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
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5943--A
2015-2016 Regular Sessions
IN SENATE
June 12, 2015
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Introduced by Sens. ORTT, ADDABBO -- read twice and ordered printed, and
when printed to be committed to the Committee on Rules -- recommitted
to the Committee on Insurance in accordance with Senate Rule 6, sec. 8
-- committee discharged, bill amended, ordered reprinted as amended
and recommitted to said committee
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 33 to read as follows:
3 (33) 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 medially 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 in 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
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD11641-02-6
S. 5943--A 2
1 not enhance or increase the essential health benefit coverage chosen by
2 the state pursuant to 45 CFR 156.100. Nothing in this paragraph shall be
3 construed to prevent the medical management or utilization review of
4 benefits for medically necessary rehabilitative and habilitative
5 purposes.
6 § 2. Subsection (l) of section 3221 of the insurance law is amended by
7 adding a new paragraph 19 to read as follows:
8 (19) Every policy which provides medical, major medical, or similar
9 comprehensive type coverage to a policyholder shall provide coverage for
10 prosthetic devices that are intended for medically necessary rehabilita-
11 tive and habilitative purposes as required by 42 U.S.C. § 18022. Cover-
12 age shall include the cost of repair or replacement of prosthetic
13 devices due to normal wear and tear, if a prosthetic device has been
14 outgrown or no longer fits properly, or where a change in the medical
15 condition makes replacement necessary. Coverage shall not include the
16 costs of repair or replacement of a prosthetic device that is covered
17 under the warranty of the manufacturer or when the repair or replacement
18 is necessary due to misuse or negligence. The term "prosthetic device"
19 as used in this paragraph includes an artificial limb, but shall not
20 include shoes or any other article considered as ordinary wearing
21 apparel, whether or not specifically constructed. The term "policyhold-
22 er" as used in this paragraph shall mean a veteran of the armed forces
23 who resides in the state of New York and whose medical need for such
24 prosthetic device resulted from an injury suffered while on active duty
25 serving in the armed forces. Such coverage shall be subject to annual
26 deductibles and coinsurance as deeded appropriate by the superintendent.
27 The coverage required by this paragraph shall be identical to, and shall
28 not enhance or increase the essential health benefit coverage chosen by
29 the state pursuant to 45 CFR 156.100. Nothing in this paragraph shall be
30 construed to prevent the medical management or utilization review of
31 benefits for medically necessary rehabilitative and habilitative
32 purposes.
33 § 3. Section 4303 of the insurance law is amended by adding a new
34 subsection (qq) to read as follows:
35 (qq) Every policy which provides medical, major medical, or similar
36 comprehensive type coverage to a policyholder shall provide coverage for
37 prosthetic devices that are intended for medically necessary rehabilita-
38 tive and habilitative purposes as required by 42 U.S.C. § 18022. Cover-
39 age shall include the cost of repair or replacement of prosthetic
40 devices due to normal wear and tear, if a prosthetic device has been
41 outgrown or no longer fits properly, or where a change in the medical
42 condition makes replacement necessary. Coverage shall not include the
43 costs of repair or replacement of a prosthetic device that is covered
44 under the warranty of the manufacturer or when the repair or replacement
45 is necessary due to misuse or negligence. The term "prosthetic device"
46 as used in this subsection includes an artificial limb, but shall not
47 include shoes or any other article considered as ordinary wearing
48 apparel, whether or not specifically constructed. The term "policyhold-
49 er" as used in this subsection shall mean a veteran of the armed forces
50 who resides in the state of New York and whose medical need for such
51 prosthetic device resulted from an injury suffered while on active duty
52 serving in the armed forces. Such coverage shall be subject to annual
53 deductibles and coinsurance as deemed appropriate by the superintendent.
54 The coverage required by this subsection shall be identical to, and
55 shall not enhance or increase the essential health benefit coverage
56 chosen by the state pursuant to 45 CFR 156.100. Nothing in this
S. 5943--A 3
1 subsection shall be construed to prevent the medical management or
2 utilization review of benefits for medically necessary rehabilitation
3 and habilitation purpose.
4 § 4. This act shall take effect January 1, 2017 and shall apply to
5 policies and contracts issued, renewed, modified, altered or amended on
6 or after such effective date.