Amd §§3231, 3239, 4235, 4317 & 4326, Ins L; amd §4405, 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
________________________________________________________________________
5535
2017-2018 Regular Sessions
IN ASSEMBLY
February 10, 2017
___________
Introduced by M. of A. GJONAJ, JAFFEE, STIRPE, BENEDETTO, COLTON, CRES-
PO, KEARNS, OTIS, RAIA, SKOUFIS, STECK, LUPARDO, McDONALD, GOTTFRIED,
HOOPER, PICHARDO, GARBARINO -- Multi-Sponsored by -- M. of A. BLANKEN-
BUSH, BRAUNSTEIN, GALEF, LOPEZ, LUPINACCI, McLAUGHLIN, PEOPLES-STOKES,
PERRY, RIVERA, SEPULVEDA, 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:
18 (1) an education program to increase the awareness of and dissem-
19 ination of information about pursuing healthier lifestyles, and which
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD07344-01-7
A. 5535 2
1 warns about risks of pursuing environmental or behavioral activities
2 that are detrimental to human health. In addition, information on the
3 availability of health screening tests to assist in the early identifi-
4 cation and treatment of diseases such as cancer, heart disease, hyper-
5 tension, diabetes, asthma, obesity or other adverse health afflictions;
6 (2) a program that encourages behavioral practices that either encour-
7 age healthy living activities or discourage unhealthy living activities.
8 Such activities or practices may include wellness programs, as provided
9 under section three thousand two hundred thirty-nine of this article;
10 and
11 (3) the monitoring of the progress of each covered person to track his
12 or her adherence to such wellness program and to provide assistance and
13 moral support to such covered person to assist him or her to attain the
14 goals of the covered person's wellness program.
15 Such wellness program shall demonstrate actuarially that it encourages
16 the general good health and well-being of the covered population. The
17 insurer or health maintenance organization shall not require specific
18 outcomes as a result of an enrollee's or insured's adherence to the
19 approved wellness program.
20 § 2. Subsections (a), (b) and (c) of section 3239 of the insurance
21 law, subsection (a) as added by chapter 592 of the laws of 2008, and
22 subsections (b) and (c) as amended by chapter 180 of the laws of 2016,
23 are amended to read as follows:
24 (a) An insurer licensed to write accident and health insurance, a
25 corporation organized pursuant to article forty-three of this chapter, a
26 health maintenance organization certified pursuant to article forty-four
27 of the public health law and a municipal cooperative health benefits
28 plan may establish a wellness program in conjunction with its issuance
29 of a group accident and health insurance policy or group subscriber
30 contract. A "wellness program" is a program designed to promote health
31 and prevent disease that may contain rewards and incentives for partic-
32 ipation. Participation in the wellness program shall be available to
33 similarly-situated members of the group and shall be voluntary on the
34 part of the member. The specific terms of the wellness program shall be
35 set forth in the policy or contract, or in a separate document provided
36 to insureds and members which shall be consistent with the provisions of
37 this section.
38 (b) A wellness program may include, but is not limited to, the follow-
39 ing programs or services:
40 (1) the use of a health risk assessment tool;
41 (2) a smoking cessation program;
42 (3) a weight management program;
43 (4) a stress and/or hypertension management program;
44 (5) a worker injury prevention program;
45 (6) a nutrition education program;
46 (7) health or fitness incentive programs;
47 (8) a coordinated weight management, nutrition, stress management and
48 physical fitness program to combat the high incidence of adult and
49 childhood obesity, asthma and other chronic respiratory conditions;
50 (9) a substance or alcohol abuse cessation program; [and]
51 (10) a program to manage and cope with chronic pain[.] ;
52 (11) assistance, financial or otherwise, provided to an employer for
53 health promotion and disease prevention; and
54 (12) incentives for insureds or members to access preventive services,
55 such as mammography screening.
A. 5535 3
1 (c)(1) A wellness program may use rewards and incentives for partic-
2 ipation provided that where the group health insurance policy or
3 subscriber contract is required to be community-rated, the rewards and
4 incentives shall not include a discounted premium rate or a rebate or
5 refund of premium, except as provided in section three thousand two
6 hundred thirty-one of this article, or section four thousand two hundred
7 thirty-five, four thousand three hundred seventeen or four thousand
8 three hundred twenty-six of this chapter, or section forty-four hundred
9 five of the public health law.
10 (2) Permissible rewards and incentives may include:
11 (A) full or partial reimbursement of the cost of participating in
12 smoking cessation, weight management, stress and/or hypertension, worker
13 injury prevention, nutrition education, substance or alcohol abuse
14 cessation, or chronic pain management and coping programs;
15 (B) full or partial reimbursement of the cost of membership in a
16 health club or fitness center;
17 (C) the waiver or reduction of copayments, coinsurance and deductibles
18 for preventive services covered under the group policy or subscriber
19 contract;
20 (D) monetary rewards in the form of gift cards or gift certificates,
21 so long as the recipient of the reward is encouraged to use the reward
22 for a product or a service that promotes good health, such as healthy
23 cook books, over the counter vitamins or exercise equipment;
24 (E) full or partial reimbursement of the cost of participating in a
25 stress management program or activity; and
26 (F) full or partial reimbursement of the cost of participating in a
27 health or fitness program.
28 (3) Where the reward involves a group member's meeting a specified
29 standard based on a health condition, the wellness program must meet the
30 requirements of 45 CFR Part 146.
31 (4) A reward or incentive which involves a discounted premium rate or
32 a rebate or refund of premium shall be based on actuarial demonstration
33 that the wellness program can reasonably be expected to result in the
34 overall good health and well being of the group as provided in section
35 three thousand two hundred thirty-one of this article, sections four
36 thousand two hundred thirty-five, four thousand three hundred seventeen
37 and four thousand three hundred twenty-six of this chapter, and section
38 forty-four hundred five of the public health law.
39 § 3. Subsection (h) of section 4235 of the insurance law is amended by
40 adding a new paragraph 5 to read as follows:
41 (5) Each insurer doing business in this state, when filing with the
42 superintendent its schedules of premium rates, rules and classification
43 of risks for use in connection with the issuance of its policies of
44 group accident, group health or group accident and health insurance, may
45 provide for an actuarially appropriate reduction in premium rates or
46 other benefits or enhancements approved by the superintendent to encour-
47 age an enrollee's or insured's active participation in a qualified well-
48 ness program. A qualified wellness program can be a risk management
49 system that identifies at-risk populations or any other systematic
50 program or course of medical conduct which helps to promote physical and
51 mental fitness, health and well-being, helps to prevent or mitigate the
52 conditions of acute or chronic sickness, disease or pain, or which mini-
53 mizes adverse health consequences due to lifestyle. Such a wellness
54 program may have some or all of the following elements to advance the
55 physical health and mental well-being of its participants:
A. 5535 4
1 (A) 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 (B) 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 chapter;
12 (C) the monitoring of the progress of each covered person to track his
13 or her adherence to such wellness program and to provide assistance and
14 moral support to such covered person to assist him or her to attain the
15 goals of the covered person's wellness program.
16 Such wellness program shall demonstrate actuarially that it encourages
17 the general good health and well-being of the covered population. The
18 insurer or health maintenance organization shall not require specific
19 outcomes as a result of an enrollee's or insured's adherence to the
20 approved wellness program.
21 § 4. Section 4317 of the insurance law is amended by adding a new
22 subsection (c-1) to read as follows:
23 (c-1) Subject to the approval of the superintendent, an insurer or
24 health maintenance organization issuing an individual or group health
25 insurance contract pursuant to this section may provide for an actuari-
26 ally appropriate reduction in premium rates or other benefits or
27 enhancements approved by the superintendent to encourage an enrollee's
28 or insured's active participation in a qualified wellness program. A
29 qualified wellness program can be a risk management system that identi-
30 fies at-risk populations or any other systematic program or course of
31 medical conduct which helps to promote physical and mental fitness,
32 health and well-being, helps to prevent or mitigate the conditions of
33 acute or chronic sickness, disease or pain, or which minimizes adverse
34 health consequences due to lifestyle. Such a wellness program may have
35 some or all of the following elements to advance the physical health and
36 mental well-being of its participants:
37 (1) an education program to increase the awareness of and dissem-
38 ination of information about pursuing healthier lifestyles, and which
39 warns about risks of pursuing environmental or behavioral activities
40 that are detrimental to human health. In addition, information on the
41 availability of health screening tests to assist in the early identifi-
42 cation and treatment of diseases such as cancer, heart disease, hyper-
43 tension, diabetes, asthma, obesity or other adverse health afflictions;
44 (2) a program that encourages behavioral practices that either encour-
45 age healthy living activities or discourage unhealthy living activities.
46 Such activities or practices may include wellness programs, as provided
47 under section three thousand two hundred thirty-nine of this chapter;
48 and
49 (3) the monitoring of the progress of each covered person to track his
50 or her adherence to such wellness program and to provide assistance and
51 moral support to such covered person to assist him or her to attain the
52 goals of the covered person's wellness program.
53 Such wellness program shall demonstrate actuarially that it encourages
54 the general good health and well-being of the covered population. The
55 insurer or health maintenance organization shall not require specific
A. 5535 5
1 outcomes as a result of an enrollee's or insured's adherence to the
2 approved wellness program.
3 § 5. Subsection (m) of section 4326 of the insurance law is amended by
4 adding a new paragraph 4 to read as follows:
5 (4) approval of the superintendent, an insurer or health maintenance
6 organization issuing a contract for qualifying small employers or indi-
7 viduals pursuant to this section may provide for an actuarially appro-
8 priate reduction in premium rates or other benefits or enhancements
9 approved by the superintendent to encourage an enrollee's or insured's
10 active participation in a qualified wellness program. A qualified well-
11 ness program can be a risk management system that identifies at-risk
12 populations or any other systematic program or course of medical conduct
13 which helps to promote physical and mental fitness, health and well-be-
14 ing, helps to prevent or mitigate the conditions of acute or chronic
15 sickness, disease or pain, or which minimizes adverse health conse-
16 quences due to lifestyle. Such a wellness program may have some or all
17 of the following elements to advance the physical health and mental
18 well-being of its participants:
19 (A) an education program to increase the awareness of and dissem-
20 ination of information about pursuing healthier lifestyles, and which
21 warns about risks of pursuing environmental or behavioral activities
22 that are detrimental to human health. In addition, information on the
23 availability of health screening tests to assist in the early identifi-
24 cation and treatment of diseases such as cancer, heart disease, hyper-
25 tension, diabetes, asthma, obesity or other adverse health afflictions;
26 (B) a program that encourages behavioral practices that either encour-
27 age healthy living activities or discourage unhealthy living activities.
28 Such activities or practices may include wellness programs, as provided
29 under section three thousand two hundred thirty-nine of this chapter;
30 and
31 (C) the monitoring of the progress of each covered person to track his
32 or her adherence to such wellness program and to provide assistance and
33 moral support to such covered person to assist him or her to attain the
34 goals of the covered person's wellness program.
35 Such wellness program shall demonstrate actuarially that it encourages
36 the general good health and well-being of the covered population. The
37 insurer or health maintenance organization shall not require specific
38 outcomes as a result of an enrollee's or insured's adherence to the
39 approved wellness program.
40 § 6. Section 4405 of the public health law is amended by adding a new
41 subdivision 5-a to read as follows:
42 5-a. subject to the approval of the superintendent of financial
43 services, the possible providing of an actuarially appropriate reduction
44 in premium rates or other benefits or enhancements approved by the
45 superintendent of financial services to encourage an enrollee's active
46 participation in a qualified wellness program. A qualified wellness
47 program can be a risk management system that identifies at-risk popu-
48 lations or any other systematic program or course of medical conduct
49 which helps to promote physical and mental fitness, health and well-be-
50 ing, helps to prevent or mitigate the conditions of acute or chronic
51 sickness, disease or pain, or which minimizes adverse health conse-
52 quences due to lifestyle. Such a wellness program may have some or all
53 of the following elements to advance the physical health and mental
54 well-being of its participants:
55 (1) an education program to increase the awareness of and dissem-
56 ination of information about pursuing healthier lifestyles, and which
A. 5535 6
1 warns about risks of pursuing environmental or behavioral activities
2 that are detrimental to human health. In addition, information on the
3 availability of health screening tests to assist in the early identifi-
4 cation and treatment of diseases such as cancer, heart disease, hyper-
5 tension, diabetes, asthma, obesity or other adverse health afflictions;
6 (2) a program that encourages behavioral practices that either encour-
7 age healthy living activities or discourage unhealthy living activities.
8 Such activities or practices may include wellness programs, as provided
9 under section three thousand two hundred thirty-nine of the insurance
10 law; and
11 (3) the monitoring of the progress of each covered person to track his
12 or her adherence to such wellness program and to provide assistance and
13 moral support to such covered person to assist him or her to attain the
14 goals of the covered person's wellness program.
15 Such wellness program shall demonstrate actuarially that it encourages
16 the general good health and well-being of the covered population. The
17 health maintenance organization shall not require specific outcomes as a
18 result of an enrollee's adherence to the approved wellness program;
19 § 7. This act shall take effect on the one hundred eightieth day after
20 it shall have become a law; provided that if chapter 180 of the laws of
21 2016 shall not have taken effect on such effective date, then section
22 two of this act shall take effect on the same date and in the same
23 manner as such chapter takes effect; provided further effective imme-
24 diately any rules and regulations necessary to implement the provisions
25 of this act on its effective date are authorized and directed to be
26 added, amended and/or repealed on or before such date.
