S T A T E O F N E W Y O R K
________________________________________________________________________
4440
2009-2010 Regular Sessions
I N A S S E M B L Y
February 4, 2009
___________
Introduced by M. of A. HYER-SPENCER, ALFANO, SPANO, WALKER, TITONE --
Multi-Sponsored by -- M. of A. BARRA, DIAZ, GABRYSZAK, MAISEL, McDO-
NOUGH, TOBACCO -- read once and referred to the Committee on Insurance
AN ACT to amend the insurance law and the executive law, in relation to
enacting the "fair insurance treatment act of 2009"
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Short title. This act shall be known and may be cited as
the "fair insurance treatment act of 2009".
S 2. Legislative findings and intent. The legislature hereby declares
that health insurance policies and health maintenance organization
contracts have traditionally discriminated against persons with mental
illness (including children with serious emotional disorders) and
persons with chemical dependency by either not including medically
necessary mental health and chemical dependency treatment and services
as covered benefits or subjecting these services to disparate benefit
limitations or cost sharing requirements. Although federal law has
prohibited the imposition of lower annual and lifetime dollars limits by
certain plans on mental health coverage, it is the intent of this legis-
lation to strengthen and enhance those protections, and to ensure that
mental health and chemical dependency coverage is provided by insurers
and health maintenance organizations, and is provided on terms compara-
ble to other health care and medical services. Nothing in this act is
intended to limit or restrict the right of health maintenance organiza-
tions and health insurers to require that all services covered by them
satisfy reasonable and appropriate utilization review requirements, in
accordance with their contracts, and applicable laws and regulations,
provided that such utilization review requirements are applied in a
consistent fashion to all services covered by such contracts.
S 3. Subsection (i) of section 3216 of the insurance law is amended by
adding a new paragraph 26 to read as follows:
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD07523-01-9
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(26) EVERY POLICY DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE WHICH
PROVIDES COVERAGE FOR MEDICAL OR HOSPITAL CARE SHALL PROVIDE COVERAGE
FOR THE TREATMENT AND DIAGNOSIS OF MENTAL, NERVOUS OR EMOTIONAL DISOR-
DERS OR AILMENTS OF ALCOHOLISM, ALCOHOL ABUSE, SUBSTANCE ABUSE,
SUBSTANCE DEPENDENCE OR CHEMICAL DEPENDENCE, HOWEVER DEFINED IN SUCH
CONTRACT. SUCH POLICY SHALL NOT IMPOSE ANY GREATER LIMITATIONS ON SUCH
COVERAGE THAN IT DOES FOR PHYSICAL HEALTH BENEFITS.
S 4. Paragraph 4 of subsection (b) of section 3217 of the insurance
law is amended to read as follows:
(4) elimination of provisions which may be contrary to the health care
needs of the public, as certified to the superintendent by the commis-
sioner of health, ELIMINATION OF PROVISIONS WHICH MAY BE CONTRARY TO THE
MENTAL HEALTH CARE NEEDS OF THE PUBLIC, AS CERTIFIED TO THE SUPERINTEN-
DENT BY THE COMMISSIONER OF MENTAL HEALTH, AND ELIMINATION OF PROVISIONS
WHICH MAY BE CONTRARY TO THE SUBSTANCE ABUSE AND CHEMICAL DEPENDENCY
CARE NEEDS OF THE PUBLIC, AS CERTIFIED TO THE SUPERINTENDENT BY THE
COMMISSIONER OF ALCOHOL AND SUBSTANCE ABUSE SERVICES; and
S 5. Paragraphs 6 and 7 of subsection (1) of section 3221 of the
insurance law, paragraph 6 as amended by chapter 558 of the laws of 1999
and paragraph 7 as amended by chapter 565 of the laws of 2000, are
amended to read as follows:
(6) (A) Every insurer delivering a group or school blanket policy or
issuing a group or school blanket policy for delivery, in this state,
which provides coverage for inpatient hospital care [must make available
and, if requested by the policyholder,] SHALL provide, AS PART OF SUCH
POLICY, coverage for the diagnosis and treatment of chemical abuse and
chemical dependence, however defined in such policy, provided, however,
that the term chemical abuse shall mean and include alcohol and
substance abuse and chemical dependence shall mean and include alcohol-
ism and substance dependence, however defined in such policy. Written
notice of the availability of such coverage shall be delivered to the
policyholder prior to inception of such group policy and annually there-
after, except that this notice shall not be required where a policy
covers two hundred or more employees or where the benefit structure was
the subject of collective bargaining affecting persons who are employed
in more than one state.
(B) Such coverage shall [be at least equal to] INCLUDE the following:
(i) [with respect to] benefits for detoxification as a consequence of
chemical dependence, inpatient benefits in a hospital or a detoxifica-
tion facility [may not be limited to less than seven days of active
treatment in any calendar year]; and
(ii) [with respect to] benefits for rehabilitation services, [such
benefits may not be limited to less than thirty days of] AND inpatient
care in [any calendar year] A HOSPITAL OR REHABILITATION FACILITY.
(C) Such coverage may be limited to facilities in New York state which
are certified by the office of alcoholism and substance abuse services
and, in other states, to those which are accredited by the joint commis-
sion on accreditation of hospitals as alcoholism, substance abuse or
chemical dependence treatment programs.
(D) Such coverage shall be made available at the inception of all new
policies and with respect to all other policies at any anniversary date
of the policy subject to evidence of insurability.
(E) Such coverage may be subject to annual deductibles and co-insu-
rance as may be deemed appropriate by the superintendent and are
consistent with those imposed on other benefits within a given policy.
[Further, each insurer shall report to the superintendent each year the
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number of contract holders to whom it has issued policies for the inpa-
tient treatment of chemical dependence, and the approximate number of
persons covered by such policies.]
(F) Such coverage shall not replace, restrict or eliminate existing
coverage provided by the policy.
(7) Every insurer delivering a group or school blanket policy or issu-
ing a group or school blanket policy for delivery in this state which
provides coverage for inpatient hospital care [must] SHALL provide
coverage, AS PART OF SUCH POLICY, for [at least sixty] outpatient
[visits in any calendar year] CARE for the diagnosis and treatment of
chemical dependence of which up to twenty VISITS may be for family
members, except that this provision shall not apply to a policy which
covers persons employed in more than one state or the benefit structure
of which was the subject of collective bargaining affecting persons who
are employed in more than one state. Such coverage may be limited to
facilities in New York state certified by the office of alcoholism and
substance abuse services or licensed by such office as outpatient clin-
ics or medically supervised ambulatory substance abuse programs and, in
other states, to those which are accredited by the joint commission on
accreditation of hospitals as alcoholism or chemical dependence treat-
ment programs. Such coverage may be subject to annual deductibles and
co-insurance as may be deemed appropriate by the superintendent and are
consistent with those imposed on other benefits within a given policy.
Such coverage shall not replace, restrict, or eliminate existing cover-
age provided by the policy. Except as otherwise provided in the applica-
ble policy or contract, no insurer delivering a group or school blanket
policy or issuing a group or school blanket policy providing coverage
for alcoholism or substance abuse services pursuant to this section
shall deny coverage to a family member who identifies themself as a
family member of a person suffering from the disease of alcoholism,
substance abuse or chemical dependency and who seeks treatment as a
family member who is otherwise covered by the applicable policy or
contract pursuant to this section. The coverage required by this para-
graph shall include treatment as a family member pursuant to such family
members' own policy or contract provided such family member (i) does not
exceed the allowable number of family visits provided by the applicable
policy or contract pursuant to this section, and (ii) is otherwise enti-
tled to coverage pursuant to this section and such family members'
applicable policy or contract.
S 6. Subsections (k) and (l) of section 4303 of the insurance law,
subsection (k) as amended by chapter 558 of the laws of 1999 and
subsection (l) as amended by chapter 565 of the laws of 2000, are
amended to read as follows:
(k) A hospital service corporation or a health service corporation
which provides group, group remittance or school blanket coverage for
inpatient hospital care [must make available and if requested by the
contract holder] SHALL provide, AS PART OF ANY CONTRACT ISSUED PURSUANT
TO THIS SECTION, coverage for the diagnosis and treatment of chemical
abuse and chemical dependence, however defined in such policy, provided,
however, that the term chemical abuse shall mean and include alcohol and
substance abuse and chemical dependence shall mean and include alcohol-
ism and substance dependence, however defined in such policy, except
that this provision shall not apply to a policy which covers persons
employed in more than one state or the benefit structure of which was
the subject of collective bargaining affecting persons who are employed
in more than one state. Such coverage shall [be at least equal to]
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INCLUDE the following: (1) [with respect to] benefits for detoxification
as a consequence of chemical dependence, inpatient benefits for care in
a hospital or detoxification facility [may not be limited to less than
seven days of active treatment in any calendar year]; and (2) [with
respect to] benefits for inpatient rehabilitation services[, such bene-
fits may not be limited to less than thirty days of] AND inpatient reha-
bilitation in a hospital based or free standing chemical dependence
facility [in any calendar year]. Such coverage may be limited to facili-
ties in New York state which are certified by the office of alcoholism
and substance abuse services and, in other states, to those which are
accredited by the joint commission on accreditation of hospitals as
alcoholism, substance abuse, or chemical dependence treatment programs.
Such coverage shall be [made available] PROVIDED at the inception of all
new policies and with respect to policies issued before the effective
date of this subsection at the first annual anniversary date thereaft-
er[, without evidence of insurability and at any subsequent annual anni-
versary date subject to evidence of insurability]. Such coverage may be
subject to annual deductibles and co-insurance as may be deemed appro-
priate by the superintendent and are consistent with those imposed on
other benefits within a given policy. Further, each hospital service
corporation or health service corporation shall report to the super-
intendent each year the number of contract holders to whom it has issued
policies for the inpatient treatment of chemical dependence, and the
approximate number of persons covered by such policies. Such coverage
shall not replace, restrict or eliminate existing coverage provided by
the policy. Written notice of the availability of such coverage shall be
delivered to the group remitting agent or group contract holder prior to
inception of such contract and annually thereafter, except that this
notice shall not be required where a policy covers two hundred or more
employees or where the benefit structure was the subject of collective
bargaining affecting persons who are employed in more than one state.
(l) A hospital service corporation or a health service corporation
which provides group, group remittance or school blanket coverage for
inpatient hospital care must provide coverage, AS PART OF ANY CONTRACT
ISSUED PURSUANT TO THIS SECTION, for [at least sixty] outpatient [visits
in any calendar year] CARE for the diagnosis and treatment of chemical
dependence of which up to twenty OUTPATIENT VISITS may be for family
members, except that this provision shall not apply to a contract issued
pursuant to section four thousand three hundred five of this article
which covers persons employed in more than one state or the benefit
structure of which was the subject of collective bargaining affecting
persons who are employed in more than one state. Such coverage may be
limited to facilities in New York state certified by the office of alco-
holism and substance abuse services or licensed by such office as outpa-
tient clinics or medically supervised ambulatory substance abuse
programs and, in other states, to those which are accredited by the
joint commission on accreditation of hospitals as alcoholism or chemical
dependence substance abuse treatment programs. Such coverage may be
subject to annual deductibles and co-insurance as may be deemed appro-
priate by the superintendent and are consistent with those imposed on
other benefits within a given policy. Such coverage shall not replace,
restrict or eliminate existing coverage provided by the policy. Except
as otherwise provided in the applicable policy or contract, no hospital
service corporation or health service corporation providing coverage for
alcoholism or substance abuse services pursuant to this section shall
deny coverage to a family member who identifies themself as a family
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member of a person suffering from the disease of alcoholism, substance
abuse or chemical dependency and who seeks treatment as a family member
who is otherwise covered by the applicable policy or contract pursuant
to this section. The coverage required by this subsection shall include
treatment as a family member pursuant to such family members' own policy
or contract provided such family member (i) does not exceed the allow-
able number of family visits provided by the applicable policy or
contract pursuant to this section, and (ii) is otherwise entitled to
coverage pursuant to this section and such family members' applicable
policy or contract.
S 7. Section 4320 of the insurance law, as added by chapter 695 of the
laws of 1993, is amended to read as follows:
S 4320. Limitations on administrative services and stop-loss coverage.
No insurer, subsidiary of an insurer, or controlled person of a holding
company system may act as an administrator or claims paying agent, as
opposed to an insurer, on behalf of a group which denies or limits bene-
fits for OR IMPOSES COST SHARING OBLIGATIONS RELATING TO a specific
disease or condition or for a procedure or treatment unique to a specif-
ic disease or condition in a manner which would be inconsistent with
this chapter or regulations promulgated by the superintendent had the
group purchased insurance OR WHICH ARE INCONSISTENT WITH LIMITS OR OBLI-
GATIONS IMPOSED WITH RESPECT TO OTHER DISEASES OR CONDITIONS IN THE
HEALTH PLAN. No insurer, subsidiary of an insurer, or controlled person
of a holding company may provide stop loss, catastrophic or reinsurance
coverage to groups which deny or limit benefits for OR IMPOSES COST
SHARING OBLIGATIONS RELATING TO a specific disease or condition or for a
procedure or treatment unique to a specific disease or condition in a
manner which would be inconsistent with this chapter or regulations
promulgated by the superintendent had the group purchased insurance OR
WHICH ARE INCONSISTENT WITH LIMITS OR OBLIGATIONS IMPOSED WITH RESPECT
TO OTHER DISEASES OR CONDITIONS IN THE HEALTH PLAN. A limit, maximum,
COST SHARING OBLIGATION or other mechanism that controls total coverage
without regard to a specific disease or condition shall not be deemed
one that denies or limits benefits for a specific disease or condition,
or for a procedure or treatment unique to a specific disease or condi-
tion. Nothing herein shall be construed to mandate the inclusion of
specified benefits in an employer group plan, if such plan is not
subject to the provisions of this chapter.
S 8. Paragraphs 17, 18 and 19 of subsection (b) of section 4322 of the
insurance law, as added by chapter 504 of the laws of 1995, are amended
to read as follows:
(17) Inpatient diagnosis and treatment of mental, nervous or emotional
disorders or ailments [up to thirty days per calendar year combined with
inpatient treatment of alcoholism and substance abuse].
(18) Inpatient diagnosis and treatment of alcoholism and alcohol abuse
and substance abuse and [substance] CHEMICAL dependence [up to thirty
days per calendar year], AND for detoxification [combined with] AND
inpatient treatment of mental, nervous or emotional disorders or
ailments.
(19) Outpatient diagnosis and treatment of mental, nervous or
emotional disorders or ailments [up to thirty non-emergency and three
emergency visits per calendar year] OR ALCOHOLISM AND ALCOHOL ABUSE AND
CHEMICAL DEPENDENCE.
S 9. Subdivision 20 of section 296 of the executive law, as renumbered
by chapter 204 of the laws of 1996, is renumbered 21 and a new subdivi-
sion 20 is added to read as follows:
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20. IT SHALL BE AN UNLAWFUL DISCRIMINATORY PRACTICE FOR ANY EMPLOYER,
LABOR ORGANIZATION, INSURER, HEALTH MAINTENANCE ORGANIZATION OR OTHER
ENTITY TO LIMIT HEALTH CARE COVERAGE FOR SPECIFIC DISEASES OR CONDI-
TIONS, INCLUDING MENTAL, NERVOUS OR EMOTIONAL DISORDERS OR AILMENTS OR
ALCOHOLISM, ALCOHOL ABUSE, SUBSTANCE ABUSE, SUBSTANCE DEPENDENCE OR
CHEMICAL DEPENDENCE, TO A SPECIFIC NUMBER OF DAYS OR TO A SPECIFIC ANNU-
AL DOLLAR AMOUNT OR TO A SPECIFIC LIFETIME DOLLAR AMOUNT OR TO IMPOSE
SPECIFIC COST-SHARING OBLIGATIONS FOR THE RECEIPT OF SUCH COVERAGE,
UNLESS SUCH LIMITS OR OBLIGATIONS APPLY, IN A CONSISTENT AND COMPARABLE
FASHION, TO ALL HEALTH CARE SERVICES PROVIDED BY SUCH COVERAGE.
S 10. 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; provided that any rules and regulations
necessary for the implementation of the provisions of this act on its
effective date are authorized and directed to be promulgated on or
before such date.