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
________________________________________________________________________
4238
2015-2016 Regular Sessions
IN ASSEMBLY
January 29, 2015
___________
Introduced by M. of A. GJONAJ, LAVINE, JAFFEE, BROOK-KRASNY, ROBERTS,
STIRPE, BENEDETTO, COLTON, CRESPO, KEARNS, OTIS, ROBINSON, RAIA,
SKOUFIS, STECK, LUPARDO, McDONALD, GOTTFRIED, HOOPER -- Multi-Spon-
sored by -- M. of A. BRAUNSTEIN, BRENNAN, CAMARA, GALEF, HEASTIE,
LOPEZ, LUPINACCI, McLAUGHLIN, PEOPLES-STOKES, PERRY, RIVERA, SEPULVE-
DA, SIMANOWITZ, SKARTADOS, TITONE, WRIGHT -- read once and referred to
the Committee on Insurance
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-
15 quences due to lifestyle. Such a wellness program may have some or all
16 of the following elements to advance the physical health and mental
17 well-being of its participants:
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD03890-01-5
A. 4238 2
1 (1) an education program to increase the awareness of and dissem-
2 ination of information about pursuing healthier lifestyles, and which
3 warns about risks of pursuing environmental or behavioral activities
4 that are detrimental to human health. In addition, information on the
5 availability of health screening tests to assist in the early identifi-
6 cation and treatment of diseases such as cancer, heart disease, hyper-
7 tension, diabetes, asthma, obesity or other adverse health afflictions;
8 (2) a program that encourages behavioral practices that either encour-
9 age healthy living activities or discourage unhealthy living activities.
10 Such activities or practices may include wellness programs, as provided
11 under section three thousand two hundred thirty-nine of this article;
12 and
13 (3) the monitoring of the progress of each covered person to track his
14 or her adherence to such wellness program and to provide assistance and
15 moral support to such covered person to assist him or her to attain the
16 goals of the covered person's wellness program.
17 Such wellness program shall demonstrate actuarially that it encourages
18 the general good health and well-being of the covered population. The
19 insurer or health maintenance organization shall not require specific
20 outcomes as a result of an enrollee's or insured's adherence to the
21 approved wellness program.
22 § 2. Subsections (a), (b) and (c) of section 3239 of the insurance
23 law, as added by chapter 592 of the laws of 2008, paragraphs 6 and 7 of
24 subsection (b) and subparagraphs (C) and (D) of paragraph 2 of
25 subsection (c) as amended, and paragraph 8 of subsection (b) and subpar-
26 agraphs (E) and (F) of paragraph 2 of subsection (c) as added by chapter
27 519 of the laws of 2013, are amended to read as follows:
28 (a) An insurer licensed to write accident and health insurance, a
29 corporation organized pursuant to article forty-three of this chapter, a
30 health maintenance organization certified pursuant to article forty-four
31 of the public health law and a municipal cooperative health benefits
32 plan may establish a wellness program in conjunction with its issuance
33 of a group accident and health insurance policy or group subscriber
34 contract. A "wellness program" is a program designed to promote health
35 and prevent disease that may contain rewards and incentives for partic-
36 ipation. Participation in the wellness program shall be available to
37 similarly-situated members of the group and shall be voluntary on the
38 part of the member. The specific terms of the wellness program shall be
39 set forth in the policy or contract, or in a separate document provided
40 to insureds and members which shall be consistent with the provisions of
41 this section.
42 (b) A wellness program may include, but is not limited to, the follow-
43 ing programs or services:
44 (1) the use of a health risk assessment tool;
45 (2) a smoking cessation program;
46 (3) a weight management program;
47 (4) a stress and/or hypertension management program;
48 (5) a worker injury prevention program;
49 (6) a nutrition education program;
50 (7) health or fitness incentive programs; [and]
51 (8) a coordinated weight management, nutrition, stress management and
52 physical fitness program to combat the high incidence of adult and
53 childhood obesity, asthma and other chronic respiratory conditions[.];
54 (9) assistance, financial or otherwise, provided to an employer for
55 health promotion and disease prevention;
A. 4238 3
1 (10) incentives for insureds or members to access preventive services,
2 such as mammography screening;
3 (11) a substance or alcohol abuse cessation program; and
4 (12) a program to manage and cope with chronic pain.
5 (c)(1) A wellness program may use rewards and incentives for partic-
6 ipation provided that where the group health insurance policy or
7 subscriber contract is required to be community-rated, the rewards and
8 incentives shall not include a discounted premium rate or a rebate or
9 refund of premium, except as provided in section three thousand two
10 hundred thirty-one of this article, or section four thousand two hundred
11 thirty-five, four thousand three hundred seventeen or four thousand
12 three hundred twenty-six of this chapter, or section forty-four hundred
13 five of the public health law.
14 (2) Permissible rewards and incentives may include:
15 (A) full or partial reimbursement of the cost of participating in
16 smoking cessation [or], weight management, stress and/or hypertension,
17 worker injury prevention, nutrition education, substance or alcohol
18 abuse cessation, or chronic pain management and coping programs;
19 (B) full or partial reimbursement of the cost of membership in a
20 health club or fitness center;
21 (C) the waiver or reduction of copayments, coinsurance and deductibles
22 for preventive services covered under the group policy or subscriber
23 contract;
24 (D) monetary rewards in the form of gift cards or gift certificates,
25 so long as the recipient of the reward is encouraged to use the reward
26 for a product or a service that promotes good health, such as healthy
27 cook books, over the counter vitamins or exercise equipment;
28 (E) full or partial reimbursement of the cost of participating in a
29 stress management program or activity; and
30 (F) full or partial reimbursement of the cost of participating in a
31 health or fitness program.
32 (3) Where the reward involves a group member's meeting a specified
33 standard based on a health condition, the wellness program must meet the
34 requirements of 45 CFR Part 146.
35 (4) A reward or incentive which involves a discounted premium rate or
36 a rebate or refund of premium shall be based on actuarial demonstration
37 that the wellness program can reasonably be expected to result in the
38 overall good health and well being of the group as provided in section
39 three thousand two hundred thirty-one of this article, sections four
40 thousand two hundred thirty-five, four thousand three hundred seventeen
41 and four thousand three hundred twenty-six of this chapter, and section
42 forty-four hundred five of the public health law.
43 § 3. Subsection (h) of section 4235 of the insurance law is amended by
44 adding a new paragraph 5 to read as follows:
45 (5) Each insurer doing business in this state, when filing with the
46 superintendent its schedules of premium rates, rules and classification
47 of risks for use in connection with the issuance of its policies of
48 group accident, group health or group accident and health insurance, may
49 provide for an actuarially appropriate reduction in premium rates or
50 other benefits or enhancements approved by the superintendent to encour-
51 age an enrollee's or insured's active participation in a qualified well-
52 ness program. A qualified wellness program can be a risk management
53 system that identifies at-risk populations or any other systematic
54 program or course of medical conduct which helps to promote physical and
55 mental fitness, health and well-being, helps to prevent or mitigate the
56 conditions of acute or chronic sickness, disease or pain, or which mini-
A. 4238 4
1 mizes adverse health consequences due to lifestyle. Such a wellness
2 program may have some or all of the following elements to advance the
3 physical health and mental well-being of its participants:
4 (A) 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 (B) a program that encourages behavioral practices that either encour-
12 age healthy living activities or discourage unhealthy living activities.
13 Such activities or practices may include wellness programs, as provided
14 under section three thousand two hundred thirty-nine of this chapter;
15 (C) the monitoring of the progress of each covered person to track his
16 or her adherence to such wellness program and to provide assistance and
17 moral support to such covered person to assist him or her to attain the
18 goals of the covered person's wellness program.
19 Such wellness program shall demonstrate actuarially that it encourages
20 the general good health and well-being of the covered population. The
21 insurer or health maintenance organization shall not require specific
22 outcomes as a result of an enrollee's or insured's adherence to the
23 approved wellness program.
24 § 4. Section 4317 of the insurance law is amended by adding a new
25 subsection (c-1) to read as follows:
26 (c-1) Subject to the approval of the superintendent, an insurer or
27 health maintenance organization issuing an individual or group health
28 insurance contract pursuant to this section may provide for an actuari-
29 ally appropriate reduction in premium rates or other benefits or
30 enhancements approved by the superintendent to encourage an enrollee's
31 or insured's active participation in a qualified wellness program. A
32 qualified wellness program can be a risk management system that identi-
33 fies at-risk populations or any other systematic program or course of
34 medical conduct which helps to promote physical and mental fitness,
35 health and well-being, helps to prevent or mitigate the conditions of
36 acute or chronic sickness, disease or pain, or which minimizes adverse
37 health consequences due to lifestyle. Such a wellness program may have
38 some or all of the following elements to advance the physical health and
39 mental well-being of its participants:
40 (1) an education program to increase the awareness of and dissem-
41 ination of information about pursuing healthier lifestyles, and which
42 warns about risks of pursuing environmental or behavioral activities
43 that are detrimental to human health. In addition, information on the
44 availability of health screening tests to assist in the early identifi-
45 cation and treatment of diseases such as cancer, heart disease, hyper-
46 tension, diabetes, asthma, obesity or other adverse health afflictions;
47 (2) a program that encourages behavioral practices that either encour-
48 age healthy living activities or discourage unhealthy living activities.
49 Such activities or practices may include wellness programs, as provided
50 under section three thousand two hundred thirty-nine of this chapter;
51 and
52 (3) the monitoring of the progress of each covered person to track his
53 or her adherence to such wellness program and to provide assistance and
54 moral support to such covered person to assist him or her to attain the
55 goals of the covered person's wellness program.
A. 4238 5
1 Such wellness program shall demonstrate actuarially that it encourages
2 the general good health and well-being of the covered population. The
3 insurer or health maintenance organization shall not require specific
4 outcomes as a result of an enrollee's or insured's adherence to the
5 approved wellness program.
6 § 5. Subsection (m) of section 4326 of the insurance law is amended by
7 adding a new paragraph 4 to read as follows:
8 (4) approval of the superintendent, an insurer or health maintenance
9 organization issuing a contract for qualifying small employers or indi-
10 viduals pursuant to this section may provide for an actuarially appro-
11 priate reduction in premium rates or other benefits or enhancements
12 approved by the superintendent to encourage an enrollee's or insured's
13 active participation in a qualified wellness program. A qualified well-
14 ness program can be a risk management system that identifies at-risk
15 populations or any other systematic program or course of medical conduct
16 which helps to promote physical and mental fitness, health and well-be-
17 ing, helps to prevent or mitigate the conditions of acute or chronic
18 sickness, disease or pain, or which minimizes adverse health conse-
19 quences due to lifestyle. Such a wellness program may have some or all
20 of the following elements to advance the physical health and mental
21 well-being of its participants:
22 (1) an education program to increase the awareness of and dissem-
23 ination of information about pursuing healthier lifestyles, and which
24 warns about risks of pursuing environmental or behavioral activities
25 that are detrimental to human health. In addition, information on the
26 availability of health screening tests to assist in the early identifi-
27 cation and treatment of diseases such as cancer, heart disease, hyper-
28 tension, diabetes, asthma, obesity or other adverse health afflictions;
29 (2) a program that encourages behavioral practices that either encour-
30 age healthy living activities or discourage unhealthy living activities.
31 Such activities or practices may include wellness programs, as provided
32 under section three thousand two hundred thirty-nine of this chapter;
33 and
34 (3) the monitoring of the progress of each covered person to track his
35 or her adherence to such wellness program and to provide assistance and
36 moral support to such covered person to assist him or her to attain the
37 goals of the covered person's wellness program.
38 Such wellness program shall demonstrate actuarially that it encourages
39 the general good health and well-being of the covered population. The
40 insurer or health maintenance organization shall not require specific
41 outcomes as a result of an enrollee's or insured's adherence to the
42 approved wellness program.
43 § 6. Section 4405 of the public health law is amended by adding a new
44 subdivision 5-a to read as follows:
45 5-a. subject to the approval of the superintendent of financial
46 services, the possible providing of an actuarially appropriate reduction
47 in premium rates or other benefits or enhancements approved by the
48 superintendent of financial services to encourage an enrollee's active
49 participation in a qualified wellness program. A qualified wellness
50 program can be a risk management system that identifies at-risk popu-
51 lations or any other systematic program or course of medical conduct
52 which helps to promote physical and mental fitness, health and well-be-
53 ing, helps to prevent or mitigate the conditions of acute or chronic
54 sickness, disease or pain, or which minimizes adverse health conse-
55 quences due to lifestyle. Such a wellness program may have some or all
A. 4238 6
1 of the following elements to advance the physical health and mental
2 well-being of its participants:
3 (1) an education program to increase the awareness of and dissem-
4 ination of information about pursuing healthier lifestyles, and which
5 warns about risks of pursuing environmental or behavioral activities
6 that are detrimental to human health. In addition, information on the
7 availability of health screening tests to assist in the early identifi-
8 cation and treatment of diseases such as cancer, heart disease, hyper-
9 tension, diabetes, asthma, obesity or other adverse health afflictions;
10 (2) a program that encourages behavioral practices that either encour-
11 age healthy living activities or discourage unhealthy living activities.
12 Such activities or practices may include wellness programs, as provided
13 under section three thousand two hundred thirty-nine of the insurance
14 law; and
15 (3) the monitoring of the progress of each covered person to track his
16 or her adherence to such wellness program and to provide assistance and
17 moral support to such covered person to assist him or her to attain the
18 goals of the covered person's wellness program.
19 Such wellness program shall demonstrate actuarially that it encourages
20 the general good health and well-being of the covered population. The
21 health maintenance organization shall not require specific outcomes as a
22 result of an enrollee's adherence to the approved wellness program;
23 § 7. This act shall take effect on the one hundred eightieth day after
24 it shall have become a law; provided that, effective immediately any
25 rules and regulations necessary to implement the provisions of this act
26 on its effective date are authorized and directed to be added, amended
27 and/or repealed on or before such date.
