altered on
     7  or after such effective date.