STATE OF NEW YORK
________________________________________________________________________
11340
IN ASSEMBLY
September 19, 2018
___________
Introduced by COMMITTEE ON RULES -- (at request of M. of A. Rozic) --
read once and referred to the Committee on Insurance
AN ACT to amend the insurance law, in relation to providing health
insurance protection to New Yorkers in the event that the federal
Affordable Care Act is repealed
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. The insurance law is amended by adding a new section 3217-i
2 to read as follows:
3 § 3217-i. Essential health benefits package. (a) Coverage required.
4 No insurer subject to this article shall decline to provide an essential
5 health benefits package as required by this section.
6 (b) Definition. The term "essential health benefits package" means,
7 with respect to any health plan, coverage that provides for the essen-
8 tial health benefits as defined by the superintendent under subsection
9 (c) of this section; limits cost-sharing for such coverage in accordance
10 with subsection (d) of this section; and subject to subsection (d) of
11 this section, provides either bronze, silver, gold or platinum level of
12 coverage as described in subsection (e) of this section.
13 (c) Superintendent's powers and duties with respect to essential
14 health benefits. (1) Subject to paragraph two of this subsection, the
15 superintendent shall define the essential health benefits, except that
16 such benefits shall include at least the following general categories
17 and the items and services covered within such categories: (i) ambulato-
18 ry patient services, (ii) emergency services, (iii) hospitalization,
19 (iv) maternity and newborn care, (v) mental health and substance use
20 disorder services, including behavioral health treatment, (vi)
21 prescription drugs, (vii) rehabilitative and habilitative services and
22 devices, (viii) laboratory services, (ix) preventive and wellness
23 services and chronic disease management, and (x) pediatric services,
24 including oral and vision care.
25 (2) The superintendent shall ensure that the scope of the essential
26 health benefits under paragraph one of this subsection is equal to the
27 scope of benefits provided under a typical employer plan, as determined
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD10208-02-7
A. 11340 2
1 by the superintendent. In defining the essential health benefits under
2 paragraph one of this subsection, the superintendent shall:
3 (A) ensure that such essential health benefits reflect an appropriate
4 balance among the categories described in paragraph one of this
5 subsection so that benefits are not unduly weighted toward any category;
6 (B) not make coverage decisions, determine reimbursement rates, estab-
7 lish incentive programs, or design benefits in ways that discriminate
8 against individuals because of their age, disability, or expected length
9 of life;
10 (C) take into account the health care needs of diverse segments of the
11 population, including women, children, persons with disabilities, and
12 other groups;
13 (D) ensure that health benefits established as essential not be
14 subject to denial to individuals against their wishes on the basis of
15 the individuals' age or expected length of life or of the individuals'
16 present or predicted disability, degree of medical dependency, or quali-
17 ty of life;
18 (E) provide that a qualified health plan shall not be treated as
19 providing coverage for the essential health benefits described in para-
20 graph one of this subsection unless the plan provides that:
21 (i) coverage for emergency department services will be provided with-
22 out imposing any requirement under the plan for prior authorization of
23 services or any limitation on coverage where the provider of services
24 does not have a contractual relationship with the plan for the providing
25 of services that is more restrictive than the requirements or limita-
26 tions that apply to emergency department services received from provid-
27 ers who do have such a contractual relationship with the plan; and
28 (ii) if such services are provided out-of-network, the cost-sharing
29 requirement, expressed as a copayment amount or coinsurance rate, is the
30 same requirement that would apply if such services were provided in-net-
31 work;
32 (F) provide that if a stand-alone dental benefits plan is offered
33 through an exchange, another health plan offered through such exchange
34 shall not fail to be treated as a qualified health plan solely because
35 the plan does not offer coverage of benefits offered through the stand-
36 alone plan that are otherwise required under subparagraph (G) of this
37 paragraph; and
38 (G) periodically update the essential health benefits under paragraph
39 one of this subsection to address any gaps in access to coverage.
40 (d) Cost-sharing requirements. (1) There shall be an annual limitation
41 on cost-sharing. (A) The cost-sharing incurred under a health plan with
42 respect to self-only coverage or coverage other than self-only coverage
43 for a plan year beginning in two thousand fourteen shall not exceed the
44 dollar amounts in effect for self-only and family coverage, respective-
45 ly, for taxable years beginning in two thousand fourteen.
46 (B) In the case of any plan year beginning in a calendar year after
47 two thousand fourteen, the limitation under this paragraph shall:
48 (i) in the case of self-only coverage, be equal to the dollar amount
49 under subparagraph (A) of this paragraph for self-only coverage for plan
50 years beginning in two thousand fourteen, increased by an amount equal
51 to the product of that amount and the premium adjustment percentage
52 under paragraph three of this subsection for the calendar year; and
53 (ii) in the case of other coverage, twice the amount in effect under
54 clause (i) of this subparagraph. If the amount of any increase under
55 clause (i) of this subparagraph is not a multiple of fifty dollars, such
56 increase shall be rounded to the next lowest multiple of fifty dollars.
A. 11340 3
1 (2) (A) The term "cost-sharing" shall include:
2 (i) deductibles, coinsurance, copayments, or similar charges; and
3 (ii) any other expenditure required of an insured individual which is
4 a qualified medical expense with respect to essential health benefits
5 covered under the plan.
6 (B) Such term does not include premiums, balance billing amounts for
7 non-network providers, or spending for non-covered services.
8 (3) For purposes of clause (i) of subparagraph (B) of paragraph one of
9 this subsection, the premium adjustment percentage for any calendar year
10 is the percentage, if any, by which the average per capita premium for
11 health insurance coverage in the United States for the preceding calen-
12 dar year exceeds such average per capita premium for the year two thou-
13 sand thirteen.
14 (e) Levels of coverage. (1) Levels of coverage described in this
15 subsection are as follows:
16 (A) Bronze level. A plan in the bronze level shall provide a level of
17 coverage that is designed to provide benefits that are actuarially
18 equivalent to sixty percent of the full actuarial value of the benefits
19 provided under the plan.
20 (B) Silver level. A plan in the silver level shall provide a level of
21 coverage that is designed to provide benefits that are actuarially
22 equivalent to seventy percent of the full actuarial value of the bene-
23 fits provided under the plan.
24 (C) Gold level. A plan in the gold level shall provide a level of
25 coverage that is designed to provide benefits that are actuarially
26 equivalent to eighty percent of the full actuarial value of the benefits
27 provided under the plan.
28 (D) Platinum level. A plan in the platinum level shall provide a level
29 of coverage that is designed to provide benefits that are actuarially
30 equivalent to ninety percent of the full actuarial value of the benefits
31 provided under the plan.
32 (2) (A) Actuarial value. Under regulations issued by the superinten-
33 dent, the level of coverage of a plan shall be determined on the basis
34 that the essential health benefits described in subsection (c) of this
35 section shall be provided to a standard population and without regard to
36 the population the plan may actually provide benefits to.
37 (B) Employer contributions. The superintendent shall issue regulations
38 under which employer contributions to a health savings account may be
39 taken into account.
40 § 2. The insurance law is amended by adding a new section 4306-h to
41 read as follows:
42 § 4306-h. Essential health benefits package. (a) Coverage required. No
43 corporation subject to this article shall decline to provide an essen-
44 tial health benefits package as required by this section.
45 (b) Definition. The term "essential health benefits package" means,
46 with respect to any health plan, coverage that provides for the essen-
47 tial health benefits as defined by the superintendent under subsection
48 (c) of this section; limits cost-sharing for such coverage in accordance
49 with subsection (d) of this section; and subject to subsection (d) of
50 this section, provides either bronze, silver, gold or platinum level of
51 coverage as described in subsection (e) of this section.
52 (c) Superintendent's powers and duties with respect to essential
53 health benefits. (1) Subject to paragraph two of this subsection, the
54 superintendent shall define the essential health benefits, except that
55 such benefits shall include at least the following general categories
56 and the items and services covered within such categories: (i) ambulato-
A. 11340 4
1 ry patient services, (ii) emergency services, (iii) hospitalization,
2 (iv) maternity and newborn care, (v) mental health and substance use
3 disorder services, including behavioral health treatment, (vi)
4 prescription drugs, (vii) rehabilitative and habilitative services and
5 devices, (viii) laboratory services, (ix) preventive and wellness
6 services and chronic disease management, and (x) pediatric services,
7 including oral and vision care.
8 (2) The superintendent shall ensure that the scope of the essential
9 health benefits under paragraph one of this subsection is equal to the
10 scope of benefits provided under a typical employer plan, as determined
11 by the superintendent. In defining the essential health benefits under
12 paragraph one of this subsection, the superintendent shall:
13 (A) ensure that such essential health benefits reflect an appropriate
14 balance among the categories described in paragraph one of this
15 subsection so that benefits are not unduly weighted toward any category;
16 (B) not make coverage decisions, determine reimbursement rates, estab-
17 lish incentive programs, or design benefits in ways that discriminate
18 against individuals because of their age, disability, or expected length
19 of life;
20 (C) take into account the health care needs of diverse segments of the
21 population, including women, children, persons with disabilities, and
22 other groups;
23 (D) ensure that health benefits established as essential not be
24 subject to denial to individuals against their wishes on the basis of
25 the individuals' age or expected length of life or of the individuals'
26 present or predicted disability, degree of medical dependency, or quali-
27 ty of life;
28 (E) provide that a qualified health plan shall not be treated as
29 providing coverage for the essential health benefits described in para-
30 graph one of this subsection unless the plan provides that:
31 (i) coverage for emergency department services will be provided with-
32 out imposing any requirement under the plan for prior authorization of
33 services or any limitation on coverage where the provider of services
34 does not have a contractual relationship with the plan for the providing
35 of services that is more restrictive than the requirements or limita-
36 tions that apply to emergency department services received from provid-
37 ers who do have such a contractual relationship with the plan; and
38 (ii) if such services are provided out-of-network, the cost-sharing
39 requirement, expressed as a copayment amount or coinsurance rate, is the
40 same requirement that would apply if such services were provided in-net-
41 work;
42 (F) provide that if a stand-alone dental benefits plan is offered
43 through an exchange, another health plan offered through such exchange
44 shall not fail to be treated as a qualified health plan solely because
45 the plan does not offer coverage of benefits offered through the stand-
46 alone plan that are otherwise required under subparagraph (G) of this
47 paragraph; and
48 (G) periodically update the essential health benefits under paragraph
49 one of this subsection to address any gaps in access to coverage.
50 (d) Cost-sharing requirements. (1) There shall be an annual limitation
51 on cost-sharing. (A) The cost-sharing incurred under a health plan with
52 respect to self-only coverage or coverage other than self-only coverage
53 for a plan year beginning in two thousand fourteen shall not exceed the
54 dollar amounts in effect for self-only and family coverage, respective-
55 ly, for taxable years beginning in two thousand fourteen.
A. 11340 5
1 (B) In the case of any plan year beginning in a calendar year after
2 two thousand fourteen, the limitation under this paragraph shall:
3 (i) in the case of self-only coverage, be equal to the dollar amount
4 under subparagraph (A) of this paragraph for self-only coverage for plan
5 years beginning in two thousand fourteen, increased by an amount equal
6 to the product of that amount and the premium adjustment percentage
7 under paragraph three of this subsection for the calendar year; and
8 (ii) in the case of other coverage, twice the amount in effect under
9 clause (i) of this subparagraph. If the amount of any increase under
10 clause (i) of this subparagraph is not a multiple of fifty dollars, such
11 increase shall be rounded to the next lowest multiple of fifty dollars.
12 (2) (A) The term "cost-sharing" shall include:
13 (i) deductibles, coinsurance, copayments, or similar charges; and
14 (ii) any other expenditure required of an insured individual which is
15 a qualified medical expense with respect to essential health benefits
16 covered under the plan.
17 (B) Such term does not include premiums, balance billing amounts for
18 non-network providers, or spending for non-covered services.
19 (3) For purposes of clause (i) of subparagraph (B) of paragraph one of
20 this subsection, the premium adjustment percentage for any calendar year
21 is the percentage, if any, by which the average per capita premium for
22 health insurance coverage in the United States for the preceding calen-
23 dar year exceeds such average per capita premium for the year two thou-
24 sand thirteen.
25 (e) Levels of coverage. (1) Levels of coverage described in this
26 subsection are as follows:
27 (A) Bronze level. A plan in the bronze level shall provide a level of
28 coverage that is designed to provide benefits that are actuarially
29 equivalent to sixty percent of the full actuarial value of the benefits
30 provided under the plan.
31 (B) Silver level. A plan in the silver level shall provide a level of
32 coverage that is designed to provide benefits that are actuarially
33 equivalent to seventy percent of the full actuarial value of the bene-
34 fits provided under the plan.
35 (C) Gold level. A plan in the gold level shall provide a level of
36 coverage that is designed to provide benefits that are actuarially
37 equivalent to eighty percent of the full actuarial value of the benefits
38 provided under the plan.
39 (D) Platinum level. A plan in the platinum level shall provide a level
40 of coverage that is designed to provide benefits that are actuarially
41 equivalent to ninety percent of the full actuarial value of the benefits
42 provided under the plan.
43 (2) (A) Actuarial value. Under regulations issued by the superinten-
44 dent, the level of coverage of a plan shall be determined on the basis
45 that the essential health benefits described in subsection (c) of this
46 section shall be provided to a standard population and without regard to
47 the population the plan may actually provide benefits to.
48 (B) Employer contributions. The superintendent shall issue regulations
49 under which employer contributions to a health savings account may be
50 taken into account.
51 § 3. Subsection (e) of section 3217-f of the insurance law, as added
52 by chapter 219 of the laws of 2011, is amended to read as follows:
53 (e) For purposes of this section, "essential health benefits" shall
54 have the same meaning [ascribed by section 1302(b) of the Affordable
55 Care Act, 42 U.S.C. § 18022(b)] as subsection (c) of section three thou-
56 sand two hundred seventeen-i of this article.
A. 11340 6
1 § 4. Subsection (h) and paragraph 19 of subsection (k) of section 3221
2 of the insurance law, subsection (h) as added by section 54 of part D of
3 chapter 56 of the laws of 2013 and paragraph 19 of subsection (k) as
4 amended by chapter 377 of the laws of 2014, are amended to read as
5 follows:
6 (h) Every small group policy or association group policy delivered or
7 issued for delivery in this state that provides coverage for hospital,
8 medical or surgical expense insurance and is not a grandfathered health
9 plan shall provide coverage for the essential health benefit package as
10 required in section [2707(a) of the public health service act, 42 U.S.C.
11 § 300gg-6(a)] three thousand two hundred seventeen-i of this article.
12 For purposes of this subsection:
13 (1) "essential health benefits package" shall have the meaning set
14 forth in [section 1302(a) of the affordable care act, 42 U.S.C. §
15 18022(a)] subsection (c) of section three thousand two hundred seven-
16 teen-i of this article;
17 (2) "grandfathered health plan" means coverage provided by an insurer
18 in which an individual was enrolled on March twenty-third, two thousand
19 ten for as long as the coverage maintains grandfathered status [in
20 accordance with section 1251(e) of the affordable care act, 42 U.S.C. §
21 18011(e)];
22 (3) "small group" means a group of fifty or fewer employees or members
23 exclusive of spouses and dependents; provided, however, that beginning
24 January first, two thousand sixteen, "small group" means a group of one
25 hundred or fewer employees or members exclusive of spouses and depen-
26 dents; and
27 (4) "association group" means a group defined in subparagraphs (B),
28 (D), (H), (K), (L) or (M) of paragraph one of subsection (c) of section
29 four thousand two hundred thirty-five of this chapter, provided that:
30 (A) the group includes one or more individual members; or
31 (B) the group includes one or more member employers or other member
32 groups that are small groups.
33 (19) Every group or blanket accident and health insurance policy
34 delivered or issued for delivery in this state which provides medical
35 coverage that includes coverage for physician services in a physician's
36 office and every policy which provides major medical or similar compre-
37 hensive-type coverage shall include coverage for equipment and supplies
38 used for the treatment of ostomies, if prescribed by a physician or
39 other licensed health care provider legally authorized to prescribe
40 under title eight of the education law. Such coverage shall be subject
41 to annual deductibles and coinsurance as deemed appropriate by the
42 superintendent. The coverage required by this paragraph shall be identi-
43 cal to, and shall not enhance or increase the coverage required as part
44 of essential health benefits [as required pursuant to section 2707 (a)
45 of the public health services act 42 U.S.C. 300 gg-6(a)] set forth in
46 section three thousand two hundred seventeen-i of this article.
47 § 5. Subsection (d) of section 3240 of the insurance law, as added by
48 section 41 of part D of chapter 56 of the laws of 2013, is amended to
49 read as follows:
50 (d) A student accident and health insurance policy or contract shall
51 provide coverage for essential health benefits as defined in [section
52 1302(b) of the affordable care act, 42 U.S.C. § 18022(b)] subsection (c)
53 of section three thousand two hundred seventeen-i of this article.
54 § 6. Subsection (u-1) of section 4303 of the insurance law, as amended
55 by chapter 377 of the laws of 2014, is amended to read as follows:
A. 11340 7
1 (u-1) A medical expense indemnity corporation or a health service
2 corporation which provides medical coverage that includes coverage for
3 physician services in a physician's office and every policy which
4 provides major medical or similar comprehensive-type coverage shall
5 include coverage for equipment and supplies used for the treatment of
6 ostomies, if prescribed by a physician or other licensed health care
7 provider legally authorized to prescribe under title eight of the educa-
8 tion law. Such coverage shall be subject to annual deductibles and coin-
9 surance as deemed appropriate by the superintendent. The coverage
10 required by this subsection shall be identical to, and shall not enhance
11 or increase the coverage required as part of essential health benefits
12 as required pursuant to section [2707(a) of the public health services
13 act 42 U.S.C. 300 gg-6(a)] four thousand three hundred six-h of this
14 article.
15 § 7. Subsection (e) of section 4306-e of the insurance law, as added
16 by chapter 219 of the laws of 2011, is amended to read as follows:
17 (e) For purposes of this section, "essential health benefits" shall
18 have the meaning ascribed by [section 1302(b) of the Affordable Care
19 Act, 42 U.S.C. § 18022(b)] subsection (c) of section four thousand three
20 hundred six-h of this article.
21 § 8. Subsections (d) and (e) of section 4326 of the insurance law, as
22 amended by section 56 of part D of chapter 56 of the laws of 2013, are
23 amended to read as follows:
24 (d) A qualifying group health insurance contract shall provide cover-
25 age for the essential health benefit package as required [in section
26 2707(a) of the public health service act, 42 U.S.C. § 300gg-6(a)] by
27 section four thousand three hundred six-h of this article. For purposes
28 of this subsection "essential health benefits package" shall have the
29 meaning set forth in [section 1302(a) of the affordable care act, 42
30 U.S.C. § 18022(a)] subsection (c) of section four thousand three hundred
31 six-h of this article.
32 (e) A qualifying group health insurance contract issued to a qualify-
33 ing small employer prior to January first, two thousand fourteen that
34 does not include all essential health benefits required pursuant to
35 section [2707(a) of the public health service act, 42 U.S.C. §
36 300gg-6(a)] four thousand three hundred six-h of this article, shall be
37 discontinued, including grandfathered health plans. For the purposes of
38 this paragraph, "grandfathered health plans" means coverage provided by
39 a corporation to individuals who were enrolled on March twenty-third,
40 two thousand ten for as long as the coverage maintains grandfathered
41 status [in accordance with section 1251(e) of the affordable care act,42 42 U.S.C. § 18011(e)]. A qualifying small employer shall be transitioned
43 to a plan that provides: (1) a level of coverage that is designed to
44 provide benefits that are actuarially equivalent to eighty percent of
45 the full actuarial value of the benefits provided under the plan; and
46 (2) coverage for the essential health benefit package as required in
47 section [2707(a) of the public health service act, 42 U.S.C. §
48 300gg-6(a)] four thousand three hundred six-h of this article. The
49 superintendent shall standardize the benefit package and cost sharing
50 requirements of qualified group health insurance contracts consistent
51 with coverage offered through the health benefit exchange [established
52 pursuant to section 1311 of the affordable care act, 42 U.S.C. § 18031].
53 § 9. Paragraph 1 of subsection (b) of section 4328 of the insurance
54 law, as added by section 46 of part D of chapter 56 of the laws of 2013,
55 is amended to read as follows:
A. 11340 8
1 (1) The individual enrollee direct payment contract offered pursuant
2 to this section shall provide coverage for the essential health benefit
3 package as required in section [2707(a) of the public health service
4 act, 42 U.S.C. § 300gg-6(a)] four thousand three hundred six-h of this
5 article. For purposes of this paragraph, "essential health benefits
6 package" shall have the meaning set forth in [section 1302(a) of the
7 affordable care act, 42 U.S.C. § 18022(a)] subsection (c) of section
8 four thousand three hundred six-h of this article.
9 § 10. Paragraphs (f) and (g) of section 3232 of the insurance law, as
10 added by chapter 219 of the laws of 2011, are amended and a new para-
11 graph (j) is added to read as follows:
12 (f) With respect to an individual under age nineteen, an insurer may
13 not impose any pre-existing condition exclusion in an individual or
14 group policy of hospital, medical, surgical or prescription drug expense
15 insurance [pursuant to the requirements of section 2704 of the Public
16 Health Service Act, 42 U.S.C. § 300gg-3, as made effective by section
17 1255(2) of the Affordable Care Act,] except for an individual under age
18 nineteen covered under an individual policy of hospital, medical, surgi-
19 cal or prescription drug expense insurance that is a grandfathered
20 health plan.
21 (g) Beginning January first, two thousand fourteen[, pursuant to
22 section 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3,] an
23 insurer may not impose any pre-existing condition exclusion in an indi-
24 vidual or group policy of hospital, medical, surgical or prescription
25 drug expense insurance except in an individual policy that is a grandfa-
26 thered health plan.
27 (j) For purposes of subsections (f) and (g) of this section, "pre-ex-
28 isting condition" shall mean a limitation or exclusion of benefits
29 relating to a condition based on the fact that the condition was present
30 before the date of enrollment for such coverage, whether or not any
31 medical advice, diagnosis, care, or treatment was recommended or
32 received before such date.
33 § 11. Subsections (f) and (g) of section 4318 of the insurance law, as
34 added by chapter 219 of the laws of 2011, are amended and a new
35 subsection (j) is added to read as follows:
36 (f) With respect to an individual under age nineteen, a corporation
37 may not impose any pre-existing condition exclusion in an individual or
38 group contract of hospital, medical, surgical or prescription drug
39 expense insurance pursuant to the requirements of section [2704 of the
40 Public Health Service Act, 42 U.S.C. § 300gg-3, as made effective by
41 section 1255(2) of the Affordable Care Act] four thousand three hundred
42 six-h of this article, except for an individual under age nineteen
43 covered under an individual contract of hospital, medical, surgical or
44 prescription drug expense insurance that is a grandfathered health plan.
45 (g) Beginning January first, two thousand fourteen, pursuant to
46 section [2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3]
47 four thousand three hundred six-h of this article, a corporation may not
48 impose any pre-existing condition exclusion in an individual or group
49 contract of hospital, medical, surgical or prescription drug expense
50 insurance except in an individual contract that is a grandfathered
51 health plan.
52 (j) For purposes of subsections (f) and (g) of this section, "pre-ex-
53 isting exclusion" shall mean a limitation or exclusion of benefits
54 relating to a condition based on the fact that the condition was present
55 before the date of enrollment for such coverage, whether or not any
A. 11340 9
1 medical advice, diagnosis, care, or treatment was recommended or
2 received before such date.
3 § 12. This act shall take effect on such date as the affordable care
4 act is fully repealed and at such time as the provisions of such act are
5 no longer in force and effect; provided that the superintendent of
6 financial services shall notify the legislative bill drafting commission
7 upon the occurrence of the repeal of the federal Affordable Care Act in
8 order that the commission may maintain an accurate and timely effective
9 data base of the official text of the laws of the state of New York in
10 furtherance of effectuating the provisions of section 44 of the legisla-
11 tive law and section 70-b of the public officers law.
