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A09539 Summary:

BILL NOA09539
 
SAME ASSAME AS S08957
 
SPONSOREichenstein
 
COSPNSRWeprin, Gallagher
 
MLTSPNSR
 
Amd 3216, 3221 & 4303, Ins L; add 4406-j, Pub Health L
 
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.
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A09539 Memo:

NEW 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.
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A09539 Text:



 
                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.
                                                                   LBD14125-05-4

        A. 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,  as

        A. 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.
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