The New York State Senate

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

                                  8890

                       2019-2020 Regular Sessions

                          I N  A S S E M B L Y

                            December 30, 2019
                               ___________

Introduced  by M. of A. SIMON -- read once and referred to the Committee
  on Insurance

AN ACT to amend the insurance law, in relation  to  enacting  the  "Give
  Kids  a Chance - Carter's Law" mandating health insurance coverage for
  congenital anomalies

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

  Section  1.  Short  title. This act shall be known and may be cited as
the "Give Kids a Chance - Carter's Law".
  § 2. Subsection (a) of section 3216 of the insurance law is amended by
adding 5 new paragraphs 5, 6, 7, 8 and 9 to read as follows:
  (5) "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.
  (6)  "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.
  (7)  "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.
  (8) "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.

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

                                                           LBD14264-03-9

A. 8890                             2

  (9) "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.
  §  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

A. 8890                             3

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.
  § 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.

A. 8890                             4

  (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
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-

A. 8890                             5

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
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

A. 8890                             6

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.
  §  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.

A. 8890                             7

  (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.
  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.