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

                                  5324

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                            February 12, 2009
                               ___________

Introduced  by  M.  of  A.  MAISEL,  SWEENEY,  MILLMAN, FIELDS, GUNTHER,
  MARKEY, MAYERSOHN, CARROZZA, ROSENTHAL -- Multi-Sponsored by -- M.  of
  A.  ABBATE,  BOYLAND,  BROOK-KRASNY,  CLARK,  DINOWITZ, GLICK, HIKIND,
  KELLNER, KOON, PHEFFER, STIRPE, WEINSTEIN, WEISENBERG -- read once and
  referred to the Committee on Insurance

AN ACT to amend the insurance law,  in  relation  to  requiring  certain
  health insurance coverage for lymphedema

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

  Section 1. Subparagraph (A) of  paragraph  20  of  subsection  (i)  of
section  3216 of the insurance law is amended by adding a new item (iii)
to read as follows:
  (III) PROSTHESES AND PHYSICAL COMPLICATIONS OF ALL STAGES OF MASTECTO-
MY, INCLUDING LYMPHEDEMA;
  S 2. Subsection (i) of section 3216 of the insurance law is amended by
adding two new paragraphs 26 and 27 to read as follows:
  (26) EVERY POLICY WHICH PROVIDES HOSPITAL, SURGICAL, MEDICAL OR  MAJOR
MEDICAL  COVERAGE  SHALL PROVIDE COVERAGE FOR THE DIFFERENTIAL DIAGNOSIS
AND TREATMENT OF LYMPHEDEMA. SUCH COVERAGE SHALL INCLUDE, IN ADDITION TO
BENEFITS FOR A COURSE OF MANUAL LYMPH DRAINAGE WHOSE FREQUENCY AND DURA-
TION IS DETERMINED BY THE  TREATING  PHYSICIAN  OR  THERAPIST  BASED  ON
MEDICAL  NECESSITY  AND NOT BASED ON PHYSICAL THERAPY AND REHABILITATION
STANDARDS, BENEFITS FOR EQUIPMENT, SUPPLIES, DEVICES, COMPLEX  DECONGES-
TIVE THERAPY, AND OUT-PATIENT SELF-MANAGEMENT TRAINING AND EDUCATION FOR
THE TREATMENT OF LYMPHEDEMA, IF PRESCRIBED BY A HEALTH CARE PROFESSIONAL
LEGALLY  AUTHORIZED TO PRESCRIBE OR PROVIDE SUCH ITEMS UNDER TITLE EIGHT
OF THE EDUCATION  LAW.    LYMPHEDEMA  THERAPY  ADMINISTERED  UNDER  THIS
SECTION  SHALL  BE ADMINISTERED ONLY BY A THERAPIST CERTIFIED TO PERFORM
LYMPHEDEMA TREATMENT BY THE  LYMPHOLOGY  ASSOCIATION  OF  NORTH  AMERICA
(LANA)  OR  CERTIFIED  IN  ACCORDANCE  WITH  STANDARDS EQUIVALENT TO THE
CERTIFICATION STANDARDS OF LANA.   SUCH EQUIPMENT, SUPPLIES  OR  DEVICES

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD07201-01-9
              

A. 5324                             2

SHALL  INCLUDE,  BUT  NOT BE LIMITED TO, BANDAGES, COMPRESSION GARMENTS,
PADS, ORTHOTIC SHOES AND DEVICES, WITH  REPLACEMENTS  WHEN  REQUIRED  TO
MAINTAIN COMPRESSIVE FUNCTION OR TO ACCOMMODATE CHANGES IN THE PATIENT'S
DIMENSIONS.  COVERAGE  SHALL  BE  PROVIDED FOR FOLLOW-UP TREATMENTS WHEN
MEDICALLY REQUIRED OR TO PERIODICALLY VALIDATE HOME TECHNIQUES, TO MONI-
TOR PROGRESS AGAINST THE WRITTEN TREATMENT PLAN AND TO MODIFY THE TREAT-
MENT PLAN AS REQUIRED. NO INDIVIDUAL, OTHER THAN  A  LICENSED  PHYSICIAN
AND  SURGEON COMPETENT TO EVALUATE THE SPECIFIC CLINICAL ISSUES INVOLVED
IN THE CARE REQUESTED, MAY DENY REQUESTS  FOR  AUTHORIZATION  OF  HEALTH
CARE SERVICES PURSUANT TO THIS SECTION.
  (A)  A  POLICY WHICH IS A MANAGED HEALTH CARE PRODUCT MAY REQUIRE SUCH
HEALTH CARE PROFESSIONAL BE A MEMBER OF SUCH MANAGED HEALTH CARE  PLAN'S
PROVIDER  NETWORK, PROVIDED THAT SUCH NETWORK INCLUDES SUFFICIENT HEALTH
CARE PROFESSIONALS WHO ARE QUALIFIED BY SPECIFIC  EDUCATION,  EXPERIENCE
AND  CREDENTIALS TO PROVIDE THE COVERED BENEFITS DESCRIBED IN THIS PARA-
GRAPH.
  (B) NO INSURER, CORPORATION, OR HEALTH MAINTENANCE ORGANIZATION  SHALL
IMPOSE UPON ANY PERSON RECEIVING BENEFITS PURSUANT TO THIS PARAGRAPH ANY
COPAYMENT,  FEE,  POLICY  YEAR  OR  CALENDAR YEAR, OR DURATIONAL BENEFIT
LIMITATION OR MAXIMUM FOR BENEFITS  OR  SERVICES  THAT  IS  NOT  EQUALLY
IMPOSED UPON ALL INDIVIDUALS IN THE SAME BENEFIT CATEGORY.
  (C)  THIS  PARAGRAPH  SHALL  NOT  APPLY TO SHORT-TERM TRAVEL, ACCIDENT
ONLY, LIMITED OR SPECIFIED DISEASE, OR INDIVIDUAL CONVERSION POLICIES OR
CONTRACTS, NOR TO POLICIES OR CONTRACTS DESIGNED FOR ISSUANCE TO PERSONS
ELIGIBLE FOR COVERAGE UNDER TITLE XVIII  OF  THE  SOCIAL  SECURITY  ACT,
KNOWN  AS MEDICARE, OR ANY OTHER SIMILAR COVERAGE UNDER STATE OR FEDERAL
GOVERNMENTAL PLANS.
  (D) FOR PURPOSES OF THIS PARAGRAPH, A  "MANAGED  CARE  PRODUCT"  SHALL
MEAN  A POLICY WHICH REQUIRES THAT MEDICAL OR OTHER HEALTH CARE SERVICES
COVERED UNDER  THE  POLICY,  OTHER  THAN  EMERGENCY  CARE  SERVICES,  BE
PROVIDED BY, OR PURSUANT TO A REFERRAL FROM A PRIMARY CARE PROVIDER, AND
THAT  SERVICES  PROVIDED  PURSUANT  TO  SUCH A REFERRAL BE RENDERED BY A
HEALTH CARE PROVIDER PARTICIPATING IN THE INSURER'S MANAGED CARE PROVID-
ER NETWORK. IN ADDITION, A MANAGED CARE  PRODUCT  SHALL  ALSO  MEAN  THE
IN-NETWORK  PORTION  OF  A CONTRACT WHICH REQUIRES THAT MEDICAL OR OTHER
HEALTH CARE SERVICES COVERED UNDER THE CONTRACT,  OTHER  THAN  EMERGENCY
CARE  SERVICES, BE PROVIDED BY, OR PURSUANT TO A REFERRAL FROM A PRIMARY
CARE PROVIDER, AND THAT SERVICES PROVIDED PURSUANT TO SUCH A REFERRAL BE
RENDERED BY A  HEALTH  CARE  PROVIDER  PARTICIPATING  IN  THE  INSURER'S
MANAGED  CARE  PROVIDER NETWORK, IN ORDER FOR THE INSURED TO BE ENTITLED
TO THE MAXIMUM REIMBURSEMENT UNDER THE CONTRACT.
  (27) PATIENTS UNDERGOING ANY SURGERY OR RADIOTHERAPY  PROCEDURE  SHALL
BE  PROVIDED  INFORMATION ON THE RISK OF LYMPHEDEMA ASSOCIATED WITH THAT
PROCEDURE, AND THE  POTENTIAL  POST-PROCEDURE  SYMPTOMS  OF  LYMPHEDEMA.
INFORMED  CONSENT  AGREEMENTS  FOR ALL SURGERIES AND RADIATION THERAPIES
SHALL INCLUDE INFORMATION ON THE RISK OF LYMPHEDEMA ASSOCIATED WITH  THE
ALTERNATIVE PROCEDURES.
  S  3.  Subparagraph  (A)  of paragraph 10 of subsection (k) of section
3221 of the insurance law is amended by adding a new item (iii) to  read
as follows:
  (III) PROSTHESES AND PHYSICAL COMPLICATIONS OF ALL STAGES OF MASTECTO-
MY, INCLUDING LYMPHEDEMA;
  S 4. Subsection (k) of section 3221 of the insurance law is amended by
adding two new paragraphs 15 and 16 to read as follows:
  (15)  EVERY  GROUP  POLICY ISSUED OR ISSUED FOR DELIVERY IN THIS STATE
WHICH PROVIDES HOSPITAL, SURGICAL, MEDICAL  OR  MAJOR  MEDICAL  COVERAGE

A. 5324                             3

SHALL  PROVIDE  COVERAGE FOR THE DIFFERENTIAL DIAGNOSIS AND TREATMENT OF
LYMPHEDEMA. SUCH COVERAGE SHALL INCLUDE, IN ADDITION TO BENEFITS  FOR  A
COURSE  OF  MANUAL LYMPH DRAINAGE WHOSE FREQUENCY AND DURATION IS DETER-
MINED  BY THE TREATING PHYSICIAN OR THERAPIST BASED ON MEDICAL NECESSITY
AND NOT BASED ON PHYSICAL THERAPY AND REHABILITATION STANDARDS, BENEFITS
FOR EQUIPMENT, SUPPLIES,  DEVICES,  COMPLEX  DECONGESTIVE  THERAPY,  AND
OUT-PATIENT  SELF-MANAGEMENT TRAINING AND EDUCATION FOR THE TREATMENT OF
LYMPHEDEMA, IF PRESCRIBED BY A HEALTH CARE PROFESSIONAL LEGALLY  AUTHOR-
IZED  TO PRESCRIBE OR PROVIDE SUCH ITEMS UNDER TITLE EIGHT OF THE EDUCA-
TION LAW.  LYMPHEDEMA THERAPY ADMINISTERED UNDER THIS SECTION  SHALL  BE
ADMINISTERED  ONLY BY A THERAPIST CERTIFIED TO PERFORM LYMPHEDEMA TREAT-
MENT BY THE LYMPHOLOGY ASSOCIATION OF NORTH AMERICA (LANA) OR  CERTIFIED
IN  ACCORDANCE  WITH STANDARDS EQUIVALENT TO THE CERTIFICATION STANDARDS
OF LANA.  SUCH EQUIPMENT, SUPPLIES OR DEVICES SHALL INCLUDE, BUT NOT  BE
LIMITED  TO,  BANDAGES,  COMPRESSION  GARMENTS, PADS, ORTHOTIC SHOES AND
DEVICES, WITH REPLACEMENTS WHEN REQUIRED TO MAINTAIN  COMPRESSIVE  FUNC-
TION  OR  TO  ACCOMMODATE  CHANGES IN THE PATIENT'S DIMENSIONS. COVERAGE
SHALL BE PROVIDED FOR FOLLOW-UP TREATMENTS WHEN MEDICALLY REQUIRED OR TO
PERIODICALLY VALIDATE HOME TECHNIQUES, TO MONITOR PROGRESS  AGAINST  THE
WRITTEN  TREATMENT PLAN AND TO MODIFY THE TREATMENT PLAN AS REQUIRED. NO
INDIVIDUAL, OTHER THAN A LICENSED PHYSICIAN  AND  SURGEON  COMPETENT  TO
EVALUATE  THE  SPECIFIC  CLINICAL ISSUES INVOLVED IN THE CARE REQUESTED,
MAY DENY REQUESTS FOR AUTHORIZATION OF HEALTH CARE SERVICES PURSUANT  TO
THIS SECTION.
  (A)  A  POLICY WHICH IS A MANAGED HEALTH CARE PRODUCT MAY REQUIRE SUCH
HEALTH CARE PROFESSIONAL BE A MEMBER OF SUCH MANAGED HEALTH CARE  PLAN'S
PROVIDER  NETWORK, PROVIDED THAT SUCH NETWORK INCLUDES SUFFICIENT HEALTH
CARE PROFESSIONALS WHO ARE QUALIFIED BY SPECIFIC  EDUCATION,  EXPERIENCE
AND  CREDENTIALS TO PROVIDE THE COVERED BENEFITS DESCRIBED IN THIS PARA-
GRAPH.
  (B) NO INSURER, CORPORATION, OR HEALTH MAINTENANCE ORGANIZATION  SHALL
IMPOSE UPON ANY PERSON RECEIVING BENEFITS PURSUANT TO THIS PARAGRAPH ANY
COPAYMENT,  FEE,  POLICY  YEAR  OR  CALENDAR YEAR, OR DURATIONAL BENEFIT
LIMITATION OR MAXIMUM FOR BENEFITS  OR  SERVICES  THAT  IS  NOT  EQUALLY
IMPOSED UPON ALL INDIVIDUALS IN THE SAME BENEFIT CATEGORY.
  (C)  THIS  PARAGRAPH  SHALL  NOT  APPLY TO SHORT-TERM TRAVEL, ACCIDENT
ONLY, LIMITED OR SPECIFIED DISEASE, OR INDIVIDUAL CONVERSION POLICIES OR
CONTRACTS, NOR TO POLICIES OR CONTRACTS DESIGNED FOR ISSUANCE TO PERSONS
ELIGIBLE FOR COVERAGE UNDER TITLE XVIII  OF  THE  SOCIAL  SECURITY  ACT,
KNOWN  AS MEDICARE, OR ANY OTHER SIMILAR COVERAGE UNDER STATE OR FEDERAL
GOVERNMENTAL PLANS.
  (D) FOR PURPOSES OF THIS PARAGRAPH, A  "MANAGED  CARE  PRODUCT"  SHALL
MEAN  A POLICY WHICH REQUIRES THAT MEDICAL OR OTHER HEALTH CARE SERVICES
COVERED UNDER  THE  POLICY,  OTHER  THAN  EMERGENCY  CARE  SERVICES,  BE
PROVIDED BY, OR PURSUANT TO A REFERRAL FROM A PRIMARY CARE PROVIDER, AND
THAT  SERVICES  PROVIDED  PURSUANT  TO  SUCH A REFERRAL BE RENDERED BY A
HEALTH CARE PROVIDER PARTICIPATING IN THE INSURER'S MANAGED CARE PROVID-
ER NETWORK. IN ADDITION, A MANAGED CARE  PRODUCT  SHALL  ALSO  MEAN  THE
IN-NETWORK  PORTION  OF  A CONTRACT WHICH REQUIRES THAT MEDICAL OR OTHER
HEALTH CARE SERVICES COVERED UNDER THE CONTRACT,  OTHER  THAN  EMERGENCY
CARE  SERVICES, BE PROVIDED BY, OR PURSUANT TO A REFERRAL FROM A PRIMARY
CARE PROVIDER, AND THAT SERVICES PROVIDED PURSUANT TO SUCH A REFERRAL BE
RENDERED BY A  HEALTH  CARE  PROVIDER  PARTICIPATING  IN  THE  INSURER'S
MANAGED  CARE  PROVIDER NETWORK, IN ORDER FOR THE INSURED TO BE ENTITLED
TO THE MAXIMUM REIMBURSEMENT UNDER THE CONTRACT.

A. 5324                             4

   (16) PATIENTS UNDERGOING ANY SURGERY OR RADIOTHERAPY PROCEDURE  SHALL
BE  PROVIDED  INFORMATION ON THE RISK OF LYMPHEDEMA ASSOCIATED WITH THAT
PROCEDURE, AND THE  POTENTIAL  POST-PROCEDURE  SYMPTOMS  OF  LYMPHEDEMA.
INFORMED  CONSENT  AGREEMENTS  FOR ALL SURGERIES AND RADIATION THERAPIES
SHALL  INCLUDE INFORMATION ON THE RISK OF LYMPHEDEMA ASSOCIATED WITH THE
ALTERNATIVE PROCEDURES.
  S 5. Paragraph 1 of subsection (x) of section 4303  of  the  insurance
law is amended by adding a new subparagraph (C) to read as follows:
  (C) PROSTHESES AND PHYSICAL COMPLICATIONS OF ALL STAGES OF MASTECTOMY,
INCLUDING LYMPHEDEMA;
  S  6.  Section  4303 of the insurance law is amended by adding two new
subsections (ff) and (gg) to read as follows:
  (FF) EVERY CONTRACT ISSUED BY A HOSPITAL SERVICE CORPORATION OR HEALTH
SERVICE CORPORATION WHICH PROVIDES HOSPITAL, SURGICAL, MEDICAL OR  MAJOR
MEDICAL  COVERAGE  SHALL PROVIDE COVERAGE FOR THE DIFFERENTIAL DIAGNOSIS
AND TREATMENT OF LYMPHEDEMA. SUCH COVERAGE SHALL INCLUDE, IN ADDITION TO
BENEFITS FOR A COURSE OF MANUAL LYMPH DRAINAGE WHOSE FREQUENCY AND DURA-
TION IS DETERMINED BY THE  TREATING  PHYSICIAN  OR  THERAPIST  BASED  ON
MEDICAL  NECESSITY  AND NOT BASED ON PHYSICAL THERAPY AND REHABILITATION
STANDARDS, BENEFITS FOR EQUIPMENT, SUPPLIES, DEVICES, COMPLEX  DECONGES-
TIVE THERAPY, AND OUT-PATIENT SELF-MANAGEMENT TRAINING AND EDUCATION FOR
THE TREATMENT OF LYMPHEDEMA, IF PRESCRIBED BY A HEALTH CARE PROFESSIONAL
LEGALLY  AUTHORIZED TO PRESCRIBE OR PROVIDE SUCH ITEMS UNDER TITLE EIGHT
OF THE EDUCATION  LAW.    LYMPHEDEMA  THERAPY  ADMINISTERED  UNDER  THIS
SECTION  SHALL  BE ADMINISTERED ONLY BY A THERAPIST CERTIFIED TO PERFORM
LYMPHEDEMA TREATMENT BY THE  LYMPHOLOGY  ASSOCIATION  OF  NORTH  AMERICA
(LANA)  OR  CERTIFIED  IN  ACCORDANCE  WITH  STANDARDS EQUIVALENT TO THE
CERTIFICATION STANDARDS OF LANA.   SUCH EQUIPMENT, SUPPLIES  OR  DEVICES
SHALL  INCLUDE,  BUT  NOT BE LIMITED TO, BANDAGES, COMPRESSION GARMENTS,
PADS, ORTHOTIC SHOES AND DEVICES, WITH  REPLACEMENTS  WHEN  REQUIRED  TO
MAINTAIN COMPRESSIVE FUNCTION OR TO ACCOMMODATE CHANGES IN THE PATIENT'S
DIMENSIONS.  COVERAGE  SHALL  BE  PROVIDED FOR FOLLOW-UP TREATMENTS WHEN
MEDICALLY REQUIRED OR TO PERIODICALLY VALIDATE HOME TECHNIQUES, TO MONI-
TOR PROGRESS AGAINST THE WRITTEN TREATMENT PLAN AND TO MODIFY THE TREAT-
MENT PLAN AS REQUIRED. NO INDIVIDUAL, OTHER THAN  A  LICENSED  PHYSICIAN
AND  SURGEON COMPETENT TO EVALUATE THE SPECIFIC CLINICAL ISSUES INVOLVED
IN THE CARE REQUESTED, MAY DENY REQUESTS  FOR  AUTHORIZATION  OF  HEALTH
CARE SERVICES PURSUANT TO THIS SECTION.
  (1)  A  POLICY WHICH IS A MANAGED HEALTH CARE PRODUCT MAY REQUIRE SUCH
HEALTH CARE PROFESSIONAL BE A MEMBER OF SUCH MANAGED HEALTH CARE  PLAN'S
PROVIDER  NETWORK, PROVIDED THAT SUCH NETWORK INCLUDES SUFFICIENT HEALTH
CARE PROFESSIONALS WHO ARE QUALIFIED BY SPECIFIC  EDUCATION,  EXPERIENCE
AND  CREDENTIALS  TO  PROVIDE  THE  COVERED  BENEFITS  DESCRIBED IN THIS
SUBSECTION.
  (2) NO INSURER, CORPORATION, OR HEALTH MAINTENANCE ORGANIZATION  SHALL
IMPOSE  UPON  ANY  PERSON RECEIVING BENEFITS PURSUANT TO THIS SUBSECTION
ANY COPAYMENT, FEE, POLICY YEAR OR CALENDAR YEAR, OR DURATIONAL  BENEFIT
LIMITATION  OR  MAXIMUM  FOR  BENEFITS  OR  SERVICES THAT IS NOT EQUALLY
IMPOSED UPON ALL INDIVIDUALS IN THE SAME BENEFIT CATEGORY.
  (3) THIS SUBSECTION SHALL NOT APPLY  TO  SHORT-TERM  TRAVEL,  ACCIDENT
ONLY, LIMITED OR SPECIFIED DISEASE, OR INDIVIDUAL CONVERSION POLICIES OR
CONTRACTS, NOR TO POLICIES OR CONTRACTS DESIGNED FOR ISSUANCE TO PERSONS
ELIGIBLE  FOR  COVERAGE  UNDER  TITLE  XVIII OF THE SOCIAL SECURITY ACT,
KNOWN AS MEDICARE, OR ANY OTHER SIMILAR COVERAGE UNDER STATE OR  FEDERAL
GOVERNMENTAL PLANS.

A. 5324                             5

  (4)  FOR  PURPOSES  OF THIS SUBSECTION, A "MANAGED CARE PRODUCT" SHALL
MEAN A POLICY WHICH REQUIRES THAT MEDICAL OR OTHER HEALTH CARE  SERVICES
COVERED  UNDER  THE  POLICY,  OTHER  THAN  EMERGENCY  CARE  SERVICES, BE
PROVIDED BY, OR PURSUANT TO A REFERRAL FROM A PRIMARY CARE PROVIDER, AND
THAT  SERVICES  PROVIDED  PURSUANT  TO  SUCH A REFERRAL BE RENDERED BY A
HEALTH CARE PROVIDER PARTICIPATING IN THE INSURER'S MANAGED CARE PROVID-
ER NETWORK. IN ADDITION, A MANAGED CARE  PRODUCT  SHALL  ALSO  MEAN  THE
IN-NETWORK  PORTION  OF  A CONTRACT WHICH REQUIRES THAT MEDICAL OR OTHER
HEALTH CARE SERVICES COVERED UNDER THE CONTRACT,  OTHER  THAN  EMERGENCY
CARE  SERVICES, BE PROVIDED BY, OR PURSUANT TO A REFERRAL FROM A PRIMARY
CARE PROVIDER, AND THAT SERVICES PROVIDED PURSUANT TO SUCH A REFERRAL BE
RENDERED BY A  HEALTH  CARE  PROVIDER  PARTICIPATING  IN  THE  INSURER'S
MANAGED  CARE  PROVIDER NETWORK, IN ORDER FOR THE INSURED TO BE ENTITLED
TO THE MAXIMUM REIMBURSEMENT UNDER THE CONTRACT.
  (GG) PATIENTS UNDERGOING ANY SURGERY OR RADIOTHERAPY  PROCEDURE  SHALL
BE  PROVIDED  INFORMATION ON THE RISK OF LYMPHEDEMA ASSOCIATED WITH THAT
PROCEDURE, AND THE  POTENTIAL  POST-PROCEDURE  SYMPTOMS  OF  LYMPHEDEMA.
INFORMED  CONSENT  AGREEMENTS  FOR ALL SURGERIES AND RADIATION THERAPIES
SHALL INCLUDE INFORMATION ON THE RISK OF LYMPHEDEMA ASSOCIATED WITH  THE
ALTERNATIVE PROCEDURES.
  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
insurance  policies,  contracts  and  plans  issued,  renewed, modified,
altered or amended on or after such effective date.