Senate Bill S1965

                                
 
BILL NUMBER: S1965

SPONSOR: LITTLE
 
TITLE OF BILL:

An act to amend the insurance law, in relation to mandatory health
insurance coverage for cleft lip and cleft palate

 
PURPOSE:

To require coverage for treatment of conditions or illness related to or
developed as a result of cleft lip and/or palate.

 
SUMMARY OF PROVISIONS:

Section 1. Adds a new paragraph 34 to subsection (i) of § 3216 of the
insurance law to require every policy that provides coverage for hospi-
tal, surgical, or medical care to provide coverage for the assessment,
evaluation, treatment, management, and follow-up care of cleft lip and
cleft palate. Such coverage shall not be denied on the grounds that it
is for cosmetic purposes or is not for -a functional defect or impair-
              

ment.

Section 2. Adds a new paragraph 20 to subsection (1) of § 3221 of the
insurance law to require every group or blanket policy that provides
coverage for hospital, surgical, or medical care to provide coverage for
hospital, surgical, or medical care to provide coverage for the assess-
ment, evaluation, treatment, management, and follow-up care of cleft lip
and cleft palate. Such coverage shall not be denied on the grounds that
it is for cosmetic purposes or is not for a functional defect or impair-
ment.

Section 3. Adds a new subsection (oo) to § 4303 of the insurance law to
require every medical expense indemnity corporation, hospital service
corporation or health service corporation that provides coverage for
hospital, surgical or medical care to provide coverage for the assess-
ment, evaluation, treatment, management, and follow-up care of cleft lip
and cleft palate. Such coverage shall not be denied on the grounds that
it is for cosmetic purposes or is not for a functional defect or impair-
ment.

Section 4. Sets forth the effective date.

 
JUSTIFICATION:

Cleft lip and/or cleft palate is a congenital birth defect in which a
child is born with an unclosed lip and/or with the roof of the mouth
unclosed. That is, there is a gap in facial structure due to incomplete
fusion of skin, muscle and bone. This defect occurs during fetal devel-
opment. It cannot be prevented and there are no specific prenatal tests
to detect the abnormality. Uncorrected, the defect causes severe diffi-
culties with eating, breathing, speaking and hearing and presents gross
facial deformities.

With appropriate surgical treatment, bone grafts or orthodontic, pros-
thodontic and dental treatment and speech and hearing intervention,
individuals gain nearly full function and approximate normal facial
appearance. There is now no New York State requirement for full coverage
for cleft lip and/or palate.
Currently, health insurance coverage varies by insurer both as to what
is offered and as to how coverage is applied. While initial surgeries to
close the structural gaps are often covered, subsequent surgeries, bone
grafts, follow up treatment and orthodontic, prosthodontic and related
care are often not covered at all, are severely restricted in coverage
or are subject to individual negotiation or confrontation with insurers.

New York law should be clear, comprehensive and consistent. This is a
matter of fairness to the citizens of New York. It would also provide a
prudent investment in our most important resource: our children.

Passage of the bill would also provide equity to insurers who are now
forced to compete with each other on a field where they are forced to
guess how their competitors will apply coverage for cleft lip and/or
palate.

Other states currently mandate comprehensive coverage for cleft lip
and/or palate. Among them, Louisiana, Colorado, Maryland, Indiana, and
North Carolina have laws specifically requiring comprehensive coverage
for cleft lip and/or palate. New York should provide its citizens with
comprehensive coverage.

 
LEGISLATIVE HISTORY:

2017-18: S.3171A/A.6397A: Referred Insurance; Referred Insurance

 
FISCAL IMPLICATIONS:

None.

 
EFFECTIVE DATE:
Ninety days after it shall have become a law and shall apply to policies
and contracts issued, renewed, modified, altered or amended on or after
such date.