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
________________________________________________________________________
7472
2019-2020 Regular Sessions
IN ASSEMBLY
May 6, 2019
___________
Introduced by M. of A. GOTTFRIED, ARROYO, BLAKE, BUTTENSCHON, COLTON,
COOK, CROUCH, CRUZ, DICKENS, DINOWITZ, FALL, GALEF, JEAN-PIERRE,
LUPARDO, MOSLEY, OTIS, SALKA, SAYEGH, SIMON, STIRPE, THIELE -- Multi-
Sponsored by -- M. of A. LAWRENCE, LENTOL -- 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
20 warns about risks of pursuing environmental or behavioral activities
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD09863-01-9
A. 7472 2
1 that are detrimental to human health. In addition, information on the
2 availability of health screening tests to assist in the early identifi-
3 cation and treatment of diseases such as cancer, heart disease, hyper-
4 tension, diabetes, asthma, obesity or other adverse health afflictions;
5 (2) a program that encourages behavioral practices that either encour-
6 age healthy living activities or discourage unhealthy living activities.
7 Such activities or practices may include wellness programs, as provided
8 under section three thousand two hundred thirty-nine of this article;
9 and
10 (3) the monitoring of the progress of each covered person to track his
11 or her adherence to such wellness program and to provide assistance and
12 moral support to such covered person to assist him or her to attain the
13 goals of the covered person's wellness program.
14 Such wellness program shall demonstrate actuarially that it encourages
15 the general good health and well-being of the covered population. The
16 insurer or health maintenance organization shall not require specific
17 outcomes as a result of an enrollee's or insured's adherence to the
18 approved wellness program.
19 § 2. Subsections (a), (b) and (c) of section 3239 of the insurance
20 law, subsection (a) as added by chapter 592 of the laws of 2008, and
21 subsections (b) and (c) as amended by chapter 180 of the laws of 2016,
22 are amended to read as follows:
23 (a) An insurer licensed to write accident and health insurance, a
24 corporation organized pursuant to article forty-three of this chapter, a
25 health maintenance organization certified pursuant to article forty-four
26 of the public health law and a municipal cooperative health benefits
27 plan may establish a wellness program in conjunction with its issuance
28 of a group accident and health insurance policy or group subscriber
29 contract. A "wellness program" is a program designed to promote health
30 and prevent disease that may contain rewards and incentives for partic-
31 ipation. Participation in the wellness program shall be available to
32 similarly-situated members of the group and shall be voluntary on the
33 part of the member. The specific terms of the wellness program shall be
34 set forth in the policy or contract, or in a separate document provided
35 to insureds and members which shall be consistent with the provisions of
36 this section.
37 (b) A wellness program may include, but is not limited to, the follow-
38 ing programs or services:
39 (1) the use of a health risk assessment tool;
40 (2) a smoking cessation program;
41 (3) a weight management program;
42 (4) a stress and/or hypertension management program;
43 (5) a worker injury prevention program;
44 (6) a nutrition education program;
45 (7) health or fitness incentive programs;
46 (8) a coordinated weight management, nutrition, stress management and
47 physical fitness program to combat the high incidence of adult and
48 childhood obesity, asthma and other chronic respiratory conditions;
49 (9) a substance or alcohol abuse cessation program; [and]
50 (10) a program to manage and cope with chronic pain[.] ;
51 (11) assistance, financial or otherwise, provided to an employer for
52 health promotion and disease prevention; and
53 (12) incentives for insureds or members to access preventive services,
54 such as mammography screening.
55 (c)(1) A wellness program may use rewards and incentives for partic-
56 ipation provided that where the group health insurance policy or
A. 7472 3
1 subscriber contract is required to be community-rated, the rewards and
2 incentives shall not include a discounted premium rate or a rebate or
3 refund of premium, except as provided in section three thousand two
4 hundred thirty-one of this article, or section four thousand two hundred
5 thirty-five, four thousand three hundred seventeen or four thousand
6 three hundred twenty-six of this chapter, or section forty-four hundred
7 five of the public health law.
8 (2) Permissible rewards and incentives may include:
9 (A) full or partial reimbursement of the cost of participating in
10 smoking cessation, weight management, stress and/or hypertension, worker
11 injury prevention, nutrition education, substance or alcohol abuse
12 cessation, or chronic pain management and coping programs;
13 (B) full or partial reimbursement of the cost of membership in a
14 health club or fitness center;
15 (C) the waiver or reduction of copayments, coinsurance and deductibles
16 for preventive services covered under the group policy or subscriber
17 contract;
18 (D) monetary rewards in the form of gift cards or gift certificates,
19 so long as the recipient of the reward is encouraged to use the reward
20 for a product or a service that promotes good health, such as healthy
21 cook books, over the counter vitamins or exercise equipment;
22 (E) full or partial reimbursement of the cost of participating in a
23 stress management program or activity; and
24 (F) full or partial reimbursement of the cost of participating in a
25 health or fitness program.
26 (3) Where the reward involves a group member's meeting a specified
27 standard based on a health condition, the wellness program must meet the
28 requirements of 45 CFR Part 146.
29 (4) A reward or incentive which involves a discounted premium rate or
30 a rebate or refund of premium shall be based on actuarial demonstration
31 that the wellness program can reasonably be expected to result in the
32 overall good health and well being of the group as provided in section
33 three thousand two hundred thirty-one of this article, sections four
34 thousand two hundred thirty-five, four thousand three hundred seventeen
35 and four thousand three hundred twenty-six of this chapter, and section
36 forty-four hundred five of the public health law.
37 § 3. Subsection (h) of section 4235 of the insurance law is amended by
38 adding a new paragraph 5 to read as follows:
39 (5) Each insurer doing business in this state, when filing with the
40 superintendent its schedules of premium rates, rules and classification
41 of risks for use in connection with the issuance of its policies of
42 group accident, group health or group accident and health insurance, may
43 provide for an actuarially appropriate reduction in premium rates or
44 other benefits or enhancements approved by the superintendent to encour-
45 age an enrollee's or insured's active participation in a qualified well-
46 ness program. A qualified wellness program can be a risk management
47 system that identifies at-risk populations or any other systematic
48 program or course of medical conduct which helps to promote physical and
49 mental fitness, health and well-being, helps to prevent or mitigate the
50 conditions of acute or chronic sickness, disease or pain, or which mini-
51 mizes adverse health consequences due to lifestyle. Such a wellness
52 program may have some or all of the following elements to advance the
53 physical health and mental well-being of its participants:
54 (A) an education program to increase the awareness of and dissem-
55 ination of information about pursuing healthier lifestyles, and which
56 warns about risks of pursuing environmental or behavioral activities
A. 7472 4
1 that are detrimental to human health. In addition, information on the
2 availability of health screening tests to assist in the early identifi-
3 cation and treatment of diseases such as cancer, heart disease, hyper-
4 tension, diabetes, asthma, obesity or other adverse health afflictions;
5 (B) a program that encourages behavioral practices that either encour-
6 age healthy living activities or discourage unhealthy living activities.
7 Such activities or practices may include wellness programs, as provided
8 under section three thousand two hundred thirty-nine of this chapter;
9 (C) the monitoring of the progress of each covered person to track his
10 or her adherence to such wellness program and to provide assistance and
11 moral support to such covered person to assist him or her to attain the
12 goals of the covered person's wellness program.
13 Such wellness program shall demonstrate actuarially that it encourages
14 the general good health and well-being of the covered population. The
15 insurer or health maintenance organization shall not require specific
16 outcomes as a result of an enrollee's or insured's adherence to the
17 approved wellness program.
18 § 4. Section 4317 of the insurance law is amended by adding a new
19 subsection (c-1) to read as follows:
20 (c-1) Subject to the approval of the superintendent, an insurer or
21 health maintenance organization issuing an individual or group health
22 insurance contract pursuant to this section may provide for an actuari-
23 ally appropriate reduction in premium rates or other benefits or
24 enhancements approved by the superintendent to encourage an enrollee's
25 or insured's active participation in a qualified wellness program. A
26 qualified wellness program can be a risk management system that identi-
27 fies at-risk populations or any other systematic program or course of
28 medical conduct which helps to promote physical and mental fitness,
29 health and well-being, helps to prevent or mitigate the conditions of
30 acute or chronic sickness, disease or pain, or which minimizes adverse
31 health consequences due to lifestyle. Such a wellness program may have
32 some or all of the following elements to advance the physical health and
33 mental well-being of its participants:
34 (1) an education program to increase the awareness of and dissem-
35 ination of information about pursuing healthier lifestyles, and which
36 warns about risks of pursuing environmental or behavioral activities
37 that are detrimental to human health. In addition, information on the
38 availability of health screening tests to assist in the early identifi-
39 cation and treatment of diseases such as cancer, heart disease, hyper-
40 tension, diabetes, asthma, obesity or other adverse health afflictions;
41 (2) a program that encourages behavioral practices that either encour-
42 age healthy living activities or discourage unhealthy living activities.
43 Such activities or practices may include wellness programs, as provided
44 under section three thousand two hundred thirty-nine of this chapter;
45 and
46 (3) the monitoring of the progress of each covered person to track his
47 or her adherence to such wellness program and to provide assistance and
48 moral support to such covered person to assist him or her to attain the
49 goals of the covered person's wellness program.
50 Such wellness program shall demonstrate actuarially that it encourages
51 the general good health and well-being of the covered population. The
52 insurer or health maintenance organization shall not require specific
53 outcomes as a result of an enrollee's or insured's adherence to the
54 approved wellness program.
55 § 5. Subsection (m) of section 4326 of the insurance law is amended by
56 adding a new paragraph 4 to read as follows:
A. 7472 5
1 (4) approval of the superintendent, an insurer or health maintenance
2 organization issuing a contract for qualifying small employers or indi-
3 viduals pursuant to this section may provide for an actuarially appro-
4 priate reduction in premium rates or other benefits or enhancements
5 approved by the superintendent to encourage an enrollee's or insured's
6 active participation in a qualified wellness program. A qualified well-
7 ness program can be a risk management system that identifies at-risk
8 populations or any other systematic program or course of medical conduct
9 which helps to promote physical and mental fitness, health and well-be-
10 ing, helps to prevent or mitigate the conditions of acute or chronic
11 sickness, disease or pain, or which minimizes adverse health conse-
12 quences due to lifestyle. Such a wellness program may have some or all
13 of the following elements to advance the physical health and mental
14 well-being of its participants:
15 (A) an education program to increase the awareness of and dissem-
16 ination of information about pursuing healthier lifestyles, and which
17 warns about risks of pursuing environmental or behavioral activities
18 that are detrimental to human health. In addition, information on the
19 availability of health screening tests to assist in the early identifi-
20 cation and treatment of diseases such as cancer, heart disease, hyper-
21 tension, diabetes, asthma, obesity or other adverse health afflictions;
22 (B) a program that encourages behavioral practices that either encour-
23 age healthy living activities or discourage unhealthy living activities.
24 Such activities or practices may include wellness programs, as provided
25 under section three thousand two hundred thirty-nine of this chapter;
26 and
27 (C) the monitoring of the progress of each covered person to track his
28 or her adherence to such wellness program and to provide assistance and
29 moral support to such covered person to assist him or her to attain the
30 goals of the covered person's wellness program.
31 Such wellness program shall demonstrate actuarially that it encourages
32 the general good health and well-being of the covered population. The
33 insurer or health maintenance organization shall not require specific
34 outcomes as a result of an enrollee's or insured's adherence to the
35 approved wellness program.
36 § 6. Section 4405 of the public health law is amended by adding a new
37 subdivision 5-a to read as follows:
38 5-a. subject to the approval of the superintendent of financial
39 services, the possible providing of an actuarially appropriate reduction
40 in premium rates or other benefits or enhancements approved by the
41 superintendent of financial services to encourage an enrollee's active
42 participation in a qualified wellness program. A qualified wellness
43 program can be a risk management system that identifies at-risk popu-
44 lations or any other systematic program or course of medical conduct
45 which helps to promote physical and mental fitness, health and well-be-
46 ing, helps to prevent or mitigate the conditions of acute or chronic
47 sickness, disease or pain, or which minimizes adverse health conse-
48 quences due to lifestyle. Such a wellness program may have some or all
49 of the following elements to advance the physical health and mental
50 well-being of its participants:
51 (1) an education program to increase the awareness of and dissem-
52 ination of information about pursuing healthier lifestyles, and which
53 warns about risks of pursuing environmental or behavioral activities
54 that are detrimental to human health. In addition, information on the
55 availability of health screening tests to assist in the early identifi-
A. 7472 6
1 cation and treatment of diseases such as cancer, heart disease, hyper-
2 tension, diabetes, asthma, obesity or other adverse health afflictions;
3 (2) a program that encourages behavioral practices that either encour-
4 age healthy living activities or discourage unhealthy living activities.
5 Such activities or practices may include wellness programs, as provided
6 under section three thousand two hundred thirty-nine of the insurance
7 law; and
8 (3) the monitoring of the progress of each covered person to track his
9 or her adherence to such wellness program and to provide assistance and
10 moral support to such covered person to assist him or her to attain the
11 goals of the covered person's wellness program.
12 Such wellness program shall demonstrate actuarially that it encourages
13 the general good health and well-being of the covered population. The
14 health maintenance organization shall not require specific outcomes as a
15 result of an enrollee's adherence to the approved wellness program;
16 § 7. This act shall take effect on the one hundred eightieth day after
17 it shall have become a law. Effective immediately, the addition, amend-
18 ment and/or repeal of any rule or regulation necessary for the implemen-
19 tation of this act on its effective date are authorized to be made and
20 completed on or before such effective date.
