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

                                  3395

                       2011-2012 Regular Sessions

                          I N  A S S E M B L Y

                            January 25, 2011
                               ___________

Introduced by M. of A. MAISEL -- 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. Item (ii) of subparagraph (A) of paragraph 20 of subsection
(i)  of section 3216 of the insurance law, as added by chapter 21 of the
laws of 1997, is amended and a new  item  (iii)  is  added  to  read  as
follows:
  (ii)  surgery  and  reconstruction  of  the  other breast to produce a
symmetrical appearance; AND
  (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 28 and 29 to read as follows:
  (28) 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.
                                                           LBD00103-01-1
              

A. 3395                             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.
  (29) 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.  Item (ii) of subparagraph (A) of paragraph 10 of subsection (k)
of section 3221 of the insurance law, as added by chapter 21 of the laws
of 1997, is amended and a new item (iii) is added to read as follows:
  (ii) surgery and reconstruction of  the  other  breast  to  produce  a
symmetrical appearance; AND
  (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 17 and 18 to read as follows:

A. 3395                             3

  (17)  EVERY  GROUP  POLICY ISSUED OR ISSUED FOR DELIVERY IN THIS STATE
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 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

A. 3395                             4

MANAGED CARE PROVIDER NETWORK, IN ORDER FOR THE INSURED TO  BE  ENTITLED
TO THE MAXIMUM REIMBURSEMENT UNDER THE CONTRACT.
   (18)  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. Subparagraph (B) of paragraph 1 of subsection (x) of section 4303
of the insurance law, as added by chapter 21 of the  laws  of  1997,  is
amended and a new subparagraph (C) is added to read as follows:
  (B)  surgery  and  reconstruction  of  the  other  breast to produce a
symmetrical appearance; AND
  (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 (hh) and (ii) to read as follows:
  (HH) 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

A. 3395                             5

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.
  (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.
  (II)  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.