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

                                  6203

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                             March 17, 2015
                               ___________

Introduced  by  M.  of  A. PAULIN, STECK, GOTTFRIED, PERSAUD, ROSENTHAL,
  SIMOTAS, WRIGHT, ZEBROWSKI, SCARBOROUGH -- Multi-Sponsored by -- M. of
  A. COOK, PERRY, TITONE, WALKER  --  read  once  and  referred  to  the
  Committee on Insurance

AN  ACT  to  amend the insurance law, in relation to mandating insurance
  companies to provide coverage for non-experimental infertility  treat-
  ments

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

  Section 1. Paragraph 13 of subsection  (i)  of  section  3216  of  the
insurance  law,  as  added by chapter 897 of the laws of 1990 and renum-
bered by chapter 131 of the laws of 1992, is amended to read as follows:
  (13) (A) Every policy which provides coverage for hospital care  shall
not  exclude  coverage  for hospital care for diagnosis and treatment of
correctable medical conditions otherwise covered by  the  policy  solely
because the medical condition results in infertility[.]; PROVIDED HOWEV-
ER THAT:
  (I)  SUBJECT  TO THE PROVISIONS OF SUBPARAGRAPH (C) OF THIS PARAGRAPH,
IN NO CASE SHALL SUCH COVERAGE EXCLUDE SURGICAL  OR  MEDICAL  PROCEDURES
PROVIDED AS PART OF SUCH HOSPITAL CARE WHICH WOULD CORRECT MALFORMATION,
DISEASE OR DYSFUNCTION RESULTING IN INFERTILITY; AND
  (II)  PROVIDED,  FURTHER  HOWEVER,  THAT  SUBJECT TO THE PROVISIONS OF
SUBPARAGRAPH (C) OF THIS PARAGRAPH,  IN  NO  CASE  SHALL  SUCH  COVERAGE
EXCLUDE  DIAGNOSTIC TESTS AND PROCEDURES PROVIDED AS PART OF SUCH HOSPI-
TAL CARE THAT ARE NECESSARY TO DETERMINE INFERTILITY OR THAT ARE  NECES-
SARY   IN   CONNECTION  WITH  ANY  SURGICAL  OR  MEDICAL  TREATMENTS  OR
PRESCRIPTION DRUG COVERAGE PROVIDED PURSUANT TO THIS PARAGRAPH,  INCLUD-
ING SUCH DIAGNOSTIC TESTS AND PROCEDURES AS HYSTEROSALPINGOGRAM, HYSTER-
OSCOPY,  ENDOMETRIAL  BIOPSY, LAPAROSCOPY, SONO-HYSTEROGRAM, POST COITAL
TESTS, TESTIS BIOPSY, SEMEN ANALYSIS, BLOOD TESTS, ULTRASOUND, OVULATION
INDUCTION, INTRAUTERINE INSEMINATION, IN-VITRO FERTILIZATION, INTRACYTO-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD08328-02-5
              

A. 6203                             2

PLASMIC SPERM INJECTION, UTERINE EMBRYO LAVAGE, EMBRYO TRANSFER,  GAMETE
INTRA-FALLOPIAN  TRANSFER,  ZYGOTE  INTRA-FALLOPIAN  TRANSFER, LOW TUBAL
OVUM TRANSFER, DONOR EGGS, AND DONOR SPERM; AND
  (III)  PROVIDED,  FURTHER  HOWEVER,  EVERY  SUCH POLICY WHICH PROVIDES
COVERAGE FOR PRESCRIPTION DRUGS SHALL  INCLUDE,  WITHIN  SUCH  COVERAGE,
COVERAGE  FOR  PRESCRIPTION  DRUGS APPROVED BY THE FEDERAL FOOD AND DRUG
ADMINISTRATION FOR USE IN THE DIAGNOSIS AND TREATMENT OF INFERTILITY  IN
ACCORDANCE WITH SUBPARAGRAPH (C) OF THIS PARAGRAPH.
  (B) Every policy which provides coverage for surgical and medical care
shall  not  exclude coverage for surgical and medical care for diagnosis
and treatment of correctable medical conditions otherwise covered by the
policy solely because the medical condition results  in  infertility[.];
PROVIDED, HOWEVER THAT:
  (I)  SUBJECT  TO THE PROVISIONS OF SUBPARAGRAPH (C) OF THIS PARAGRAPH,
IN NO CASE SHALL SUCH COVERAGE EXCLUDE SURGICAL  OR  MEDICAL  PROCEDURES
PROVIDED AS PART OF SUCH HOSPITAL CARE WHICH WOULD CORRECT MALFORMATION,
DISEASE OR DYSFUNCTION RESULTING IN INFERTILITY; AND
  (II)  PROVIDED,  FURTHER  HOWEVER,  THAT  SUBJECT TO THE PROVISIONS OF
SUBPARAGRAPH (C) OF THIS PARAGRAPH,  IN  NO  CASE  SHALL  SUCH  COVERAGE
EXCLUDE  DIAGNOSTIC TESTS AND PROCEDURES PROVIDED AS PART OF SUCH HOSPI-
TAL CARE THAT ARE NECESSARY TO DETERMINE INFERTILITY OR THAT ARE  NECES-
SARY   IN   CONNECTION  WITH  ANY  SURGICAL  OR  MEDICAL  TREATMENTS  OR
PRESCRIPTION DRUG COVERAGE PROVIDED PURSUANT TO THIS PARAGRAPH,  INCLUD-
ING SUCH DIAGNOSTIC TESTS AND PROCEDURES AS HYSTEROSALPINGOGRAM, HYSTER-
OSCOPY,  ENDOMETRIAL  BIOPSY, LAPAROSCOPY, SONO-HYSTEROGRAM, POST COITAL
TESTS, TESTIS BIOPSY, SEMEN ANALYSIS, BLOOD TESTS, ULTRASOUND, OVULATION
INDUCTION, INTRAUTERINE INSEMINATION, IN-VITRO FERTILIZATION, INTRACYTO-
PLASMIC SPERM INJECTION, UTERINE EMBRYO LAVAGE, EMBRYO TRANSFER,  GAMETE
INTRA-FALLOPIAN  TRANSFER,  ZYGOTE  INTRA-FALLOPIAN  TRANSFER, LOW TUBAL
OVUM TRANSFER, DONOR EGGS, AND DONOR SPERM; AND
  (III) PROVIDED, FURTHER HOWEVER,  EVERY  SUCH  POLICY  WHICH  PROVIDES
COVERAGE  FOR  PRESCRIPTION  DRUGS  SHALL INCLUDE, WITHIN SUCH COVERAGE,
COVERAGE FOR PRESCRIPTION DRUGS APPROVED BY THE FEDERAL  FOOD  AND  DRUG
ADMINISTRATION  FOR USE IN THE DIAGNOSIS AND TREATMENT OF INFERTILITY IN
ACCORDANCE WITH SUBPARAGRAPH (C) OF THIS PARAGRAPH.
  (C)  COVERAGE  OF  DIAGNOSTIC  AND  TREATMENT  PROCEDURES,   INCLUDING
PRESCRIPTION  DRUGS,  USED IN THE DIAGNOSIS AND TREATMENT OF INFERTILITY
AS REQUIRED BY SUBPARAGRAPHS (A) AND (B)  OF  THIS  PARAGRAPH  SHALL  BE
PROVIDED IN ACCORDANCE WITH THE PROVISIONS OF THIS SUBPARAGRAPH.
  (I) COVERAGE SHALL BE PROVIDED FOR PERSONS WHOSE AGES RANGE FROM TWEN-
TY-ONE  THROUGH  FORTY-FOUR  YEARS OF AGE, PROVIDED THAT NOTHING IN THIS
SUBPARAGRAPH SHALL PRECLUDE THE PROVISION OF COVERAGE TO  PERSONS  WHOSE
AGE IS BELOW OR ABOVE SUCH RANGE.
  (II)  DIAGNOSIS  AND  TREATMENT  OF INFERTILITY SHALL BE PRESCRIBED AS
PART OF A PHYSICIAN'S OVERALL PLAN  OF  CARE  AND  CONSISTENT  WITH  THE
GUIDELINES FOR COVERAGE AS REFERENCED IN THIS SUBPARAGRAPH.
  (III)  COVERAGE MAY BE SUBJECT TO CO-PAYMENTS, COINSURANCE AND DEDUCT-
IBLES AS MAY BE DEEMED APPROPRIATE BY  THE  SUPERINTENDENT  AND  AS  ARE
CONSISTENT  WITH  THOSE  ESTABLISHED  FOR  OTHER BENEFITS WITHIN A GIVEN
POLICY.
  (IV) COVERAGE SHALL BE LIMITED TO  THOSE  INDIVIDUALS  WHO  HAVE  BEEN
PREVIOUSLY COVERED UNDER THE POLICY FOR A PERIOD OF NOT LESS THAN TWELVE
MONTHS,  PROVIDED  THAT FOR THE PURPOSES OF THIS SUBPARAGRAPH "PERIOD OF
NOT LESS THAN TWELVE MONTHS" SHALL BE  DETERMINED  BY  CALCULATING  SUCH
TIME FROM EITHER THE DATE THE INSURED WAS FIRST COVERED UNDER THE EXIST-

A. 6203                             3

ING POLICY OR FROM THE DATE THE INSURED WAS FIRST COVERED BY A PREVIOUS-
LY IN-FORCE CONVERTED POLICY, WHICHEVER IS EARLIER.
  (V) COVERAGE SHALL NOT BE REQUIRED TO INCLUDE THE DIAGNOSIS AND TREAT-
MENT OF INFERTILITY IN CONNECTION WITH:
  (I) THE REVERSAL OF ELECTIVE STERILIZATIONS;
  (II) SEX CHANGE PROCEDURES;
  (III) CLONING; OR
  (IV)  MEDICAL OR SURGICAL SERVICES OR PROCEDURES THAT ARE DEEMED TO BE
EXPERIMENTAL IN ACCORDANCE WITH CLINICAL GUIDELINES REFERENCED IN CLAUSE
(VI) OF THIS SUBPARAGRAPH.
  (VI) THE SUPERINTENDENT, IN  CONSULTATION  WITH  THE  COMMISSIONER  OF
HEALTH,  SHALL  PROMULGATE  REGULATIONS WHICH SHALL STIPULATE THE GUIDE-
LINES AND STANDARDS WHICH SHALL BE USED IN CARRYING OUT  THE  PROVISIONS
OF THIS SUBPARAGRAPH, WHICH SHALL INCLUDE:
  (I)  THE  DETERMINATION OF "INFERTILITY" IN ACCORDANCE WITH THE STAND-
ARDS AND GUIDELINES ESTABLISHED AND ADOPTED BY THE AMERICAN  COLLEGE  OF
OBSTETRICIANS  AND  GYNECOLOGISTS AND THE AMERICAN SOCIETY FOR REPRODUC-
TIVE MEDICINE;
  (II) THE IDENTIFICATION OF EXPERIMENTAL PROCEDURES AND TREATMENTS  NOT
COVERED  FOR  THE  DIAGNOSIS  AND TREATMENT OF INFERTILITY DETERMINED IN
ACCORDANCE WITH THE STANDARDS AND GUIDELINES ESTABLISHED AND ADOPTED  BY
THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS AND THE AMERICAN
SOCIETY FOR REPRODUCTIVE MEDICINE;
  (III)  THE  IDENTIFICATION  OF  THE  REQUIRED TRAINING, EXPERIENCE AND
OTHER STANDARDS FOR HEALTH CARE PROVIDERS FOR THE  PROVISION  OF  PROCE-
DURES  AND  TREATMENTS  FOR  THE  DIAGNOSIS AND TREATMENT OF INFERTILITY
DETERMINED IN ACCORDANCE WITH THE STANDARDS AND  GUIDELINES  ESTABLISHED
AND  ADOPTED  BY THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS
AND THE AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE; AND
  (IV) THE DETERMINATION OF APPROPRIATE MEDICAL CANDIDATES BY THE TREAT-
ING PHYSICIAN IN ACCORDANCE WITH THE  STANDARDS  AND  GUIDELINES  ESTAB-
LISHED AND ADOPTED BY THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOL-
OGISTS AND/OR THE AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE.
  (VII)  A  POLICY  PROVIDING COVERAGE UNDER THIS PARAGRAPH MAY HAVE THE
FOLLOWING REQUIREMENTS AND LIMITATIONS:
  (I) LIMIT COVERAGE FOR IN-VITRO FERTILIZATION, GAMETE  INTRA-FALLOPIAN
TRANSFER, ZYGOTE INTRA-FALLOPIAN TRANSFER AND LOW TUBAL OVUM TRANSFER TO
THOSE INDIVIDUALS WHO HAVE BEEN UNABLE TO CONCEIVE OR PRODUCE CONCEPTION
OR  SUSTAIN  A SUCCESSFUL PREGNANCY THROUGH LESS EXPENSIVE AND MEDICALLY
VIABLE INFERTILITY TREATMENT OR PROCEDURES COVERED UNDER SUCH A POLICY;
  (II) NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO DENY THE  COVER-
AGE  REQUIRED BY THIS SECTION TO ANY INDIVIDUAL WHO FORGOES A PARTICULAR
INFERTILITY TREATMENT OR PROCEDURE IF THE INDIVIDUAL'S PHYSICIAN  DETER-
MINES THAT SUCH A TREATMENT OR PROCEDURE IS LIKELY TO BE UNSUCCESSFUL;
  (III) LIMIT COVERAGE TO A LIFETIME CAP OF ONE HUNDRED THOUSAND DOLLARS
FOR  OVULATION INDUCTION, INTRAUTERINE INSEMINATION, IN-VITRO FERTILIZA-
TION, INTRACYTOPLASMIC SPERM INJECTION, UTERINE  EMBRYO  LAVAGE,  EMBRYO
TRANSFER, GAMETE INTRA-FALLOPIAN TRANSFER, ZYGOTE INTRA-FALLOPIAN TRANS-
FER, LOW TUBAL OVUM TRANSFER, DONOR EGGS, AND DONOR SPERM;
  (IV)  REQUIRE  DISCLOSURE  BY  THE INDIVIDUAL SEEKING SUCH COVERAGE TO
SUCH INDIVIDUAL'S EXISTING HEALTH  INSURANCE  CARRIER  OF  ANY  PREVIOUS
INFERTILITY  TREATMENT  OR PROCEDURES FOR WHICH SUCH INDIVIDUAL RECEIVED
COVERAGE UNDER A DIFFERENT  HEALTH  INSURANCE  POLICY.  SUCH  DISCLOSURE
SHALL BE MADE ON A FORM AND IN THE MANNER PRESCRIBED BY THE COMMISSIONER
OF THE DEPARTMENT OF FINANCIAL SERVICES.

A. 6203                             4

  S  2.  Subparagraphs (A), (B) and (C) of paragraph 6 of subsection (k)
of section 3221 of the insurance law, as amended by section 1 of part  K
of chapter 82 of the laws of 2002, are amended to read as follows:
  (A)  Every  group  policy  issued  or  delivered  in  this state which
provides coverage for hospital  care  shall  not  exclude  coverage  for
hospital  care for diagnosis and treatment of correctable medical condi-
tions [otherwise covered by  the  policy]  solely  because  the  medical
condition results in infertility; provided, however that:
  (i)  subject  to the provisions of subparagraph (C) of this paragraph,
in no case shall such coverage exclude surgical  or  medical  procedures
provided as part of such hospital care which would correct malformation,
disease or dysfunction resulting in infertility; and
  (ii)  provided,  further  however,  that  subject to the provisions of
subparagraph (C) of this paragraph,  in  no  case  shall  such  coverage
exclude  diagnostic tests and procedures provided as part of such hospi-
tal care that are necessary to determine infertility or that are  neces-
sary   in   connection  with  any  surgical  or  medical  treatments  or
prescription drug coverage provided pursuant to this paragraph,  includ-
ing such diagnostic tests and procedures as hysterosalpingogram, hyster-
oscopy,  endometrial  biopsy, laparoscopy, sono-hysterogram, post coital
tests, testis biopsy, semen analysis,  blood  tests  [and],  ultrasound,
OVULATION  INDUCTION, INTRAUTERINE INSEMINATION, IN-VITRO FERTILIZATION,
INTRACYTOPLASMIC SPERM INJECTION, UTERINE EMBRYO LAVAGE,  EMBRYO  TRANS-
FER,  GAMETE  INTRA-FALLOPIAN TRANSFER, ZYGOTE INTRA-FALLOPIAN TRANSFER,
LOW TUBAL OVUM TRANSFER, DONOR EGGS, AND DONOR SPERM; and
  (iii) provided, further however,  every  such  policy  which  provides
coverage  for  prescription  drugs  shall include, within such coverage,
coverage for prescription drugs approved by the federal  Food  and  Drug
Administration  for use in the diagnosis and treatment of infertility in
accordance with subparagraph (C) of this paragraph.
  (B) Every group  policy  issued  or  delivered  in  this  state  which
provides coverage for surgical and medical care shall not exclude cover-
age for surgical and medical care for diagnosis and treatment of correc-
table  medical  conditions  [otherwise  covered  by  the  policy] solely
because the medical condition results in infertility; provided,  however
that:
  (i)  subject  to the provisions of subparagraph (C) of this paragraph,
in no case shall such coverage exclude surgical  or  medical  procedures
which  would  correct  malformation, disease or dysfunction resulting in
infertility; and
  (ii) provided, further however, that  subject  to  the  provisions  of
subparagraph  (C)  of  this  paragraph,  in  no case shall such coverage
exclude diagnostic tests and procedures that are necessary to  determine
infertility  or  that  are  necessary in connection with any surgical or
medical treatments or prescription drug coverage  provided  pursuant  to
this  paragraph,  including  such  diagnostic  tests  and  procedures as
hysterosalpingogram,  hysteroscopy,  endometrial  biopsy,   laparoscopy,
sono-hysterogram,  post  coital  tests,  testis  biopsy, semen analysis,
blood tests [and], ultrasound, OVULATION INDUCTION, INTRAUTERINE INSEMI-
NATION,  IN-VITRO  FERTILIZATION,  INTRACYTOPLASMIC   SPERM   INJECTION,
UTERINE EMBRYO LAVAGE, EMBRYO TRANSFER, GAMETE INTRA-FALLOPIAN TRANSFER,
ZYGOTE  INTRA-FALLOPIAN  TRANSFER,  LOW TUBAL OVUM TRANSFER, DONOR EGGS,
AND DONOR SPERM; and
  (iii) provided, further however,  every  such  policy  which  provides
coverage  for  prescription  drugs  shall include, within such coverage,
coverage for prescription drugs approved by the federal  Food  and  Drug

A. 6203                             5

Administration  for use in the diagnosis and treatment of infertility in
accordance with subparagraph (C) of this paragraph.
  (C)   Coverage  of  diagnostic  and  treatment  procedures,  including
prescription drugs, used in the diagnosis and treatment  of  infertility
as  required  by  subparagraphs  (A)  and (B) of this paragraph shall be
provided in accordance with the provisions of this subparagraph.
  (i) Coverage shall be provided for persons whose ages range from twen-
ty-one through forty-four years,  provided  that  nothing  herein  shall
preclude  the  provision  of  coverage  to persons whose age is below or
above such range.
  (ii) Diagnosis and treatment of infertility  shall  be  prescribed  as
part  of  a  physician's  overall  plan  of care and consistent with the
guidelines for coverage as referenced in this subparagraph.
  (iii) Coverage may be subject to co-payments, coinsurance and  deduct-
ibles  as  may  be  deemed  appropriate by the superintendent and as are
consistent with those established for  other  benefits  within  a  given
policy.
  (iv)  Coverage  shall  be  limited  to those individuals who have been
previously covered under the policy for a period of not less than twelve
months, provided that for the purposes of this subparagraph  "period  of
not  less  than  twelve  months" shall be determined by calculating such
time from either the date the insured was first covered under the exist-
ing policy or from the date the insured was first covered by a previous-
ly in-force converted policy, whichever is earlier.
  (v) Coverage shall not be required to include the diagnosis and treat-
ment of infertility in connection with:  (I)  [in  vitro  fertilization,
gamete  intrafallopian  tube  transfers  or  zygote  intrafallopian tube
transfers; (II)] the reversal of elective sterilizations;  [(III)]  (II)
sex  change  procedures;  [(IV)] (III) cloning; or [(V)] (IV) medical or
surgical services or procedures that are deemed to  be  experimental  in
accordance  with  clinical  guidelines referenced in clause (vi) of this
subparagraph.
  (vi) The superintendent, in  consultation  with  the  commissioner  of
health,  shall  promulgate  regulations which shall stipulate the guide-
lines and standards which shall be used in carrying out  the  provisions
of this subparagraph, which shall include:
  (I)  The  determination of "infertility" in accordance with the stand-
ards and guidelines established and adopted by the American  College  of
Obstetricians  and  Gynecologists and the American Society for Reproduc-
tive Medicine;
  (II) The identification of experimental procedures and treatments  not
covered  for  the  diagnosis  and treatment of infertility determined in
accordance with the standards and guidelines established and adopted  by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine;
  (III)  The  identification  of  the  required training, experience and
other standards for health care providers for the  provision  of  proce-
dures  and  treatments  for  the  diagnosis and treatment of infertility
determined in accordance with the standards and  guidelines  established
and  adopted  by the American College of Obstetricians and Gynecologists
and the American Society for Reproductive Medicine; and
  (IV) The determination of appropriate medical candidates by the treat-
ing physician in accordance with the  standards  and  guidelines  estab-
lished and adopted by the American College of Obstetricians and Gynecol-
ogists and/or the American Society for Reproductive Medicine.

A. 6203                             6

  (VII)  A  POLICY  PROVIDING COVERAGE UNDER THIS PARAGRAPH MAY HAVE THE
FOLLOWING REQUIREMENTS AND LIMITATIONS:
  (I)  LIMIT COVERAGE FOR IN-VITRO FERTILIZATION, GAMETE INTRA-FALLOPIAN
TRANSFER, ZYGOTE INTRA-FALLOPIAN TRANSFER AND LOW TUBAL OVUM TRANSFER TO
THOSE INDIVIDUALS WHO HAVE BEEN UNABLE TO CONCEIVE OR PRODUCE CONCEPTION
OR SUSTAIN A SUCCESSFUL PREGNANCY THROUGH LESS EXPENSIVE  AND  MEDICALLY
VIABLE INFERTILITY TREATMENT OR PROCEDURES COVERED UNDER SUCH A POLICY;
  (II)  NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO DENY THE COVER-
AGE REQUIRED BY THIS SECTION TO ANY INDIVIDUAL WHO FORGOES A  PARTICULAR
INFERTILITY  TREATMENT OR PROCEDURE IF THE INDIVIDUAL'S PHYSICIAN DETER-
MINES THAT SUCH A TREATMENT OR PROCEDURE IS LIKELY TO BE UNSUCCESSFUL;
  (III) LIMIT COVERAGE TO A LIFETIME CAP OF ONE HUNDRED THOUSAND DOLLARS
FOR OVULATION INDUCTION, INTRAUTERINE INSEMINATION, IN-VITRO  FERTILIZA-
TION,  INTRACYTOPLASMIC  SPERM  INJECTION, UTERINE EMBRYO LAVAGE, EMBRYO
TRANSFER, GAMETE INTRA-FALLOPIAN TRANSFER, ZYGOTE INTRA-FALLOPIAN TRANS-
FER, LOW TUBAL OVUM TRANSFER, DONOR EGGS, AND DONOR SPERM;
  (IV) REQUIRE DISCLOSURE BY THE INDIVIDUAL  SEEKING  SUCH  COVERAGE  TO
SUCH  INDIVIDUAL'S  EXISTING  HEALTH  INSURANCE  CARRIER OF ANY PREVIOUS
INFERTILITY TREATMENT OR PROCEDURES FOR WHICH SUCH  INDIVIDUAL  RECEIVED
COVERAGE  UNDER  A  DIFFERENT  HEALTH  INSURANCE POLICY. SUCH DISCLOSURE
SHALL BE MADE ON A FORM AND IN THE MANNER PRESCRIBED BY THE COMMISSIONER
OF THE DEPARTMENT OF FINANCIAL SERVICES.
  S 3. Paragraphs 1, 2 and 3 of subsection (s) of section  4303  of  the
insurance  law,  as  amended by section 2 of part K of chapter 82 of the
laws of 2002, are amended to read as follows:
  (1) A hospital service corporation or health service corporation which
provides coverage for hospital  care  shall  not  exclude  coverage  for
hospital  care for diagnosis and treatment of correctable medical condi-
tions [otherwise covered by  the  policy]  solely  because  the  medical
condition results in infertility; provided, however that:
  (A)  subject  to the provisions of paragraph three of this subsection,
in no case shall such coverage exclude surgical  or  medical  procedures
provided as part of such hospital care which would correct malformation,
disease or dysfunction resulting in infertility; and
  (B) provided, further however, that subject to the provisions of para-
graph  three  of this subsection, in no case shall such coverage exclude
diagnostic tests and procedures provided as part of such  hospital  care
that  are  necessary  to  determine infertility or that are necessary in
connection with any surgical or medical treatments or prescription  drug
coverage provided pursuant to this subsection, including such diagnostic
tests  and  procedures as hysterosalpingogram, hysteroscopy, endometrial
biopsy, laparoscopy, sono-hysterogram, post coital tests, testis biopsy,
semen analysis, blood  tests  [and],  ultrasound,  OVULATION  INDUCTION,
INTRAUTERINE   INSEMINATION,  IN-VITRO  FERTILIZATION,  INTRACYTOPLASMIC
SPERM  INJECTION,  UTERINE  EMBRYO  LAVAGE,  EMBRYO   TRANSFER,   GAMETE
INTRA-FALLOPIAN  TRANSFER,  ZYGOTE  INTRA-FALLOPIAN  TRANSFER, LOW TUBAL
OVUM TRANSFER, DONOR EGGS, AND DONOR SPERM; and
  (C) provided, further however, every such policy which provides cover-
age for prescription drugs shall include, within such coverage, coverage
for prescription drugs approved by the federal Food  and  Drug  Adminis-
tration for use in the diagnosis and treatment of infertility in accord-
ance with paragraph three of this subsection.
  (2)  A  medical  expense indemnity or health service corporation which
provides coverage for surgical and medical care shall not exclude cover-
age for surgical and medical care for diagnosis and treatment of correc-

A. 6203                             7

table medical conditions otherwise covered by the policy solely  because
the medical condition results in infertility; provided, however that:
  (A)  subject  to the provisions of paragraph three of this subsection,
in no case shall such coverage exclude surgical  or  medical  procedures
which  would  correct  malformation, disease or dysfunction resulting in
infertility; and
  (B) provided, further however, that subject to the provisions of para-
graph three of this subsection, in no case shall such  coverage  exclude
diagnostic  tests  and procedures that are necessary to determine infer-
tility or that are necessary in connection with any surgical or  medical
treatments  or  prescription  drug  coverage  provided  pursuant to this
subsection, including such diagnostic tests and procedures  as  hystero-
salpingogram, hysteroscopy, endometrial biopsy, laparoscopy, sono-hyste-
rogram,  post  coital  tests, testis biopsy, semen analysis, blood tests
[and],  ultrasound,  OVULATION  INDUCTION,  INTRAUTERINE   INSEMINATION,
IN-VITRO FERTILIZATION, INTRACYTOPLASMIC SPERM INJECTION, UTERINE EMBRYO
LAVAGE,  EMBRYO TRANSFER, GAMETE INTRA-FALLOPIAN TRANSFER, ZYGOTE INTRA-
FALLOPIAN TRANSFER, LOW TUBAL  OVUM  TRANSFER,  DONOR  EGGS,  AND  DONOR
SPERM; and
  (C) provided, further however, every such policy which provides cover-
age for prescription drugs shall include, within such coverage, coverage
for  prescription  drugs  approved by the federal Food and Drug Adminis-
tration for use in the diagnosis and treatment of infertility in accord-
ance with paragraph three of this subsection.
  (3)  Coverage  of  diagnostic  and  treatment  procedures,   including
prescription drugs used in the diagnosis and treatment of infertility as
required  by paragraphs one and two of this subsection shall be provided
in accordance with this paragraph.
  (A) Coverage shall be provided for persons whose ages range from twen-
ty-one through forty-four years,  provided  that  nothing  herein  shall
preclude  the  provision  of  coverage  to persons whose age is below or
above such range.
  (B) Diagnosis and treatment of infertility shall be prescribed as part
of a physician's overall plan of care and consistent with the guidelines
for coverage as referenced in this paragraph.
  (C) Coverage may be subject to co-payments,  coinsurance  and  deduct-
ibles  as  may  be  deemed  appropriate by the superintendent and as are
consistent with those established for  other  benefits  within  a  given
policy.
  (D)  Coverage  shall  be  limited  to  those individuals who have been
previously covered under the policy for a period of not less than twelve
months, provided that for the purposes of this paragraph "period of  not
less  than  twelve  months" shall be determined by calculating such time
from either the date the insured was first covered  under  the  existing
policy  or  from  the date the insured was first covered by a previously
in-force converted policy, whichever is earlier.
  (E) Coverage shall not be required to include the diagnosis and treat-
ment of infertility in connection with:  (i)  [in  vitro  fertilization,
gamete  intrafallopian  tube  transfers  or  zygote  intrafallopian tube
transfers; (ii)] the reversal of elective sterilizations;  [(iii)]  (II)
sex  change  procedures;  [(iv)] (III) cloning; or [(v)] (IV) medical or
surgical services or procedures that are deemed to  be  experimental  in
accordance  with  clinical  guidelines referenced in subparagraph (F) of
this paragraph.
  (F) The superintendent,  in  consultation  with  the  commissioner  of
health,  shall  promulgate  regulations which shall stipulate the guide-

A. 6203                             8

lines and standards which shall be used in carrying out  the  provisions
of this paragraph, which shall include:
  (i)  The  determination of "infertility" in accordance with the stand-
ards and guidelines established and adopted by the American  College  of
Obstetricians  and  Gynecologists and the American Society for Reproduc-
tive Medicine;
  (ii) The identification of experimental procedures and treatments  not
covered  for  the  diagnosis  and treatment of infertility determined in
accordance with the standards and guidelines established and adopted  by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine;
  (iii)  The  identification  of  the  required training, experience and
other standards for health care providers for the  provision  of  proce-
dures  and  treatments  for  the  diagnosis and treatment of infertility
determined in accordance with the standards and  guidelines  established
and  adopted  by the American College of Obstetricians and Gynecologists
and the American Society for Reproductive Medicine; and
  (iv) The determination of appropriate medical candidates by the treat-
ing physician in accordance with the  standards  and  guidelines  estab-
lished and adopted by the American College of Obstetricians and Gynecol-
ogists and/or the American Society for Reproductive Medicine.
  (G)  A  POLICY  PROVIDING  COVERAGE UNDER THIS SUBSECTION MAY HAVE THE
FOLLOWING REQUIREMENTS AND LIMITATIONS:
  (I) LIMIT COVERAGE FOR IN-VITRO FERTILIZATION, GAMETE  INTRA-FALLOPIAN
TRANSFER, ZYGOTE INTRA-FALLOPIAN TRANSFER AND LOW TUBAL OVUM TRANSFER TO
THOSE INDIVIDUALS WHO HAVE BEEN UNABLE TO CONCEIVE OR PRODUCE CONCEPTION
OR  SUSTAIN  A SUCCESSFUL PREGNANCY THROUGH LESS EXPENSIVE AND MEDICALLY
VIABLE INFERTILITY TREATMENT OR PROCEDURES COVERED UNDER SUCH A POLICY.
  (II) NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO DENY THE  COVER-
AGE  REQUIRED BY THIS SECTION TO ANY INDIVIDUAL WHO FORGOES A PARTICULAR
INFERTILITY TREATMENT OR PROCEDURE IF THE INDIVIDUAL'S PHYSICIAN  DETER-
MINES THAT SUCH A TREATMENT OR PROCEDURE IS LIKELY TO BE UNSUCCESSFUL;
  (III) LIMIT COVERAGE TO A LIFETIME CAP OF ONE HUNDRED THOUSAND DOLLARS
FOR  OVULATION INDUCTION, INTRAUTERINE INSEMINATION, IN-VITRO FERTILIZA-
TION, INTRACYTOPLASMIC SPERM INJECTION, UTERINE  EMBRYO  LAVAGE,  EMBRYO
TRANSFER, GAMETE INTRA-FALLOPIAN TRANSFER, ZYGOTE INTRA-FALLOPIAN TRANS-
FER, LOW TUBAL OVUM TRANSFER, DONOR EGGS, AND DONOR SPERM;
  (IV)  REQUIRE  DISCLOSURE  BY  THE INDIVIDUAL SEEKING SUCH COVERAGE TO
SUCH INDIVIDUAL'S EXISTING HEALTH  INSURANCE  CARRIER  OF  ANY  PREVIOUS
INFERTILITY  TREATMENT  OR PROCEDURES FOR WHICH SUCH INDIVIDUAL RECEIVED
COVERAGE UNDER A DIFFERENT  HEALTH  INSURANCE  POLICY.  SUCH  DISCLOSURE
SHALL BE MADE ON A FORM AND IN THE MANNER PRESCRIBED BY THE COMMISSIONER
OF THE DEPARTMENT OF FINANCIAL SERVICES.
  S 4. This act shall take effect immediately.