Requires mandatory health insurance coverage for prosthetic devices; requires coverage where the model is determined to be medically necessary for rehabilitative and habilitative purposes.
STATE OF NEW YORK
________________________________________________________________________
1315
2023-2024 Regular Sessions
IN SENATE
January 11, 2023
___________
Introduced by Sen. ORTT -- read twice and ordered printed, and when
printed to be committed to the Committee on Insurance
AN ACT to amend the insurance law, in relation to mandatory health
insurance coverage for providing prosthetic devices
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 39 to read as follows:
3 (39) Every policy which provides medical, major medical, or similar
4 comprehensive type coverage to a policyholder shall provide coverage for
5 prosthetic devices that are intended for medically necessary rehabilita-
6 tive and habilitative purposes as required by 42 U.S.C. § 18022. Cover-
7 age shall include the cost of repair or replacement of prosthetic
8 devices due to normal wear and tear, if a prosthetic device has been
9 outgrown or no longer fits properly, or where a change in the medical
10 condition makes replacement necessary. Coverage shall not include the
11 costs of repair or replacement of a prosthetic device that is covered
12 under the warranty of the manufacture or when the repair or replacement
13 is necessary due to misuse or negligence. The term "prosthetic device"
14 as used in this paragraph includes an artificial limb, but shall not
15 include shoes or any other article considered as ordinary wearing
16 apparel, whether or not specifically constructed. The term "policyhold-
17 er" as used in this paragraph shall mean a veteran of the armed forces
18 who resides in the state of New York and whose medical need for such
19 prosthetic device resulted from an injury suffered while on active duty
20 serving in the armed forces. Such coverage shall be subject to annual
21 deductibles and coinsurance as deemed appropriate by the superintendent.
22 The coverage required by this paragraph shall be identical to, and shall
23 not enhance or increase the essential health benefit coverage chosen by
24 the state pursuant to 45 CFR 156.100. Nothing in this paragraph shall be
25 construed to prevent the medical management or utilization review of
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD05098-01-3
S. 1315 2
1 benefits for medically necessary rehabilitative and habilitative
2 purposes.
3 §2. Subsection (l) of section 3221 of the insurance law is amended by
4 adding a new paragraph 22 to read as follows:
5 (22) Every policy which provides medical, major medical, or similar
6 comprehensive type coverage to a policyholder shall provide coverage for
7 prosthetic devices that are intended for medically necessary rehabilita-
8 tive and habilitative purposes as required by 42 U.S.C. § 18022. Cover-
9 age shall include the cost of repair or replacement of prosthetic
10 devices due to normal wear and tear, if a prosthetic device has been
11 outgrown or no longer fits properly, or where a change in the medical
12 condition makes replacement necessary. Coverage shall not include the
13 costs of repair or replacement of a prosthetic device that is covered
14 under the warranty of the manufacturer or when the repair or replacement
15 is necessary due to misuse or negligence. The term "prosthetic device"
16 as used in this paragraph includes an artificial limb, but shall not
17 include shoes or any other article considered as ordinary wearing
18 apparel, whether or not specifically constructed. The term "policyhold-
19 er" as used in this paragraph shall mean a veteran of the armed forces
20 who resides in the state of New York and whose medical need for such
21 prosthetic device resulted from an injury suffered while on active duty
22 serving in the armed forces. Such coverage shall be subject to annual
23 deductibles and coinsurance as deemed appropriate by the superintendent.
24 The coverage required by this paragraph shall be identical to, and shall
25 not enhance or increase the essential health benefit coverage chosen by
26 the state pursuant to 45 CFR 156.100. Nothing in this paragraph shall be
27 construed to prevent the medical management or utilization review of
28 benefits for medically necessary rehabilitative and habilitative
29 purposes.
30 §3. Section 4303 of the insurance law is amended by adding a new
31 subsection (uu) to read as follows:
32 (uu) Every policy which provides medical, major medical, or similar
33 comprehensive type coverage to a policyholder shall provide coverage for
34 prosthetic devices that are intended for medically necessary rehabilita-
35 tive and habilitative purposes as required by 42 U.S.C. § 18022. Cover-
36 age shall include the cost of repair or replacement of prosthetic
37 devices due to normal wear and tear, if a prosthetic device has been
38 outgrown or no longer fits properly, or where a change in the medical
39 condition makes replacement necessary. Coverage shall not include the
40 costs of repair or replacement of a prosthetic device that is covered
41 under the warranty of the manufacturer or when the repair or replacement
42 is necessary due to misuse or negligence. The term "prosthetic device"
43 as used in this subsection includes an artificial limb, but shall not
44 include shoes or any other article considered as ordinary wearing
45 apparel, whether or not specifically constructed. The term "policyhold-
46 er" as used in this subsection shall mean a veteran of the armed forces
47 who resides in the state of New York and whose medical need for such
48 prosthetic device resulted from an injury suffered while on active duty
49 serving in the armed forces. Such coverage shall be subject to annual
50 deductibles and coinsurance as deemed appropriate by the superintendent.
51 The coverage required by this subsection shall be identical to, and
52 shall not enhance or increase the essential health benefit coverage
53 chosen by the state pursuant to 45 CFR 156.100. Nothing in this
54 subsection shall be construed to prevent the medical management or
55 utilization review of benefits for medically necessary rehabilitative
56 and habilitative purposes.
S. 1315 3
1 § 4. This act shall take effect on the one hundred eightieth day after
2 it shall have become a law and shall apply to policies and contracts
3 issued, renewed, modified, altered or amended on or after such effective
4 date.
