Assembly Bill A213C

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

                                   213

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 7, 2009
                               ___________

Introduced by M. of A. MARKEY -- read once and referred to the Committee
  on Insurance

AN ACT to amend the insurance law, in relation to insurance coverage for
  out-of-network dialysis

  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 26 to read as follows:
  (26)(A)  EVERY  POLICY  THAT  INCLUDES COVERAGE FOR DIALYSIS TREATMENT
WHICH REQUIRES SUCH SERVICES TO BE PROVIDED BY  AN  IN-NETWORK  PROVIDER
SHALL  NOT  DENY  COVERAGE  BECAUSE  IT IS PROVIDED BY AN OUT-OF-NETWORK
PROVIDER DULY LICENSED TO PRACTICE AND AUTHORIZED TO PROVIDE SUCH TREAT-
MENT, PROVIDED THAT EACH OF THE FOLLOWING CONDITIONS ARE MET:
  (I) THE HEALTHCARE PROVIDER TREATING THE  INSURED  FOR  THE  CONDITION
ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT IN HIS OR HER
OPINION SUCH TREATMENT IS NECESSARY;
  (II) THE INSURED HAS NOTIFIED, IN WRITING, THE INSURER AT LEAST THIRTY
DAYS  IN  ADVANCE  OF  THE PROPOSED DATE OR DATES OF SUCH OUT-OF-NETWORK
DIALYSIS TREATMENT.  THE NOTICE SHALL INCLUDE THE AUTHORIZATION REQUIRED
BY CLAUSE (I) OF THIS SUBPARAGRAPH. IN THE EVENT THE INSURED MUST TRAVEL
ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMERGENCY, SHORTER NOTICE MAY BE
PERMITTED, PROVIDED THAT  THE  INSURER  HAS  REASONABLE  OPPORTUNITY  TO
REVIEW THE TRAVEL AND TREATMENT PLANS OF THE INSURED;
  (III)  THE  INSURER  SHALL  HAVE THE RIGHT TO PRE-APPROVE THE DIALYSIS
TREATMENT AND SCHEDULE; AND
  (IV) SUCH COVERAGE IS LIMITED TO NO GREATER THAN  FOUR  OUT-OF-NETWORK
REQUESTS NOT TO EXCEED FIFTEEN TREATMENTS IN A CALENDAR YEAR.
  (B)  NO  INSURER  SHALL  BE  OBLIGATED TO REIMBURSE THE OUT-OF-NETWORK
PROVIDER AT AN AMOUNT GREATER THAN IT  WOULD  HAVE  PAID  FOR  THE  SAME
TREATMENT  WITHIN  A  NETWORK,  AND  ANY AMOUNT CHARGED BY A PROVIDER IN

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

                                                           LBD00183-01-9

A. 213                              2

EXCESS OF THE AMOUNT REIMBURSED BY THE INSURER SHALL BE THE RESPONSIBIL-
ITY OF THE INSURED RECEIVING THE OUT-OF-NETWORK SERVICES.
  (C)  SUCH COVERAGE MAY BE SUBJECT TO OTHER TERMS AND CONDITIONS OF THE
POLICY, INCLUDING, BUT NOT LIMITED TO, UTILIZATION REVIEW, ANNUAL DEDUC-
TIBLES, COPAYMENTS, AND COINSURANCE AS ARE  DEEMED  APPROPRIATE  BY  THE
SUPERINTENDENT  AND  CONSISTENT  WITH  THOSE  REQUIRED FOR OTHER SIMILAR
BENEFITS UNDER THE POLICY.
  S 2. Subsection (k) of section 3221 of the insurance law is amended by
adding a new paragraph 15 to read as follows:
  (15)(A) EVERY GROUP OR BLANKET POLICY THAT INCLUDES COVERAGE FOR DIAL-
YSIS TREATMENT WHICH REQUIRES SUCH SERVICES TO BE PROVIDED BY AN IN-NET-
WORK PROVIDER SHALL NOT DENY COVERAGE BECAUSE IT IS PROVIDED BY AN  OUT-
OF-NETWORK  PROVIDER DULY LICENSED TO PRACTICE AND AUTHORIZED TO PROVIDE
SUCH TREATMENT, PROVIDED THAT EACH OF THE FOLLOWING CONDITIONS ARE MET:
  (I) THE HEALTHCARE PROVIDER TREATING THE  INSURED  FOR  THE  CONDITION
ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT IN HIS OR HER
OPINION SUCH TREATMENT IS NECESSARY;
  (II) THE INSURED HAS NOTIFIED, IN WRITING, THE INSURER AT LEAST THIRTY
DAYS  IN  ADVANCE  OF  THE PROPOSED DATE OR DATES OF SUCH OUT-OF-NETWORK
DIALYSIS TREATMENT.  THE NOTICE SHALL INCLUDE THE AUTHORIZATION REQUIRED
BY CLAUSE (I) OF THIS SUBPARAGRAPH. IN THE EVENT THE INSURED MUST TRAVEL
ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMERGENCY, SHORTER NOTICE MAY BE
PERMITTED, PROVIDED THAT  THE  INSURER  HAS  REASONABLE  OPPORTUNITY  TO
REVIEW THE TRAVEL AND TREATMENT PLANS OF THE INSURED;
  (III)  THE  INSURER  SHALL  HAVE THE RIGHT TO PRE-APPROVE THE DIALYSIS
TREATMENT AND SCHEDULE; AND
  (IV) SUCH COVERAGE IS LIMITED TO NO GREATER THAN  FOUR  OUT-OF-NETWORK
REQUESTS NOT TO EXCEED FIFTEEN TREATMENTS IN A CALENDAR YEAR.
  (B)  NO  INSURER  SHALL  BE  OBLIGATED TO REIMBURSE THE OUT-OF-NETWORK
PROVIDER AT AN AMOUNT GREATER THAN IT  WOULD  HAVE  PAID  FOR  THE  SAME
TREATMENT  WITHIN  A  NETWORK,  AND  ANY AMOUNT CHARGED BY A PROVIDER IN
EXCESS OF THE AMOUNT REIMBURSED BY THE INSURER SHALL BE THE RESPONSIBIL-
ITY OF THE INSURED RECEIVING THE OUT-OF-NETWORK SERVICES.
  (C) SUCH COVERAGE MAY BE SUBJECT TO OTHER TERMS AND CONDITIONS OF  THE
POLICY, INCLUDING, BUT NOT LIMITED TO, UTILIZATION REVIEW, ANNUAL DEDUC-
TIBLES,  COPAYMENTS,  AND  COINSURANCE  AS ARE DEEMED APPROPRIATE BY THE
SUPERINTENDENT AND CONSISTENT WITH  THOSE  REQUIRED  FOR  OTHER  SIMILAR
BENEFITS UNDER THE POLICY.
  S  3.  Section  4303  of  the insurance law is amended by adding a new
subsection (ff) to read as follows:
  (FF) (1) EVERY CONTRACT ISSUED  BY  A  HOSPITAL  SERVICE  CORPORATION,
HEALTH SERVICE CORPORATION OR MEDICAL EXPENSE INDEMNITY CORPORATION THAT
INCLUDES COVERAGE FOR DIALYSIS TREATMENT WHICH REQUIRES SUCH SERVICES TO
BE PROVIDED BY AN IN-NETWORK PROVIDER SHALL NOT DENY COVERAGE BECAUSE IT
IS  PROVIDED BY AN OUT-OF-NETWORK PROVIDER DULY LICENSED TO PRACTICE AND
AUTHORIZED TO PROVIDE SUCH TREATMENT, PROVIDED THAT EACH OF THE  FOLLOW-
ING CONDITIONS ARE MET:
  (A) THE HEALTHCARE PROVIDER TREATING THE COVERED PERSON FOR THE CONDI-
TION  ISSUES  A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT IN HIS
OR HER OPINION SUCH TREATMENT IS NECESSARY;
  (B) THE COVERED PERSON HAS NOTIFIED, IN WRITING,  THE  CORPORATION  AT
LEAST  THIRTY DAYS IN ADVANCE OF THE PROPOSED DATE OR DATES OF SUCH OUT-
OF-NETWORK DIALYSIS TREATMENT.  THE NOTICE SHALL  INCLUDE  THE  AUTHORI-
ZATION  REQUIRED BY SUBPARAGRAPH (A) OF THIS PARAGRAPH. IN THE EVENT THE
COVERED PERSON MUST TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMER-
GENCY, SHORTER NOTICE MAY BE PERMITTED, PROVIDED  THAT  THE  CORPORATION

A. 213                              3

HAS  REASONABLE  OPPORTUNITY TO REVIEW THE TRAVEL AND TREATMENT PLANS OF
THE COVERED PERSON;
  (C)  THE  CORPORATION SHALL HAVE THE RIGHT TO PRE-APPROVE THE DIALYSIS
TREATMENT AND SCHEDULE; AND
  (D) SUCH COVERAGE IS LIMITED TO NO GREATER  THAN  FOUR  OUT-OF-NETWORK
REQUESTS NOT TO EXCEED FIFTEEN TREATMENTS IN A CALENDAR YEAR.
  (2)  NO CORPORATION SHALL BE OBLIGATED TO REIMBURSE THE OUT-OF-NETWORK
PROVIDER AT AN AMOUNT GREATER THAN IT  WOULD  HAVE  PAID  FOR  THE  SAME
TREATMENT  WITHIN  A  NETWORK,  AND  ANY AMOUNT CHARGED BY A PROVIDER IN
EXCESS OF THE AMOUNT REIMBURSED BY THE CORPORATION SHALL BE THE  RESPON-
SIBILITY OF THE COVERED PERSON RECEIVING THE OUT-OF-NETWORK SERVICES.
  (3)  SUCH COVERAGE MAY BE SUBJECT TO OTHER TERMS AND CONDITIONS OF THE
CONTRACT, INCLUDING, BUT NOT  LIMITED  TO,  UTILIZATION  REVIEW,  ANNUAL
DEDUCTIBLES,  COPAYMENTS,  AND  COINSURANCE AS ARE DEEMED APPROPRIATE BY
THE SUPERINTENDENT AND CONSISTENT WITH THOSE REQUIRED FOR OTHER  SIMILAR
BENEFITS UNDER THE CONTRACT.
  S  4.  Paragraph 12 of subsection (b) of section 4322 of the insurance
law, as added by chapter 504 of the laws of 1995, is amended to read  as
follows:
  (12)   Hemodialysis   services   CONSISTENT  WITH  THE  PROVISIONS  OF
SUBSECTION (FF) OF SECTION FOUR THOUSAND THREE  HUNDRED  THREE  OF  THIS
ARTICLE.
  S  5. 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
insurance policies and contracts issued, renewed, modified or altered on
or after such effective date.

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

                                 213--A
                                                         Cal. No. 33

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 7, 2009
                               ___________

Introduced  by M. of A. MARKEY, REILLY, ABBATE, COLTON, GUNTHER, JAFFEE,
  SPANO, PHEFFER, MILLMAN, BARRON, GALEF, ORTIZ,  ZEBROWSKI,  DenDEKKER,
  CARROZZA,  PEOPLES-STOKES  --  Multi-Sponsored  by -- M. of A. ALFANO,
  AMEDORE,  BRENNAN,  BURLING,  CALHOUN,  CHRISTENSEN,  CONTE,   CROUCH,
  DelMONTE,  ERRIGO, FINCH, GLICK, GOTTFRIED, HYER-SPENCER, KOON, LUPAR-
  DO, MAYERSOHN, McDONOUGH, McENENY, MENG, PERRY, RAIA,  RUSSELL,  SCAR-
  BOROUGH,  SCHIMEL,  SWEENEY,  THIELE, TOBACCO, WEISENBERG -- read once
  and referred to the Committee on Insurance -- amended on  the  special
  order  of  third  reading, ordered reprinted as amended, retaining its
  place on the special order of third reading

AN ACT to amend the insurance law, in relation to insurance coverage for
  out-of-network dialysis

  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 26 to read as follows:
  (26)(A) EVERY POLICY THAT INCLUDES  COVERAGE  FOR  DIALYSIS  TREATMENT
THAT  REQUIRES  SUCH  SERVICES  TO BE PROVIDED BY AN IN-NETWORK PROVIDER
SHALL NOT DENY COVERAGE  OF  SUCH  SERVICES  BECAUSE  THE  SERVICES  ARE
PROVIDED  BY  AN  OUT-OF-NETWORK  PROVIDER,  PROVIDED  THAT  EACH OF THE
FOLLOWING CONDITIONS ARE MET:
  (I) THE OUT-OF-NETWORK PROVIDER  IS  DULY  LICENSED  TO  PRACTICE  AND
AUTHORIZED TO PROVIDE SUCH TREATMENT;
  (II)  THE  OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE SERVICE AREA
OF THE INSURER;
  (III) THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE INSURED FOR  THE
CONDITION  ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT IN
HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;
  (IV) THE INSURED HAS NOTIFIED, IN WRITING, THE INSURER AT LEAST THIRTY
DAYS IN ADVANCE OF THE PROPOSED DATE OR  DATES  OF  SUCH  OUT-OF-NETWORK
DIALYSIS TREATMENT.  THE NOTICE SHALL INCLUDE THE AUTHORIZATION REQUIRED
BY  CLAUSE  (III)  OF  THIS  SUBPARAGRAPH. IN THE EVENT THE INSURED MUST
              

TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMERGENCY, SHORTER NOTICE

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
A                                                          LBD00183-03-9

A. 213--A                           2

MAY BE PERMITTED, PROVIDED THAT THE INSURER HAS  REASONABLE  OPPORTUNITY
TO REVIEW THE TRAVEL AND TREATMENT PLANS OF THE INSURED;
  (V)  THE  INSURER  SHALL  HAVE  THE  RIGHT TO PRE-APPROVE THE DIALYSIS
TREATMENT AND SCHEDULE; AND
  (VI) SUCH COVERAGE IS LIMITED TO NO GREATER  THAN  TEN  OUT-OF-NETWORK
TREATMENTS IN A CALENDAR YEAR.
  (B) THE OUT-OF-NETWORK PROVIDER SHALL BE BOUND BY THE TERMS AND CONDI-
TIONS  OF THE INSURERS PROVIDER NETWORK CONTRACT AND NO INSURER SHALL BE
OBLIGATED TO REIMBURSE THE OUT-OF-NETWORK PROVIDER AT AN AMOUNT  GREATER
THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK, INCLUD-
ING ALL DRUGS AND ANCILLARY SERVICES TIED TO DIALYSIS TREATMENT, AND ANY
AMOUNT  CHARGED  BY A PROVIDER IN EXCESS OF THE AMOUNT REIMBURSED BY THE
INSURER SHALL  BE  THE  RESPONSIBILITY  OF  THE  INSURED  RECEIVING  THE
OUT-OF-NETWORK SERVICES.
  (C)  SUCH  COVERAGE  OF  OUT-OF-NETWORK  DIALYSIS SERVICES REQUIRED BY
SUBPARAGRAPH (A) OF THIS PARAGRAPH SHALL OTHERWISE  BE  SUBJECT  TO  THE
LIMITATIONS,  EXCLUSIONS  AND  TERMS  OF  THE POLICY, INCLUDING, BUT NOT
LIMITED TO, UTILIZATION  REVIEW,  ANNUAL  DEDUCTIBLES,  COPAYMENTS,  AND
COINSURANCE,  CONSISTENT  WITH THOSE REQUIRED FOR OTHER SIMILAR BENEFITS
UNDER THE POLICY.
  S 2. Subsection (k) of section 3221 of the insurance law is amended by
adding a new paragraph 15 to read as follows:
  (15)(A) EVERY GROUP OR BLANKET POLICY THAT INCLUDES COVERAGE FOR DIAL-
YSIS TREATMENT THAT REQUIRES SUCH SERVICES TO BE PROVIDED BY AN  IN-NET-
WORK  PROVIDER  SHALL  NOT  DENY  COVERAGE  OF SUCH SERVICES BECAUSE THE
SERVICES ARE PROVIDED BY AN OUT-OF-NETWORK PROVIDER, PROVIDED THAT  EACH
OF THE FOLLOWING CONDITIONS ARE MET:
  (I)  THE  OUT-OF-NETWORK  PROVIDER  IS  DULY  LICENSED TO PRACTICE AND
AUTHORIZED TO PROVIDE SUCH TREATMENT;
  (II) THE OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE  SERVICE  AREA
OF THE INSURER;
  (III)  THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE INSURED FOR THE
CONDITION ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT  IN
HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;
  (IV) THE INSURED HAS NOTIFIED, IN WRITING, THE INSURER AT LEAST THIRTY
DAYS  IN  ADVANCE  OF  THE PROPOSED DATE OR DATES OF SUCH OUT-OF-NETWORK
DIALYSIS TREATMENT.  THE NOTICE SHALL INCLUDE THE AUTHORIZATION REQUIRED
BY CLAUSE (III) OF THIS SUBPARAGRAPH. IN  THE  EVENT  THE  INSURED  MUST
TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMERGENCY, SHORTER NOTICE
MAY  BE  PERMITTED, PROVIDED THAT THE INSURER HAS REASONABLE OPPORTUNITY
TO REVIEW THE TRAVEL AND TREATMENT PLANS OF THE INSURED;
  (V) THE INSURER SHALL HAVE  THE  RIGHT  TO  PRE-APPROVE  THE  DIALYSIS
TREATMENT AND SCHEDULE; AND
  (VI)  SUCH  COVERAGE  IS LIMITED TO NO GREATER THAN TEN OUT-OF-NETWORK
TREATMENTS IN A CALENDAR YEAR.
  (B) THE OUT-OF-NETWORK PROVIDER SHALL BE BOUND BY THE TERMS AND CONDI-
TIONS OF THE INSURERS PROVIDER NETWORK CONTRACT AND NO INSURER SHALL  BE
OBLIGATED  TO REIMBURSE THE OUT-OF-NETWORK PROVIDER AT AN AMOUNT GREATER
THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK, INCLUD-
ING ALL DRUGS AND ANCILLARY SERVICES TIED TO DIALYSIS TREATMENT, AND ANY
AMOUNT CHARGED BY A PROVIDER IN EXCESS OF THE AMOUNT REIMBURSED  BY  THE
INSURER  SHALL  BE  THE  RESPONSIBILITY  OF  THE  INSURED  RECEIVING THE
OUT-OF-NETWORK SERVICES.
  (C) SUCH COVERAGE OF  OUT-OF-NETWORK  DIALYSIS  SERVICES  REQUIRED  BY
SUBPARAGRAPH  (A)  OF  THIS  PARAGRAPH SHALL OTHERWISE BE SUBJECT TO THE
LIMITATIONS, EXCLUSIONS AND TERMS OF  THE  POLICY,  INCLUDING,  BUT  NOT

A. 213--A                           3

LIMITED  TO,  UTILIZATION  REVIEW,  ANNUAL  DEDUCTIBLES, COPAYMENTS, AND
COINSURANCE, CONSISTENT WITH THOSE REQUIRED FOR OTHER  SIMILAR  BENEFITS
UNDER THE POLICY.
  S  3.  Section  4303  of  the insurance law is amended by adding a new
subsection (ff) to read as follows:
  (FF) (1) EVERY CONTRACT ISSUED  BY  A  HOSPITAL  SERVICE  CORPORATION,
HEALTH SERVICE CORPORATION OR MEDICAL EXPENSE INDEMNITY CORPORATION THAT
INCLUDES  COVERAGE FOR DIALYSIS TREATMENT THAT REQUIRES SUCH SERVICES TO
BE PROVIDED BY AN IN-NETWORK PROVIDER SHALL NOT DENY  COVERAGE  OF  SUCH
SERVICES  BECAUSE THE SERVICES ARE PROVIDED BY AN OUT-OF-NETWORK PROVID-
ER, PROVIDED THAT EACH OF THE FOLLOWING CONDITIONS ARE MET:
  (A) THE OUT-OF-NETWORK PROVIDER  IS  DULY  LICENSED  TO  PRACTICE  AND
AUTHORIZED TO PROVIDE SUCH TREATMENT;
  (B) THE OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE SERVICE AREA OF
THE INSURER;
  (C) THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE COVERED PERSON FOR
THE CONDITION ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT
IN HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;
  (D)  THE  COVERED  PERSON HAS NOTIFIED, IN WRITING, THE CORPORATION AT
LEAST THIRTY DAYS IN ADVANCE OF THE PROPOSED DATE OR DATES OF SUCH  OUT-
OF-NETWORK  DIALYSIS  TREATMENT.   THE NOTICE SHALL INCLUDE THE AUTHORI-
ZATION REQUIRED BY SUBPARAGRAPH (C) OF THIS PARAGRAPH. IN THE EVENT  THE
COVERED PERSON MUST TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMER-
GENCY,  SHORTER  NOTICE  MAY BE PERMITTED, PROVIDED THAT THE CORPORATION
HAS REASONABLE OPPORTUNITY TO REVIEW THE TRAVEL AND TREATMENT  PLANS  OF
THE COVERED PERSON;
  (E)  THE  CORPORATION SHALL HAVE THE RIGHT TO PRE-APPROVE THE DIALYSIS
TREATMENT AND SCHEDULE; AND
  (F) SUCH COVERAGE IS LIMITED TO NO  GREATER  THAN  TEN  OUT-OF-NETWORK
TREATMENTS IN A CALENDAR YEAR.
  (2) THE OUT-OF-NETWORK PROVIDER SHALL BE BOUND BY THE TERMS AND CONDI-
TIONS OF THE INSURERS PROVIDER NETWORK CONTRACT AND NO CORPORATION SHALL
BE  OBLIGATED  TO  REIMBURSE  THE  OUT-OF-NETWORK  PROVIDER AT AN AMOUNT
GREATER THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK,
INCLUDING ALL DRUGS AND ANCILLARY SERVICES TIED TO  DIALYSIS  TREATMENT,
AND  ANY AMOUNT CHARGED BY A PROVIDER IN EXCESS OF THE AMOUNT REIMBURSED
BY THE CORPORATION SHALL BE THE RESPONSIBILITY  OF  THE  COVERED  PERSON
RECEIVING THE OUT-OF-NETWORK SERVICES.
  (3)  SUCH  COVERAGE  OF  OUT-OF-NETWORK  DIALYSIS SERVICES REQUIRED BY
PARAGRAPH ONE OF THIS SUBSECTION SHALL OTHERWISE BE SUBJECT TO THE LIMI-
TATIONS, EXCLUSIONS AND TERMS OF THE POLICY, INCLUDING, BUT NOT  LIMITED
TO, UTILIZATION REVIEW, ANNUAL DEDUCTIBLES, COPAYMENTS, AND COINSURANCE,
CONSISTENT  WITH  THOSE  REQUIRED  FOR  OTHER SIMILAR BENEFITS UNDER THE
POLICY.
  S 4. Paragraph 12 of subsection (b) of section 4322 of  the  insurance
law,  as added by chapter 504 of the laws of 1995, is amended to read as
follows:
  (12)  Hemodialysis  services  CONSISTENT  WITH   THE   PROVISIONS   OF
SUBSECTION  (FF)  OF  SECTION  FOUR THOUSAND THREE HUNDRED THREE OF THIS
ARTICLE.
  S 5. 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
insurance policies and contracts issued, renewed, modified or altered on
or after such effective date.

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

                                 213--B
                                                          Cal. No. 7

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 7, 2009
                               ___________

Introduced  by M. of A. MARKEY, REILLY, ABBATE, COLTON, GUNTHER, JAFFEE,
  SPANO, PHEFFER, MILLMAN, BARRON, GALEF, ORTIZ,  ZEBROWSKI,  DenDEKKER,
  CARROZZA,  PEOPLES-STOKES  --  Multi-Sponsored  by -- M. of A. ALFANO,
  AMEDORE,  BRENNAN,  BURLING,  CALHOUN,  CHRISTENSEN,  CONTE,   CROUCH,
  DelMONTE,  ERRIGO, FINCH, GLICK, GOTTFRIED, HYER-SPENCER, KOON, LUPAR-
  DO, MAYERSOHN, McDONOUGH, McENENY, MENG, PERRY, RAIA,  RUSSELL,  SCAR-
  BOROUGH,  SCHIMEL,  SWEENEY,  THIELE, TOBACCO, WEISENBERG -- read once
  and referred to the Committee on Insurance -- amended on  the  special
  order  of  third  reading, ordered reprinted as amended, retaining its
  place on the special order of third reading -- reported  from  commit-
  tee,  advanced  to  a  third  reading,  amended and ordered reprinted,
  retaining its place on the order of third reading

AN ACT to amend the insurance law, in relation to insurance coverage for
  out-of-network dialysis

  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 27 to read as follows:
  (27)(A) EVERY POLICY THAT INCLUDES  COVERAGE  FOR  DIALYSIS  TREATMENT
THAT  REQUIRES  SUCH  SERVICES  TO BE PROVIDED BY AN IN-NETWORK PROVIDER
SHALL NOT DENY COVERAGE  OF  SUCH  SERVICES  BECAUSE  THE  SERVICES  ARE
PROVIDED  BY  AN  OUT-OF-NETWORK  PROVIDER,  PROVIDED  THAT  EACH OF THE
FOLLOWING CONDITIONS ARE MET:
  (I) THE OUT-OF-NETWORK PROVIDER  IS  DULY  LICENSED  TO  PRACTICE  AND
AUTHORIZED TO PROVIDE SUCH TREATMENT;
  (II)  THE  OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE SERVICE AREA
OF THE INSURER;
  (III) THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE INSURED FOR  THE
CONDITION  ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT IN
HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                      [ ] is old law to be omitted.
                                                           LBD00183-04-0

A. 213--B                           2

  (IV) THE INSURED HAS NOTIFIED, IN WRITING, THE INSURER AT LEAST THIRTY
DAYS IN ADVANCE OF THE PROPOSED DATE OR  DATES  OF  SUCH  OUT-OF-NETWORK
DIALYSIS TREATMENT.  THE NOTICE SHALL INCLUDE THE AUTHORIZATION REQUIRED
BY  CLAUSE  (III)  OF  THIS  SUBPARAGRAPH. IN THE EVENT THE INSURED MUST
TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMERGENCY, SHORTER NOTICE
MAY  BE  PERMITTED, PROVIDED THAT THE INSURER HAS REASONABLE OPPORTUNITY
TO REVIEW THE TRAVEL AND TREATMENT PLANS OF THE INSURED;
  (V) THE INSURER SHALL HAVE  THE  RIGHT  TO  PRE-APPROVE  THE  DIALYSIS
TREATMENT AND SCHEDULE; AND
  (VI)  SUCH  COVERAGE  IS LIMITED TO NO GREATER THAN TEN OUT-OF-NETWORK
TREATMENTS IN A CALENDAR YEAR.
  (B) THE OUT-OF-NETWORK PROVIDER SHALL BE BOUND BY THE TERMS AND CONDI-
TIONS OF THE INSURERS PROVIDER NETWORK CONTRACT AND NO INSURER SHALL  BE
OBLIGATED  TO REIMBURSE THE OUT-OF-NETWORK PROVIDER AT AN AMOUNT GREATER
THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK, INCLUD-
ING ALL DRUGS AND ANCILLARY SERVICES TIED TO DIALYSIS TREATMENT, AND ANY
AMOUNT CHARGED BY A PROVIDER IN EXCESS OF THE AMOUNT REIMBURSED  BY  THE
INSURER  SHALL  BE  THE  RESPONSIBILITY  OF  THE  INSURED  RECEIVING THE
OUT-OF-NETWORK SERVICES.
  (C) SUCH COVERAGE OF  OUT-OF-NETWORK  DIALYSIS  SERVICES  REQUIRED  BY
SUBPARAGRAPH  (A)  OF  THIS  PARAGRAPH SHALL OTHERWISE BE SUBJECT TO THE
LIMITATIONS, EXCLUSIONS AND TERMS OF  THE  POLICY,  INCLUDING,  BUT  NOT
LIMITED  TO,  UTILIZATION  REVIEW,  ANNUAL  DEDUCTIBLES, COPAYMENTS, AND
COINSURANCE, CONSISTENT WITH THOSE REQUIRED FOR OTHER  SIMILAR  BENEFITS
UNDER THE POLICY.
  S 2. Subsection (k) of section 3221 of the insurance law is amended by
adding a new paragraph 16 to read as follows:
  (16)(A) EVERY GROUP OR BLANKET POLICY THAT INCLUDES COVERAGE FOR DIAL-
YSIS  TREATMENT THAT REQUIRES SUCH SERVICES TO BE PROVIDED BY AN IN-NET-
WORK PROVIDER SHALL NOT DENY  COVERAGE  OF  SUCH  SERVICES  BECAUSE  THE
SERVICES  ARE PROVIDED BY AN OUT-OF-NETWORK PROVIDER, PROVIDED THAT EACH
OF THE FOLLOWING CONDITIONS ARE MET:
  (I) THE OUT-OF-NETWORK PROVIDER  IS  DULY  LICENSED  TO  PRACTICE  AND
AUTHORIZED TO PROVIDE SUCH TREATMENT;
  (II)  THE  OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE SERVICE AREA
OF THE INSURER;
  (III) THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE INSURED FOR  THE
CONDITION  ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT IN
HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;
  (IV) THE INSURED HAS NOTIFIED, IN WRITING, THE INSURER AT LEAST THIRTY
DAYS IN ADVANCE OF THE PROPOSED DATE OR  DATES  OF  SUCH  OUT-OF-NETWORK
DIALYSIS TREATMENT.  THE NOTICE SHALL INCLUDE THE AUTHORIZATION REQUIRED
BY  CLAUSE  (III)  OF  THIS  SUBPARAGRAPH. IN THE EVENT THE INSURED MUST
TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMERGENCY, SHORTER NOTICE
MAY BE PERMITTED, PROVIDED THAT THE INSURER HAS  REASONABLE  OPPORTUNITY
TO REVIEW THE TRAVEL AND TREATMENT PLANS OF THE INSURED;
  (V)  THE  INSURER  SHALL  HAVE  THE  RIGHT TO PRE-APPROVE THE DIALYSIS
TREATMENT AND SCHEDULE; AND
  (VI) SUCH COVERAGE IS LIMITED TO NO GREATER  THAN  TEN  OUT-OF-NETWORK
TREATMENTS IN A CALENDAR YEAR.
  (B) THE OUT-OF-NETWORK PROVIDER SHALL BE BOUND BY THE TERMS AND CONDI-
TIONS  OF THE INSURERS PROVIDER NETWORK CONTRACT AND NO INSURER SHALL BE
OBLIGATED TO REIMBURSE THE OUT-OF-NETWORK PROVIDER AT AN AMOUNT  GREATER
THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK, INCLUD-
ING ALL DRUGS AND ANCILLARY SERVICES TIED TO DIALYSIS TREATMENT, AND ANY
AMOUNT  CHARGED  BY A PROVIDER IN EXCESS OF THE AMOUNT REIMBURSED BY THE

A. 213--B                           3

INSURER SHALL  BE  THE  RESPONSIBILITY  OF  THE  INSURED  RECEIVING  THE
OUT-OF-NETWORK SERVICES.
  (C)  SUCH  COVERAGE  OF  OUT-OF-NETWORK  DIALYSIS SERVICES REQUIRED BY
SUBPARAGRAPH (A) OF THIS PARAGRAPH SHALL OTHERWISE  BE  SUBJECT  TO  THE
LIMITATIONS,  EXCLUSIONS  AND  TERMS  OF  THE POLICY, INCLUDING, BUT NOT
LIMITED TO, UTILIZATION  REVIEW,  ANNUAL  DEDUCTIBLES,  COPAYMENTS,  AND
COINSURANCE,  CONSISTENT  WITH THOSE REQUIRED FOR OTHER SIMILAR BENEFITS
UNDER THE POLICY.
  S 3. Section 4303 of the insurance law is  amended  by  adding  a  new
subsection (gg) to read as follows:
  (GG)  (1)  EVERY  CONTRACT  ISSUED  BY A HOSPITAL SERVICE CORPORATION,
HEALTH SERVICE CORPORATION OR MEDICAL EXPENSE INDEMNITY CORPORATION THAT
INCLUDES COVERAGE FOR DIALYSIS TREATMENT THAT REQUIRES SUCH SERVICES  TO
BE  PROVIDED  BY  AN IN-NETWORK PROVIDER SHALL NOT DENY COVERAGE OF SUCH
SERVICES BECAUSE THE SERVICES ARE PROVIDED BY AN OUT-OF-NETWORK  PROVID-
ER, PROVIDED THAT EACH OF THE FOLLOWING CONDITIONS ARE MET:
  (A)  THE  OUT-OF-NETWORK  PROVIDER  IS  DULY  LICENSED TO PRACTICE AND
AUTHORIZED TO PROVIDE SUCH TREATMENT;
  (B) THE OUT-OF-NETWORK PROVIDER IS LOCATED OUTSIDE THE SERVICE AREA OF
THE INSURER;
  (C) THE IN-NETWORK HEALTHCARE PROVIDER TREATING THE COVERED PERSON FOR
THE CONDITION ISSUES A WRITTEN ORDER FOR DIALYSIS TREATMENT STATING THAT
IN HIS OR HER OPINION SUCH TREATMENT IS NECESSARY;
  (D) THE COVERED PERSON HAS NOTIFIED, IN WRITING,  THE  CORPORATION  AT
LEAST  THIRTY DAYS IN ADVANCE OF THE PROPOSED DATE OR DATES OF SUCH OUT-
OF-NETWORK DIALYSIS TREATMENT.  THE NOTICE SHALL  INCLUDE  THE  AUTHORI-
ZATION  REQUIRED BY SUBPARAGRAPH (C) OF THIS PARAGRAPH. IN THE EVENT THE
COVERED PERSON MUST TRAVEL ON SUDDEN NOTICE DUE TO FAMILY OR OTHER EMER-
GENCY, SHORTER NOTICE MAY BE PERMITTED, PROVIDED  THAT  THE  CORPORATION
HAS  REASONABLE  OPPORTUNITY TO REVIEW THE TRAVEL AND TREATMENT PLANS OF
THE COVERED PERSON;
  (E) THE CORPORATION SHALL HAVE THE RIGHT TO PRE-APPROVE  THE  DIALYSIS
TREATMENT AND SCHEDULE; AND
  (F)  SUCH  COVERAGE  IS  LIMITED TO NO GREATER THAN TEN OUT-OF-NETWORK
TREATMENTS IN A CALENDAR YEAR.
  (2) THE OUT-OF-NETWORK PROVIDER SHALL BE BOUND BY THE TERMS AND CONDI-
TIONS OF THE INSURERS PROVIDER NETWORK CONTRACT AND NO CORPORATION SHALL
BE OBLIGATED TO REIMBURSE  THE  OUT-OF-NETWORK  PROVIDER  AT  AN  AMOUNT
GREATER THAN IT WOULD HAVE PAID FOR THE SAME TREATMENT WITHIN A NETWORK,
INCLUDING  ALL  DRUGS AND ANCILLARY SERVICES TIED TO DIALYSIS TREATMENT,
AND ANY AMOUNT CHARGED BY A PROVIDER IN EXCESS OF THE AMOUNT  REIMBURSED
BY  THE  CORPORATION  SHALL  BE THE RESPONSIBILITY OF THE COVERED PERSON
RECEIVING THE OUT-OF-NETWORK SERVICES.
  (3) SUCH COVERAGE OF  OUT-OF-NETWORK  DIALYSIS  SERVICES  REQUIRED  BY
PARAGRAPH ONE OF THIS SUBSECTION SHALL OTHERWISE BE SUBJECT TO THE LIMI-
TATIONS,  EXCLUSIONS AND TERMS OF THE POLICY, INCLUDING, BUT NOT LIMITED
TO, UTILIZATION REVIEW, ANNUAL DEDUCTIBLES, COPAYMENTS, AND COINSURANCE,
CONSISTENT WITH THOSE REQUIRED FOR  OTHER  SIMILAR  BENEFITS  UNDER  THE
POLICY.
  S  4.  Paragraph 12 of subsection (b) of section 4322 of the insurance
law, as added by chapter 504 of the laws of 1995, is amended to read  as
follows:
  (12)   Hemodialysis   services   CONSISTENT  WITH  THE  PROVISIONS  OF
SUBSECTION (GG) OF SECTION FOUR THOUSAND THREE  HUNDRED  THREE  OF  THIS
ARTICLE.

A. 213--B                           4

  S  5. 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
insurance policies and contracts issued, renewed, modified or altered on
or after such effective date.