senate Bill S176

Provides that health insurance coverage may not deny reimbursements because the registered laboratory providing laboratory services has not been approved

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Bill Status


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed/Vetoed by Governor
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actions

  • 05 / Jan / 2011
    • REFERRED TO INSURANCE
  • 04 / Jan / 2012
    • REFERRED TO INSURANCE

Summary

Provides that health insurance coverage may not deny reimbursements because the registered laboratory providing laboratory services has not been approved by the insurer or other entity; provides that in such case the insured pays excess costs therefor above the covered benefit.

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Bill Details

Versions:
S176
Legislative Cycle:
2011-2012
Current Committee:
Senate Insurance
Law Section:
Insurance Law
Laws Affected:
Amd ยงยง3216, 3221, 4303, 4402, 4413 & 4301, Ins L
Versions Introduced in 2009-2010 Legislative Cycle:
S1053

Sponsor Memo

BILL NUMBER:S176

TITLE OF BILL:
An act
to amend the insurance law, in relation to health insurance coverage and
eligibility for employee benefits provided by employee welfare funds for
laboratory services

PURPOSE:
To prohibit the denial of health insurance coverage for
pharmaceuticals strictly because the registered pharmacy providing
the pharmaceutical products has not been approved by the health
insurance plan.

SUMMARY OF PROVISIONS:
Amends sections 3216, 3221, 4301, 4303, 4402 and 4413 of the New York
State Insurance Law to provide that health insurance coverage
providers may not deny reimbursements because the registered pharmacy
providing pharmaceutical products has not been approved by the
insurer or other entity.

This amendment would require individuals who select a pharmacy that is
not part of the insurer's panel to be responsible for paying any
differential between the benefits provided under the health care
insurance contract and the cost of the services selected. The fund,
employer or union would be precluded from denying eligibility for
reimbursement to any registered pharmacy which is willing to meet
minimum standard conditions per participation requirements of the fund.

JUSTIFICATION:
Individuals and families should not be denied the ability to obtain
services from a registered pharmacy of their choice simply on the
basis of their membership in the health insurance plan made available
to them. A personal choice is being taken away from an insured when
they are directed to only obtain services from a specified pharmacy
rather than to the pharmacist they have sought services from their
entire lives. The insured may be more comfortable with a pharmacist
that he/she has come to know and rely upon and who is familiar with
their health history. Further, limiting participating pharmacies is
particularly difficult for insureds living in rural areas who may
have to travel miles to a pharmacy and for the homebound.

This bill ensures that insureds will be able to access any registered
pharmacy that is willing to provide service in accordance with the
minimum criteria established by the health insurance contract.

This bill allows the insured freedom of choice and limits the financial
exposure of the insurer as well as that of an employee welfare fund to
the level of benefits agreed to between the bargaining agent of the
employee and the employer. The insurer would not be required to
provide the benefit to anyone that is not already insured, nor would
the insurer be required to reimburse pharmacies at a higher rate than
it reimburses participating providers. This bill would simply require
the insurer to reimburse any "duly registered pharmacy" of the
insured's choosing, instead of a limited number of pharmacies of the
insurance company's choosing.


LEGISLATIVE HISTORY:
S.1053/A.509D of 2009/2010; Referred to Senate Insurance Committee
S.48/A.6728 of 2007/2008; Referred to Senate Insurance Committee
S.19132/A.10403 of 2005/2006; Referred to Senate Insurance Committee
S.5878/A.4439 of 2003/2004; Referred to Senate Insurance Committee

FISCAL IMPLICATIONS: None.

EFFECTIVE DATE: Effective on January 1, next succeeding passage, and
shall apply to all policies and contracts issued, modified, altered or
amended thereafter.

view bill text
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                   176

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                               (PREFILED)

                             January 5, 2011
                               ___________

Introduced  by Sens. MAZIARZ, FLANAGAN, GOLDEN -- read twice and ordered
  printed, and when printed to be committed to the Committee  on  Insur-
  ance

AN  ACT  to  amend  the  insurance  law, in relation to health insurance
  coverage and eligibility for employee benefits  provided  by  employee
  welfare funds for laboratory services

  THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1. Subsection (i) of section 3216  of  the  insurance  law  is
amended by adding a new paragraph 28 to read as follows:
  (28)  NO  SUCH  POLICY  SHALL LIMIT BENEFITS OR DENY REIMBURSEMENT FOR
BENEFITS TO ANY INSURED ON THE BASIS THAT THE LABORATORY PROVIDING  SUCH
BENEFITS HAS NOT BEEN SPECIFICALLY SELECTED OR APPROVED. IF THE INSURED,
HIS  OR  HER  DEPENDENTS  OR  BOTH RECEIVE SERVICES FROM A LABORATORY OF
THEIR OWN CHOOSING, SUCH INSURED SHALL PAY THE COST OF  SUCH  LABORATORY
SERVICES  TO  THE  EXTENT  THAT  SUCH COST EXCEEDS THE BENEFITS PROVIDED
UNDER THE POLICY WITHOUT FORFEITURE OF THE BENEFITS PROVIDED UNDER  SUCH
POLICY.  NO SUCH POLICY SHALL PROHIBIT A DULY REGISTERED LABORATORY FROM
PROVIDING SERVICES, PROVIDED SUCH  LABORATORY  AGREES  TO  PROVIDE  SUCH
SERVICES  IN  ACCORDANCE  WITH  THE MINIMUM STANDARDS AND CONDITIONS FOR
SIMILAR PROVIDERS THAT HAVE BEEN ESTABLISHED BY SUCH POLICY.
  S 2. Subsection (e) of section 3221 of the insurance law is amended by
adding a new paragraph 12 to read as follows:
  (12) NO SUCH GROUP OR BLANKET POLICY  SHALL  LIMIT  BENEFITS  OR  DENY
REIMBURSEMENT  FOR BENEFITS TO ANY INSURED ON THE BASIS THAT THE LABORA-
TORY PROVIDING SUCH BENEFITS  HAS  NOT  BEEN  SPECIFICALLY  SELECTED  OR
APPROVED  BY  THE  GROUP  OR  BLANKET POLICY. IF THE INSURED, HIS OR HER
DEPENDENTS OR BOTH RECEIVE SERVICES  FROM  A  LABORATORY  OF  THEIR  OWN
CHOOSING, SUCH INSURED SHALL PAY THE COST OF SUCH LABORATORY SERVICES TO
THE  EXTENT THAT SUCH COST EXCEEDS THE BENEFITS PROVIDED UNDER THE GROUP

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01580-01-1

S. 176                              2

OR BLANKET POLICY WITHOUT FORFEITURE OF THE BENEFITS PROVIDED UNDER SUCH
GROUP OR BLANKET POLICY. NO SUCH GROUP OR BLANKET POLICY SHALL  PROHIBIT
A  DULY  REGISTERED  LABORATORY  FROM  PROVIDING SERVICES, PROVIDED SUCH
LABORATORY  AGREES TO PROVIDE SUCH SERVICES IN ACCORDANCE WITH THE MINI-
MUM STANDARDS AND CONDITIONS FOR SIMILAR PROVIDERS THAT HAVE BEEN ESTAB-
LISHED BY SUCH GROUP OR BLANKET POLICY.
  S 3. Section 4303 of the insurance law is  amended  by  adding  a  new
subsection (hh) to read as follows:
  (HH)  NO  SUCH  POLICY  ISSUED  BY A THIRD PARTY BENEFIT PROGRAM SHALL
LIMIT BENEFITS OR DENY REIMBURSEMENT FOR SERVICES TO ANY INSURED ON  THE
BASIS  THAT  THE LABORATORY PROVIDING SUCH BENEFITS HAS NOT BEEN SPECIF-
ICALLY SELECTED OR APPROVED BY THE THIRD PARTY BENEFIT PROGRAM.  IF  THE
INSURED, HIS OR HER DEPENDENTS OR BOTH RECEIVE SERVICES FROM A LABORATO-
RY OF THEIR OWN CHOOSING, SUCH INSURED SHALL PAY THE COST OF SUCH TREAT-
MENT  TO  THE  EXTENT THAT SUCH COST EXCEEDS THE BENEFITS PROVIDED UNDER
THE POLICY WITHOUT FORFEITURE OF THE BENEFITS PROVIDED UNDER SUCH  POLI-
CY. NO SUCH THIRD PARTY BENEFIT PROGRAM SHALL PROHIBIT A DULY REGISTERED
LABORATORY  FROM  PROVIDING SERVICES, PROVIDED SUCH LABORATORY AGREES TO
PROVIDE SERVICES IN ACCORDANCE WITH THE MINIMUM STANDARDS AND CONDITIONS
FOR SIMILAR PROVIDERS THAT HAVE BEEN ESTABLISHED  BY  SUCH  THIRD  PARTY
BENEFIT PROGRAM.
  S 4. Subsection (b) of section 4402 of the insurance law is amended to
read as follows:
  (b)  "Employee  benefits"  means  one or more benefits or services for
employees or their families or dependents, or for both,  including,  but
not  limited to, medical, surgical or hospital care or benefits PROVIDED
BY OR PERFORMED BY ANY LABORATORY, benefits in the  event  of  sickness,
accident, disability or death, benefits in the event of unemployment, or
retirement benefits.
  S 5. Subsection (b) of section 4413 of the insurance law is amended by
adding a new paragraph 1-a to read as follows:
  (1-A) NO SUCH FUND SHALL LIMIT EMPLOYEE BENEFITS OR DENY REIMBURSEMENT
FOR  EMPLOYEE  BENEFITS  TO  ANY ELIGIBLE EMPLOYEE ON THE BASIS THAT THE
LABORATORY PROVIDING SUCH BENEFITS HAS NOT BEEN SPECIFICALLY SELECTED OR
APPROVED BY THE WELFARE FUND, THE EMPLOYER  OR  THE  LABOR  ORGANIZATION
REPRESENTING  THE  EMPLOYEES ELIGIBLE FOR SUCH EMPLOYEE BENEFITS. IF THE
ELIGIBLE EMPLOYEE, HIS OR HER DEPENDENTS OR BOTH RECEIVE SERVICES FROM A
LABORATORY OF THEIR OWN CHOOSING, SUCH EMPLOYEE SHALL PAY  THE  COST  OF
SUCH  TREATMENT  TO  THE  EXTENT  THAT  SUCH  COST  EXCEEDS THE BENEFITS
PROVIDED UNDER THE PLAN WITHOUT  FORFEITURE  OF  THE  BENEFITS  PROVIDED
UNDER  SUCH  PLAN.    NO SUCH FUND, EMPLOYER OR LABOR ORGANIZATION SHALL
PROHIBIT A DULY REGISTERED LABORATORY FROM PROVIDING EMPLOYEE  BENEFITS,
PROVIDED  SUCH  LABORATORY AGREES TO PROVIDE SUCH SERVICES IN ACCORDANCE
WITH THE MINIMUM STANDARDS AND CONDITIONS  FOR  SIMILAR  PROVIDERS  THAT
HAVE BEEN ESTABLISHED BY SUCH FUND, EMPLOYER OR LABOR ORGANIZATION.
  S 6. Subsection (b) of section 4301 of the insurance law is amended by
adding a new paragraph 4 to read as follows:
  (4)  IF  A  CONTRACT  ISSUED BY A THIRD PARTY BENEFIT PROGRAM PROVIDES
BENEFITS FOR LABORATORY SERVICES, ANY LABORATORY WILLING TO  PARTICIPATE
UNDER  THE  TERMS  OF  THE  CONTRACT  SHALL  NOT BE DENIED ACCESS TO THE
PROVIDER PANEL.
  S 7. This act shall take effect on the first of January next  succeed-
ing  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 effective date.

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