A09539 Summary:
BILL NO | A09539 |
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SAME AS | SAME AS S08957 |
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SPONSOR | Eichenstein |
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COSPNSR | Weprin, Gallagher |
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MLTSPNSR | |
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Amd 3216, 3221 & 4303, Ins L; add 4406-j, Pub Health L | |
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Requires insurers to provide insurance coverage for treatment of rare diseases, life-threatening conditions or diseases, degenerative and disabling conditions, or diagnoses involving medically fragile children, by a provider of the patient's choice. |
A09539 Actions:
BILL NO | A09539 | |||||||||||||||||||||||||||||||||||||||||||||||||
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03/20/2024 | referred to insurance | |||||||||||||||||||||||||||||||||||||||||||||||||
05/22/2024 | reported referred to rules | |||||||||||||||||||||||||||||||||||||||||||||||||
06/07/2024 | reported | |||||||||||||||||||||||||||||||||||||||||||||||||
06/07/2024 | rules report cal.575 | |||||||||||||||||||||||||||||||||||||||||||||||||
06/07/2024 | ordered to third reading rules cal.575 |
A09539 Memo:
Go to topNEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)   BILL NUMBER: A9539 SPONSOR: Eichenstein
  TITLE OF BILL: An act to amend the insurance law and the public health law, in relation to providing insurance coverage for rare diseases, life-threatening conditions or diseases, degenerative and disabling conditions, or diag- noses involving medically fragile children   PURPOSE: To require insurance coverage in certain instances for rare diseases, life-threatening conditions or diseases, degenerative and disabling conditions or diagnoses involving medically fragile children.   SUMMARY OF PROVISIONS: Sections one through three amend various sections of the insurance law to require insurance coverage for above referenced conditions by out of network providers if (i) costs are equal or less than in network, and there is no cost for traveling,(ii) advanced notice is provided to the patient's network plan, and (iii) the chosen provider is specialized in the area of treatment. Section four provides for conforming changes to the public health law to include health maintenance organizations in the requirements for treat- ing the conditions covered by the insurance law. Section five provides for an effective date of ninety days from enact- ment.   JUSTIFICATION: Individuals who are diagnosed with rare diseases, life threatening or life altering diseases, or are deemed medically fragile children are already undergoing enormous amounts of stress without having to consider who they are going to seek medical care from. Their focus should instead be on who is going to provide them with the best chance of survival or success from their diagnosis. This should also be the policy of the State. No one should be told that there is a better more qualified specialist available at the same cost, but they cannot see them because they are arbitrarily either in or out of network. This legislation is intended to offer individuals confronted with rare or life altering circumstances the ability to choose the best treatment option for them. These changes also take into account mandates on the insurance plans by controlling costs, providing notice, and ensuring the chosen provider is a qualified specialist. Individuals who find them- selves in these daunting circumstances should have the ability to explore options, even if those are out of network in order to provide them with the greatest chance of a positive outcome.   LEGISLATIVE HISTORY: New bill.   LEGISLATIVE HISTORY:   FISCAL IMPLICATIONS FOR STATE AND LOCAL GOVERNMENTS: None to the State.   EFFECTIVE DATE: Ninety days after it shall have become law.
A09539 Text:
Go to top STATE OF NEW YORK ________________________________________________________________________ 9539 IN ASSEMBLY March 20, 2024 ___________ Introduced by M. of A. EICHENSTEIN -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law and the public health law, in relation to providing insurance coverage for rare diseases, life-threatening conditions or diseases, degenerative and disabling conditions, or diagnoses involving medically fragile children 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) (A) Every policy which provides hospital, surgical, medical or 4 major medical coverage shall provide coverage for medically necessary 5 services from a chosen provider for a confirmed diagnosis that is deemed 6 to be a rare disease, life-threatening condition or disease, degenera- 7 tive and disabling condition, or involves a medically fragile child, 8 with no restriction to a plan network, if the following conditions are 9 met: 10 (i) (A) The costs of the chosen provider are equal to or less than the 11 average cost that would have otherwise been paid to a local network 12 provider who possesses a similar subspecialty as such chosen provider; 13 and 14 (B) the patient's treating specialist or primary care provider 15 provides a written statement to recommend the chosen provider for the 16 particular disease. 17 (ii) The chosen provider or the patient's primary care physician 18 provides advance notice to such patient's network plan prior to a 19 planned procedure covered pursuant to this paragraph. 20 (iii) The chosen provider is accredited or designated by the depart- 21 ment of health, the federal government, or a voluntary national health 22 organization as having special expertise in treating, or has demon- 23 strated a clinical focus in the area of, the confirmed diagnosis for 24 which coverage is sought pursuant to this paragraph. Provided however, 25 that nothing in this paragraph shall require such chosen provider to be 26 participating in the patient's network or located within the state; EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD14125-05-4A. 9539 2 1 provided further that nothing herein shall obligate to cover cost 2 related to travel to the chosen provider. 3 (B) For the purposes of this paragraph, the following terms shall have 4 the following meanings: 5 (i) "Rare disease" shall have the same meaning as set forth in subdi- 6 vision seven-g of section forty-nine hundred of the public health law. 7 (ii) "Life-threatening condition or disease" shall have the same mean- 8 ing as set forth in subdivision seven-a of section forty-nine hundred of 9 the public health law. 10 (iii) "Degenerative and disabling condition" shall mean a condition or 11 disease which (a) requires specialized medical care over a prolonged 12 period of time, or (b) qualifies the patient as a disabled person, as 13 defined by subdivision five of section two hundred eight of the social 14 services law. 15 (iv) "Medically fragile child" shall have the same meaning as set 16 forth in subdivision nine of section forty-four hundred one of the 17 public health law. 18 § 2. Subsection (k) of section 3221 of the insurance law is amended by 19 adding a new paragraph 23 to read as follows: 20 (23) (A) Every policy which provides hospital, surgical, medical or 21 major medical coverage shall provide coverage for medically necessary 22 services from a chosen provider for a confirmed diagnosis that is deemed 23 to be a rare disease, life-threatening condition or disease, degenera- 24 tive and disabling condition, or involves a medically fragile child, 25 with no restriction to a plan network, if the following conditions are 26 met: 27 (i) (I) The costs of the chosen provider are equal to or less than the 28 average cost that would have otherwise been paid to a local network 29 provider who possesses a similar subspecialty as such chosen provider; 30 and 31 (II) the patient's treating specialist or primary care provider 32 provides a written statement to recommend the chosen provider for the 33 particular disease. 34 (ii) The chosen provider or the patient's primary care physician 35 provides advance notice to such patient's network plan prior to a 36 planned procedure covered pursuant to this paragraph. 37 (iii) The chosen provider is accredited or designated by the depart- 38 ment of health, the federal government, or a voluntary national health 39 organization as having special expertise in treating, or has demon- 40 strated a clinical focus in the area of, the confirmed diagnosis for 41 which coverage is sought pursuant to this paragraph. Provided however, 42 that nothing in this paragraph shall require such chosen provider to be 43 participating in the patient's network or located within the state; 44 provided further that nothing herein shall obligate to cover cost 45 related to travel to the chosen provider. 46 (B) For the purposes of this paragraph, the following terms shall have 47 the following meanings: 48 (i) "Rare disease" shall have the same meaning as set forth in subdi- 49 vision seven-g of section forty-nine hundred of the public health law. 50 (ii) "Life-threatening condition or disease" shall have the same mean- 51 ing as set forth in subdivision seven-a of section forty-nine hundred of 52 the public health law. 53 (iii) "Degenerative and disabling condition" shall mean a condition or 54 disease which (a) requires specialized medical care over a prolonged 55 period of time, or (b) qualifies the patient as a disabled person, asA. 9539 3 1 defined by subdivision five of section two hundred eight of the social 2 services law. 3 (iv) "Medically fragile child" shall have the same meaning as set 4 forth in subdivision nine of section forty-four hundred one of the 5 public health law. 6 § 3. Section 4303 of the insurance law is amended by adding a new 7 subsection (vv) to read as follows: 8 (vv) (1) Every policy which provides hospital, surgical, medical or 9 major medical coverage shall provide coverage for medically necessary 10 services from a chosen provider for a confirmed diagnosis that is deemed 11 to be a rare disease, life-threatening condition or disease, degenera- 12 tive and disabling condition, or involves a medically fragile child, 13 with no restriction to a plan network, if the following conditions are 14 met: 15 (A) (i) The costs of the chosen provider are equal to or less than the 16 average cost that would have otherwise been paid to a local network 17 provider who possesses a similar subspecialty as such chosen provider; 18 and 19 (ii) the patient's treating specialist or primary care provider 20 provides a written statement to recommend the chosen provider for the 21 particular disease. 22 (B) The chosen provider or the patient's primary care physician 23 provides advance notice to such patient's network plan prior to a 24 planned procedure covered pursuant to this subsection. 25 (C) The chosen provider is accredited or designated by the department 26 of health, the federal government, or a voluntary national health organ- 27 ization as having special expertise in treating, or has demonstrated a 28 clinical focus in the area of, the confirmed diagnosis for which cover- 29 age is sought pursuant to this subsection. Provided however, that noth- 30 ing in this subsection shall require such chosen provider to be partic- 31 ipating in the patient's network or located within the state; provided 32 further that nothing herein shall obligate to cover cost related to 33 travel to the chosen provider. 34 (2) For the purposes of this subsection, the following terms shall 35 have the following meanings: 36 (A) "Rare disease" shall have the same meaning as set forth in subdi- 37 vision seven-g of section forty-nine hundred of the public health law. 38 (B) "Life-threatening condition or disease" shall have the same mean- 39 ing as set forth in subdivision seven-a of section forty-nine hundred of 40 the public health law. 41 (C) "Degenerative and disabling condition" shall mean a condition or 42 disease which (i) requires specialized medical care over a prolonged 43 period of time, or (ii) qualifies the patient as a disabled person, as 44 defined by subdivision five of section two hundred eight of the social 45 services law. 46 (D) "Medically fragile child" shall have the same meaning as set forth 47 in subdivision nine of section forty-four hundred one of the public 48 health law. 49 § 4. The public health law is amended by adding a new section 4406-j 50 to read as follows: 51 § 4406-j. Extraordinary out-of-network coverage. No health maintenance 52 organization subject to this article shall, by contract, written policy, 53 or procedure, limit a patient enrollee's direct access to services from 54 a chosen provider for a rare disease, life-threatening condition or 55 disease, degenerative and disabling condition, or diagnosis involving a 56 medically fragile child if such services are covered pursuant to para-A. 9539 4 1 graph thirty-nine of subsection (i) of section three thousand sixteen of 2 the insurance law, paragraph twenty-three of subsection (k) of section 3 three thousand two hundred twenty-one of the insurance law, or 4 subsection (vv) of section four thousand three hundred three of the 5 insurance law; provided, however, that such patient enrollee's access to 6 such services are otherwise subject to the terms and conditions of the 7 plan under which such patient enrollee is covered. 8 § 5. This act shall take effect on the ninetieth day after it shall 9 have become a law and shall apply to all insurance policies and 10 contracts issued, renewed, modified, altered, or amended on or after 11 such effective date.