[ ] is old law to be omitted.
LBD14264-03-9
S. 7709 2
CIAL MALFORMATIONS, DISORDERS OF METABOLISM, AND OTHER CONDITIONS THAT
ARE MEDICALLY DIAGNOSED TO BE CONGENITAL ANOMALIES.
§ 3. Paragraph 4 of subsection (c) of section 3216 of the insurance
law is amended by adding a new subparagraph (D) to read as follows:
(D) (1) FOR THE PURPOSE OF THIS SUBPARAGRAPH, THE TERM "TREATMENT"
INCLUDES INPATIENT AND OUTPATIENT CARE AND SERVICES PERFORMED TO IMPROVE
OR RESTORE BODY FUNCTION, OR PERFORMED TO APPROXIMATE A NORMAL APPEAR-
ANCE, AS A RESULT OF A CONGENITAL ANOMALY AND SHALL NOT INCLUDE COSMETIC
SURGERY. INPATIENT AND OUTPATIENT CARE AND SERVICES SHALL INCLUDE TREAT-
MENT TO ANY AND ALL MISSING OR ABNORMAL BODY PARTS, INCLUDING TEETH, THE
ORAL CAVITY, AND THEIR ASSOCIATED STRUCTURES, THAT WOULD OTHERWISE BE
PROVIDED UNDER THE PLAN OR COVERAGE FOR ANY OTHER INJURY AND SICKNESS,
INCLUDING:
(I) ALL INPATIENT AND OUTPATIENT RECONSTRUCTIVE SERVICES AND PROCE-
DURES;
(II) ALL SERVICES, PROCEDURES, AND ADJUNCTIVE NEEDS, INCLUDING BUT NOT
LIMITED TO PROSTHETICS AND APPLIANCES, RESULTING FROM COMPLICATIONS;
(III) ADJUNCTIVE DENTAL, ORTHODONTIC OR PROSTHODONTIC SUPPORT FROM
BIRTH UNTIL THE MEDICAL OR SURGICAL TREATMENT OF THE ANOMALY HAS BEEN
COMPLETED, INCLUDING ONGOING OR SUBSEQUENT TREATMENT REQUIRED TO MAIN-
TAIN FUNCTION OR APPROXIMATE A NORMAL APPEARANCE;
(IV) PROCEDURES THAT DO NOT MATERIALLY RESTORE OR IMPROVE THE FUNCTION
OF THE BODY PART BEING TREATED; AND
(V) PROCEDURES FOR SECONDARY CONDITIONS AND FOLLOW-UP TREATMENTS.
(2) (I) EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE
BENEFITS FOR RECONSTRUCTIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL
TO OR FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES
OF THE INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT IS
PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL DISEASE OR
ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
(II) EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE BENE-
FITS FOR HABILITATIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL TO OR
FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES OF THE
INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT IS
PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL DISEASE OR
ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
(III) EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT MAY BE SUBJECT TO
ANNUAL DEDUCTIBLE, CO-PAYMENT, AND COINSURANCE PROVISIONS AS MAY BE
DEEMED APPROPRIATE AND AS ARE CONSISTENT WITH THOSE ESTABLISHED FOR
OTHER BENEFITS UNDER THE PLAN OR COVERAGE.
(IV) NO POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL:
A. DENY TO A PATIENT ELIGIBILITY OR CONTINUED ELIGIBILITY, TO ENROLL
OR TO RENEW, COVERAGE UNDER THE TERMS OF THE PLAN, SOLELY FOR THE
PURPOSE OF AVOIDING THE REQUIREMENTS OF THIS SUBPARAGRAPH; OR
B. PENALIZE OR OTHERWISE REDUCE OR LIMIT THE REIMBURSEMENT OF A TREAT-
ING PROVIDER, OR PROVIDE MONETARY OR OTHER INCENTIVES TO A TREATING
PROVIDER TO INDUCE THE PROVIDER TO PROVIDE CARE TO AN INDIVIDUAL PARTIC-
IPANT OR BENEFICIARY IN A MANNER INCONSISTENT WITH THIS SUBPARAGRAPH.
(V) WRITTEN NOTICE OF THE AVAILABILITY OF THE COVERAGE SHALL BE DELIV-
ERED TO THE PARTICIPANT UPON ENROLLMENT AND ANNUALLY THEREAFTER.
(3) (I) IN ACCORDANCE WITH SECTION FORTY-FOUR HUNDRED EIGHT OF THE
PUBLIC HEALTH LAW, AN ENROLLEE HAS THE RIGHT TO APPEAL ANY DENIAL OF
CARE THAT THE CARRIER DETERMINES IS NOT MEDICALLY NECESSARY OR EXPER-
IMENTAL.
(II) AN INTERNAL APPEAL OF DENIAL FILED BY AN ENROLLEE OR THE
ENROLLEE'S PROVIDER TO THE INSURANCE CARRIER REGARDING COVERAGE FOR
S. 7709 3
RECONSTRUCTIVE OR HABILITATIVE SERVICES TO TREAT A CONGENITAL ANOMALY
SHALL BE EXPEDITED BY THE CARRIER. THE HEALTH PLAN SHALL RESPOND ORALLY
WITH A DECISION WITHIN FORTY-EIGHT HOURS, FOLLOWED BY A CONFIRMATION IN
WRITING WITHIN SEVEN DAYS.
§ 4. Subsection (f) of section 4235 of the insurance law is amended by
adding a new paragraph 5 to read as follows:
(5) (A) AS USED IN THIS PARAGRAPH:
(I) "CONGENITAL ANOMALY" MEANS A MEDICALLY DIAGNOSED CONDITION EXIST-
ING AT OR FROM BIRTH THAT IS A DEVIATION FROM THE COMMON STRUCTURE OR
FUNCTION OF THE BODY, WHETHER CAUSED BY A HEREDITARY OR DEVELOPMENTAL
DISABILITY OR DISEASE.
(II) "COSMETIC SURGERY" MEANS SURGICAL AND NONSURGICAL ELECTIVE PROCE-
DURES THAT ENHANCE AND RESHAPE STRUCTURES OF THE BODY TO IMPROVE APPEAR-
ANCE AND CONFIDENCE, BUT ARE NOT NECESSARY TO IMPROVE BODY STRUCTURE OR
FUNCTION.
(III) "HABILITATIVE SERVICES" MEANS HEALTHCARE SERVICES THAT HELP AN
INDIVIDUAL KEEP, LEARN, OR IMPROVE SKILLS AND FUNCTIONING FOR DAILY
LIVING. HABILITATIVE SERVICES SHALL INCLUDE BUT IS NOT LIMITED TO PHYS-
ICAL AND OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY, AND SERVICES
FOR PEOPLE WITH DISABILITIES IN A VARIETY OF INPATIENT AND/OR OUTPATIENT
SETTINGS.
(IV) "RECONSTRUCTIVE SERVICES" MEANS PROCEDURES OR SURGERY THAT ARE
PERFORMED TO TREAT STRUCTURES OF THE BODY AFFECTED AESTHETICALLY OR
FUNCTIONALLY BY CONGENITAL ANOMALIES, DEVELOPMENTAL ABNORMALITIES, TRAU-
MA, INFECTION, TUMORS, OR DISEASE. RECONSTRUCTIVE SERVICES ARE INTENDED
TO IMPROVE FUNCTION AND ABILITY, AND MAY ALSO BE PERFORMED TO ACHIEVE A
MORE TYPICAL APPEARANCE OF THE AFFECTED STRUCTURE.
(V) "DEVIATION" MEANS AN ANOMALY THAT IMPAIRS THE FUNCTION OF THE BODY
AND INCLUDES BUT IS NOT LIMITED TO THE CONDITIONS OF CLEFT LIP, CLEFT
PALATE, WEBBED FINGERS OR TOES, SUPERNUMERARY TOES OR FINGERS, CRANIOFA-
CIAL MALFORMATIONS, DISORDERS OF METABOLISM, AND OTHER CONDITIONS THAT
ARE MEDICALLY DIAGNOSED TO BE CONGENITAL ANOMALIES.
(B) (I) FOR THE PURPOSE OF THIS PARAGRAPH, THE TERM "TREATMENT"
INCLUDES INPATIENT AND OUTPATIENT CARE AND SERVICES PERFORMED TO IMPROVE
OR RESTORE BODY FUNCTION, OR PERFORMED TO APPROXIMATE A NORMAL APPEAR-
ANCE, AS A RESULT OF A CONGENITAL ANOMALY AND SHALL NOT INCLUDE COSMETIC
SURGERY. INPATIENT AND OUTPATIENT CARE AND SERVICES SHALL INCLUDE TREAT-
MENT TO ANY AND ALL MISSING OR ABNORMAL BODY PARTS, INCLUDING TEETH, THE
ORAL CAVITY, AND THEIR ASSOCIATED STRUCTURES, THAT WOULD OTHERWISE BE
PROVIDED UNDER THE PLAN OR COVERAGE FOR ANY OTHER INJURY AND SICKNESS,
INCLUDING:
(I) ALL INPATIENT AND OUTPATIENT RECONSTRUCTIVE SERVICES AND PROCE-
DURES;
(II) ALL SERVICES, PROCEDURES, AND ADJUNCTIVE NEEDS, INCLUDING BUT NOT
LIMITED TO PROSTHETICS AND APPLIANCES, RESULTING FROM COMPLICATIONS;
(III) ADJUNCTIVE DENTAL, ORTHODONTIC OR PROSTHODONTIC SUPPORT FROM
BIRTH UNTIL THE MEDICAL OR SURGICAL TREATMENT OF THE ANOMALY HAS BEEN
COMPLETED, INCLUDING ONGOING OR SUBSEQUENT TREATMENT REQUIRED TO MAIN-
TAIN FUNCTION OR APPROXIMATE A NORMAL APPEARANCE;
(IV) PROCEDURES THAT DO NOT MATERIALLY RESTORE OR IMPROVE THE FUNCTION
OF THE BODY PART BEING TREATED; AND
(V) PROCEDURES FOR SECONDARY CONDITIONS AND FOLLOW-UP TREATMENTS.
(II) (I) EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE
BENEFITS FOR RECONSTRUCTIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL
TO OR FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES
OF THE INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT IS
S. 7709 4
PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL DISEASE OR
ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
(II) EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE BENE-
FITS FOR HABILITATIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL TO OR
FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES OF THE
INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT IS
PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL DISEASE OR
ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
(III) EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT MAY BE SUBJECT TO
ANNUAL DEDUCTIBLE, CO-PAYMENT, AND COINSURANCE PROVISIONS AS MAY BE
DEEMED APPROPRIATE AND AS ARE CONSISTENT WITH THOSE ESTABLISHED FOR
OTHER BENEFITS UNDER THE PLAN OR COVERAGE.
(IV) NO POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL:
A. DENY TO A PATIENT ELIGIBILITY OR CONTINUED ELIGIBILITY, TO ENROLL
OR TO RENEW, COVERAGE UNDER THE TERMS OF THE PLAN, SOLELY FOR THE
PURPOSE OF AVOIDING THE REQUIREMENTS OF THIS PARAGRAPH; OR
B. PENALIZE OR OTHERWISE REDUCE OR LIMIT THE REIMBURSEMENT OF A TREAT-
ING PROVIDER, OR PROVIDE MONETARY OR OTHER INCENTIVES TO A TREATING
PROVIDER TO INDUCE THE PROVIDER TO PROVIDE CARE TO AN INDIVIDUAL PARTIC-
IPANT OR BENEFICIARY IN A MANNER INCONSISTENT WITH THIS PARAGRAPH.
(V) WRITTEN NOTICE OF THE AVAILABILITY OF THE COVERAGE SHALL BE DELIV-
ERED TO THE PARTICIPANT UPON ENROLLMENT AND ANNUALLY THEREAFTER.
(III) (I) IN ACCORDANCE WITH SECTION FORTY-FOUR HUNDRED EIGHT OF THE
PUBLIC HEALTH LAW, AN ENROLLEE HAS THE RIGHT TO APPEAL ANY DENIAL OF
CARE THAT THE CARRIER DETERMINES IS NOT MEDICALLY NECESSARY OR EXPER-
IMENTAL.
(II) AN INTERNAL APPEAL OF DENIAL FILED BY AN ENROLLEE OR THE
ENROLLEE'S PROVIDER TO THE INSURANCE CARRIER REGARDING COVERAGE FOR
RECONSTRUCTIVE OR HABILITATIVE SERVICES TO TREAT A CONGENITAL ANOMALY
SHALL BE EXPEDITED BY THE CARRIER. THE HEALTH PLAN SHALL RESPOND ORALLY
WITH A DECISION WITHIN FORTY-EIGHT HOURS, FOLLOWED BY A CONFIRMATION IN
WRITING WITHIN SEVEN DAYS.
§ 5. Paragraph 1 of subsection (d) of section 4304 of the insurance
law is amended by adding a new subparagraph (D) to read as follows:
(D) (I) AS USED IN THIS PARAGRAPH:
1. "CONGENITAL ANOMALY" MEANS A MEDICALLY DIAGNOSED CONDITION EXISTING
AT OR FROM BIRTH THAT IS A DEVIATION FROM THE COMMON STRUCTURE OR FUNC-
TION OF THE BODY, WHETHER CAUSED BY A HEREDITARY OR DEVELOPMENTAL DISA-
BILITY OR DISEASE.
2. "COSMETIC SURGERY" MEANS SURGICAL AND NONSURGICAL ELECTIVE PROCE-
DURES THAT ENHANCE AND RESHAPE STRUCTURES OF THE BODY TO IMPROVE APPEAR-
ANCE AND CONFIDENCE, BUT ARE NOT NECESSARY TO IMPROVE BODY STRUCTURE OR
FUNCTION.
3. "HABILITATIVE SERVICES" MEANS HEALTHCARE SERVICES THAT HELP AN
INDIVIDUAL KEEP, LEARN, OR IMPROVE SKILLS AND FUNCTIONING FOR DAILY
LIVING. HABILITATIVE SERVICES SHALL INCLUDE BUT IS NOT LIMITED TO PHYS-
ICAL AND OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY, AND SERVICES
FOR PEOPLE WITH DISABILITIES IN A VARIETY OF INPATIENT AND/OR OUTPATIENT
SETTINGS.
4. "RECONSTRUCTIVE SERVICES" MEANS PROCEDURES OR SURGERY THAT ARE
PERFORMED TO TREAT STRUCTURES OF THE BODY AFFECTED AESTHETICALLY OR
FUNCTIONALLY BY CONGENITAL ANOMALIES, DEVELOPMENTAL ABNORMALITIES, TRAU-
MA, INFECTION, TUMORS, OR DISEASE. RECONSTRUCTIVE SERVICES ARE INTENDED
TO IMPROVE FUNCTION AND ABILITY, AND MAY ALSO BE PERFORMED TO ACHIEVE A
MORE TYPICAL APPEARANCE OF THE AFFECTED STRUCTURE.
S. 7709 5
5. "DEVIATION" MEANS AN ANOMALY THAT IMPAIRS THE FUNCTION OF THE BODY
AND INCLUDES BUT IS NOT LIMITED TO THE CONDITIONS OF CLEFT LIP, CLEFT
PALATE, WEBBED FINGERS OR TOES, SUPERNUMERARY TOES OR FINGERS, CRANIOFA-
CIAL MALFORMATIONS, DISORDERS OF METABOLISM, AND OTHER CONDITIONS THAT
ARE MEDICALLY DIAGNOSED TO BE CONGENITAL ANOMALIES.
(II) FOR THE PURPOSE OF THIS SUBPARAGRAPH, THE TERM "TREATMENT"
INCLUDES INPATIENT AND OUTPATIENT CARE AND SERVICES PERFORMED TO IMPROVE
OR RESTORE BODY FUNCTION, OR PERFORMED TO APPROXIMATE A NORMAL APPEAR-
ANCE, AS A RESULT OF A CONGENITAL ANOMALY AND SHALL NOT INCLUDE COSMETIC
SURGERY. INPATIENT AND OUTPATIENT CARE AND SERVICES SHALL INCLUDE TREAT-
MENT TO ANY AND ALL MISSING OR ABNORMAL BODY PARTS, INCLUDING TEETH, THE
ORAL CAVITY, AND THEIR ASSOCIATED STRUCTURES, THAT WOULD OTHERWISE BE
PROVIDED UNDER THE PLAN OR COVERAGE FOR ANY OTHER INJURY AND SICKNESS,
INCLUDING:
1. ALL INPATIENT AND OUTPATIENT RECONSTRUCTIVE SERVICES AND PROCE-
DURES;
2. ALL SERVICES, PROCEDURES, AND ADJUNCTIVE NEEDS, INCLUDING PROSTHET-
ICS AND APPLIANCES, RESULTING FROM COMPLICATIONS;
3. ADJUNCTIVE DENTAL, ORTHODONTIC OR PROSTHODONTIC SUPPORT FROM BIRTH
UNTIL THE MEDICAL OR SURGICAL TREATMENT OF THE ANOMALY HAS BEEN
COMPLETED, INCLUDING ONGOING OR SUBSEQUENT TREATMENT REQUIRED TO MAIN-
TAIN FUNCTION OR APPROXIMATE A NORMAL APPEARANCE;
4. PROCEDURES THAT DO NOT MATERIALLY RESTORE OR IMPROVE THE FUNCTION
OF THE BODY PART BEING TREATED; AND
5. PROCEDURES FOR SECONDARY CONDITIONS AND FOLLOW-UP TREATMENTS.
(III) 1. EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE
BENEFITS FOR RECONSTRUCTIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL
TO OR FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES
OF THE INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT IS
PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL DISEASE OR
ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
2. EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE BENEFITS
FOR HABILITATIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL TO OR
FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES OF THE
INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT IS
PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL DISEASE OR
ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
3. EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT MAY BE SUBJECT TO ANNU-
AL DEDUCTIBLE, CO-PAYMENT, AND COINSURANCE PROVISIONS AS MAY BE DEEMED
APPROPRIATE AND AS ARE CONSISTENT WITH THOSE ESTABLISHED FOR OTHER BENE-
FITS UNDER THE PLAN OR COVERAGE.
4. NO POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL:
A. DENY TO A PATIENT ELIGIBILITY OR CONTINUED ELIGIBILITY, TO ENROLL
OR TO RENEW, COVERAGE UNDER THE TERMS OF THE PLAN, SOLELY FOR THE
PURPOSE OF AVOIDING THE REQUIREMENTS OF THIS SUBPARAGRAPH; OR
B. PENALIZE OR OTHERWISE REDUCE OR LIMIT THE REIMBURSEMENT OF A TREAT-
ING PROVIDER, OR PROVIDE MONETARY OR OTHER INCENTIVES TO A TREATING
PROVIDER TO INDUCE THE PROVIDER TO PROVIDE CARE TO AN INDIVIDUAL PARTIC-
IPANT OR BENEFICIARY IN A MANNER INCONSISTENT WITH THIS SUBPARAGRAPH.
(IV) WRITTEN NOTICE OF THE AVAILABILITY OF THE COVERAGE SHALL BE
DELIVERED TO THE PARTICIPANT UPON ENROLLMENT AND ANNUALLY THEREAFTER.
(V) 1. IN ACCORDANCE WITH SECTION FORTY-FOUR HUNDRED EIGHT OF THE
PUBLIC HEALTH LAW, AN ENROLLEE HAS THE RIGHT TO APPEAL ANY DENIAL OF
CARE THAT THE CARRIER DETERMINES IS NOT MEDICALLY NECESSARY OR EXPER-
IMENTAL.
S. 7709 6
2. AN INTERNAL APPEAL OF DENIAL FILED BY AN ENROLLEE OR THE ENROLLEE'S
PROVIDER TO THE INSURANCE CARRIER REGARDING COVERAGE FOR RECONSTRUCTIVE
OR HABILITATIVE SERVICES TO TREAT A CONGENITAL ANOMALY SHALL BE EXPE-
DITED BY THE CARRIER. THE HEALTH PLAN SHALL RESPOND ORALLY WITH A DECI-
SION WITHIN FORTY-EIGHT HOURS, FOLLOWED BY A CONFIRMATION IN WRITING
WITHIN SEVEN DAYS.
§ 6. Paragraph 1 of subsection (c) of section 4305 of the insurance
law is amended by adding a new subparagraph (D) to read as follows:
(D)(I) AS USED IN THIS SUBPARAGRAPH:
1. "CONGENITAL ANOMALY" MEANS A MEDICALLY DIAGNOSED CONDITION EXISTING
AT OR FROM BIRTH THAT IS A DEVIATION FROM THE COMMON STRUCTURE OR FUNC-
TION OF THE BODY, WHETHER CAUSED BY A HEREDITARY OR DEVELOPMENTAL DISA-
BILITY OR DISEASE.
2. "COSMETIC SURGERY" MEANS SURGICAL AND NONSURGICAL ELECTIVE PROCE-
DURES THAT ENHANCE AND RESHAPE STRUCTURES OF THE BODY TO IMPROVE APPEAR-
ANCE AND CONFIDENCE, BUT ARE NOT NECESSARY TO IMPROVE BODY STRUCTURE OR
FUNCTION.
3. "HABILITATIVE SERVICES" MEANS HEALTHCARE SERVICES THAT HELP AN
INDIVIDUAL KEEP, LEARN, OR IMPROVE SKILLS AND FUNCTIONING FOR DAILY
LIVING. HABILITATIVE SERVICES SHALL INCLUDE BUT IS NOT LIMITED TO PHYS-
ICAL AND OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY, AND SERVICES
FOR PEOPLE WITH DISABILITIES IN A VARIETY OF INPATIENT AND/OR OUTPATIENT
SETTINGS.
4. "RECONSTRUCTIVE SERVICES" MEANS PROCEDURES OR SURGERY THAT ARE
PERFORMED TO TREAT STRUCTURES OF THE BODY AFFECTED AESTHETICALLY OR
FUNCTIONALLY BY CONGENITAL ANOMALIES, DEVELOPMENTAL ABNORMALITIES, TRAU-
MA, INFECTION, TUMORS, OR DISEASE. RECONSTRUCTIVE SERVICES ARE INTENDED
TO IMPROVE FUNCTION AND ABILITY, AND MAY ALSO BE PERFORMED TO ACHIEVE A
MORE TYPICAL APPEARANCE OF THE AFFECTED STRUCTURE.
5. "DEVIATION" MEANS AN ANOMALY THAT IMPAIRS THE FUNCTION OF THE BODY
AND INCLUDES BUT IS NOT LIMITED TO THE CONDITIONS OF CLEFT LIP, CLEFT
PALATE, WEBBED FINGERS OR TOES, SUPERNUMERARY TOES OR FINGERS, CRANIOFA-
CIAL MALFORMATIONS, DISORDERS OF METABOLISM, AND OTHER CONDITIONS THAT
ARE MEDICALLY DIAGNOSED TO BE CONGENITAL ANOMALIES.
(II) FOR THE PURPOSE OF THIS SUBPARAGRAPH, THE TERM "TREATMENT"
INCLUDES INPATIENT AND OUTPATIENT CARE AND SERVICES PERFORMED TO IMPROVE
OR RESTORE BODY FUNCTION, OR PERFORMED TO APPROXIMATE A NORMAL APPEAR-
ANCE, AS A RESULT OF A CONGENITAL ANOMALY AND SHALL NOT INCLUDE COSMETIC
SURGERY. INPATIENT AND OUTPATIENT CARE AND SERVICES SHALL INCLUDE TREAT-
MENT TO ANY AND ALL MISSING OR ABNORMAL BODY PARTS, INCLUDING TEETH, THE
ORAL CAVITY, AND THEIR ASSOCIATED STRUCTURES, THAT WOULD OTHERWISE BE
PROVIDED UNDER THE PLAN OR COVERAGE FOR ANY OTHER INJURY AND SICKNESS,
INCLUDING:
1. ALL INPATIENT AND OUTPATIENT RECONSTRUCTIVE SERVICES AND PROCE-
DURES;
2. ALL SERVICES, PROCEDURES, AND ADJUNCTIVE NEEDS, INCLUDING PROSTHET-
ICS AND APPLIANCES, RESULTING FROM COMPLICATIONS;
3. ADJUNCTIVE DENTAL, ORTHODONTIC OR PROSTHODONTIC SUPPORT FROM BIRTH
UNTIL THE MEDICAL OR SURGICAL TREATMENT OF THE ANOMALY HAS BEEN
COMPLETED, INCLUDING ONGOING OR SUBSEQUENT TREATMENT REQUIRED TO MAIN-
TAIN FUNCTION OR APPROXIMATE A NORMAL APPEARANCE;
4. PROCEDURES THAT DO NOT MATERIALLY RESTORE OR IMPROVE THE FUNCTION
OF THE BODY PART BEING TREATED; AND
5. PROCEDURES FOR SECONDARY CONDITIONS AND FOLLOW-UP TREATMENTS.
(III) 1. EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE
BENEFITS FOR RECONSTRUCTIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL
S. 7709 7
TO OR FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES
OF THE INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT IS
PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL DISEASE OR
ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
2. EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE BENEFITS
FOR HABILITATIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL TO OR
FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES OF THE
INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT IS
PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL DISEASE OR
ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
3. EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT MAY BE SUBJECT TO ANNU-
AL DEDUCTIBLE, CO-PAYMENT, AND COINSURANCE PROVISIONS AS MAY BE DEEMED
APPROPRIATE AND AS ARE CONSISTENT WITH THOSE ESTABLISHED FOR OTHER BENE-
FITS UNDER THE PLAN OR COVERAGE.
4. NO POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL:
A. DENY TO A PATIENT ELIGIBILITY OR CONTINUED ELIGIBILITY, TO ENROLL
OR TO RENEW, COVERAGE UNDER THE TERMS OF THE PLAN, SOLELY FOR THE
PURPOSE OF AVOIDING THE REQUIREMENTS OF THIS SUBPARAGRAPH; OR
B. PENALIZE OR OTHERWISE REDUCE OR LIMIT THE REIMBURSEMENT OF A TREAT-
ING PROVIDER OR PROVIDE MONETARY OR OTHER INCENTIVES TO A TREATING
PROVIDER TO INDUCE THE PROVIDER TO PROVIDE CARE TO AN INDIVIDUAL PARTIC-
IPANT OR BENEFICIARY IN A MANNER INCONSISTENT WITH THIS SUBPARAGRAPH.
(IV) WRITTEN NOTICE OF THE AVAILABILITY OF THE COVERAGE SHALL BE
DELIVERED TO THE PARTICIPANT UPON ENROLLMENT AND ANNUALLY THEREAFTER.
(V) 1. IN ACCORDANCE WITH SECTION FORTY-FOUR HUNDRED EIGHT OF THE
PUBLIC HEALTH LAW, AN ENROLLEE HAS THE RIGHT TO APPEAL ANY DENIAL OF
CARE THAT THE CARRIER DETERMINES IS NOT MEDICALLY NECESSARY OR EXPER-
IMENTAL.
2. AN INTERNAL APPEAL OF DENIAL FILED BY AN ENROLLEE OR THE ENROLLEE'S
PROVIDER TO THE INSURANCE CARRIER REGARDING COVERAGE FOR RECONSTRUCTIVE
OR HABILITATIVE SERVICES TO TREAT A CONGENITAL ANOMALY SHALL BE EXPE-
DITED BY THE CARRIER. THE HEALTH PLAN SHALL RESPOND ORALLY WITH A DECI-
SION WITHIN FORTY-EIGHT HOURS, FOLLOWED BY A CONFIRMATION IN WRITING
WITHIN SEVEN DAYS.
§ 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
policies and contracts issued, renewed, modified, altered or amended on
or after such date.
