NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A7793
SPONSOR: Simon (MS)
 
TITLE OF BILL:
An act to amend the insurance law, in relation to enacting the "Give
Kids a Chance - Carter's Law" mandating health insurance coverage for
congenital anomalies
 
PURPOSE:
To require coverage for medical and dental treatments as well as rehabi-
litative therapies (physical, speech, occupational, etc.) to address
conditions or illness related to or developed as a result of a congen-
ital anomaly.
 
SUMMARY OF PROVISIONS:
Section 1. Adds 5 new paragraphs 5, 6, 7, 8 and 9 to subsection (a) of
3216 of the insurance law to require every policy that provides coverage
for hospital, surgical, or medical care to provide coverage for the
assessment, evaluation, treatment, management, and follow-up care of
congenital abnormalities. Such.,coverage shall not be denied on the
grounds that it is for cosmetic purposes or is not for -a functional
defect or impairment.
Section 2. Paragraph 4 of Subsection (C) of section § 3216 of the insur-
ance law is amended by adding a new subparagraph (D).
Section 3. Adds a new paragraph 5 to subsection (F) of § 4235 of the
insurance law to require every group or blanket policy that provides
coverage for hospital, surgical or medical care to provide coverage for
hospital, surgical, or medical care to provide coverage for the assess-
ment, evaluation, treatment, management, and follow-up care of congen-
ital abnormalities. Such coverage shall not be denied on the grounds
that it is for cosmetic purposes or is not for a functional defect or
impairment.
Section 4. Adds a new subsection (d) to § 4304 of the insurance law to
require every medical expense indemnity corporation, hospital service
corporation or health service corporation that provides coverage for
hospital, surgical or medical care to provide coverage for the assess-
ment, evaluation, treatment, management, and follow-up care of congen-
ital abnormalities. Such coverage shall not be denied on the grounds
that it is for cosmetic purposes or is not for a functional defect or
impaiLwent.
Section 5. Paragraph 1 of subsection (c) of section § 4305 is amended by
adding a new subparagraph (d)
Section 6. Sets forth the effective date.
 
JUSTIFICATION:
For every 38 babies born in New York State one is diagnosed with a
congenital anomaly. There are a variety of different congenital anoma-
lies New York's children are born with, ranging from atrial septal
defect with 11,316 cases annually to trisomy 21 with 2,790 cases annual-
ly.
Two of the most commonly recognized congenital anomalies are cleft lip
and cleft palate. A child would be:diagnosed with cleft lip and/or cleft
palate where the child is born with 'an Unclosed lip and/or with an
unclosed roof of the mouth. Basically, there is a gap in facial struc-
ture due to incomplete fusion of skin, muscle and bone. This defect
occurs during fetal development. Uncorrected, the defect causes severe
eating, breathing, speaking and hearing difficulties and presents gross
facial deformities.
With appropriate surgical treatment, bone grafts, orthodontic, prostho-
dontic and dental treatment as well as,Speech, physical and occupational
therapies, individuals can gain nearly full function and approximate
normal facial appearance. There is currently no New York State require-
ment for full coverage (medical, dental and related therapies) for cleft
lip, cleft palate or any other congenital anomaly. Currently, health
insurance coverage varies by insurer both as to what is offered and as
to how coverage is applied when covering costs related to congenital
anomalies. While initial surgeries to close the structural gap for cleft
lip and/or cleft palate are often covered, subsequent surgeries, bone
grafts, follow up treatment and orthodontic, prosthodontic and related
care are often not covered at all, are severely restricted in coverage
or are subject to individual negotiation or confrontation with insurers.
This lack of coverage consistency is the same when dealing with other
congenital anomalies. For example, .a,6 month old male with sagittal
craniosynostosis (premature closing, of a baby's skull) who had to wear
a prescribed helmet to protect post-operative treatment was denied
coverage for a second helmet as he continued to grow.
New York law should be clear, comprehensive and consistent. This is a
matter of fairness to the citizens of New York. Children should be
covered for all procedures and therapies from infancy until they are no
longer eligible to be covered on their parents' health "insurance.
Correcting this gap in insurance coverage would provide a prudent
investment in our most important resource: our children. Passage of the
bill would also provide equity to insurers who are now forced to compete
with each other on a field Where they are forced to guess how their
competitors will apply coverage for congenital anomalies.
Other states currently mandate comprehensive coverage for all congenital
defects diagnosed by a doctor among them, Louisiana, Colorado, New Hamp-
shire, Indiana, and North Carolina have laws specifically requiring
comprehensive coverage for any Congenital anomaly. New York should join
these states and make sure everyone receives comprehensive coverage.
 
LEGISLATIVE HISTORY:
2021-22: A1943 Simon S24 Kaplan -referred to insurance
2020: A.8890 Simon S.7709 Kaplan -referred to insurance
 
FISCAL IMPLICATIONS:
None
 
LOCAL FISCAL IMPLICATIONS:
None
 
EFFECTIVE DATE:
this act shall take effect on the first of January next succeeding the
date on which it shall have become a law and shall apply to all policies
and contracts issued, renewed, modified, altered, or amended on or after
such date.