S T A T E O F N E W Y O R K
________________________________________________________________________
11406
I N A S S E M B L Y
May 15, 2026
___________
Introduced by COMMITTEE ON RULES -- (at request of M. of A. Ramos) --
read once and referred to the Committee on Insurance
AN ACT to amend the insurance law, the social services law and the
public health law, in relation to requiring certain health insurance
coverage for prostheses and custom orthoses
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Subsection (i) of section 3216 of the insurance law is
amended by adding a new paragraph 42 to read as follows:
(42) (A) EVERY POLICY THAT PROVIDES COVERAGE FOR HOSPITAL, MEDICAL OR
SURGICAL EXPENSES SHALL INCLUDE COVERAGE FOR PROSTHETIC AND ORTHOTIC
DEVICES THAT EQUALS THE COVERAGE AND PAYMENT PROVIDED FOR BY FEDERAL
LAWS AND REGULATIONS FOR THE AGED AND DISABLED PURSUANT TO 42 U.S.C.,
SECTIONS 1395K, 1395L AND 1395M AND 42 C.F.R., SECTIONS 414.202,
414.210, 414.228 AND 410.100, AND ANY SUCCESSOR REGULATIONS, INCLUDING
PAYMENT AT A RATE NO LESS THAN THE CURRENT QUARTER'S MEDICARE DURABLE
MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES FEE SCHEDULE
ESTABLISHED BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES FOR PROS-
THETIC AND ORTHOTIC DEVICES AND SERVICES.
(B) COVERAGE PROVIDED UNDER THIS PARAGRAPH SHALL INCLUDE:
(I) A PROSTHETIC OR ORTHOTIC DEVICE DETERMINED BY THE ENROLLEE'S
HEALTH CARE PROVIDER TO BE THE MOST APPROPRIATE MODEL THAT ADEQUATELY
MEETS THE MEDICAL NEEDS OF SUCH ENROLLEE;
(II) A PROSTHETIC OR CUSTOM ORTHOTIC DEVICE DETERMINED BY THE
ENROLLEE'S HEALTH CARE PROVIDER TO BE THE MOST APPROPRIATE MODEL THAT
MEETS THE MEDICAL NEEDS OF SUCH ENROLLEE FOR PURPOSES OF PERFORMING
PHYSICAL ACTIVITIES, INCLUDING, BUT NOT LIMITED TO, RUNNING, BIKING,
SWIMMING, STRENGTH TRAINING, AND TO MAXIMIZE SUCH ENROLLEE'S WHOLE-BODY
HEALTH AND LOWER AND/OR UPPER LIMB FUNCTION;
(III) A PROSTHETIC OR CUSTOM ORTHOTIC DEVICE DETERMINED BY THE
ENROLLEE'S HEALTH CARE PROVIDER TO BE THE MOST APPROPRIATE MODEL THAT
MEETS THE MEDICAL NEEDS OF SUCH ENROLLEE FOR PURPOSES OF SHOWERING OR
BATHING;
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD15475-02-6
A. 11406 2
(IV) ALL MATERIALS AND COMPONENTS NECESSARY FOR THE USE OF THE
PROSTHESES AND ORTHOSES;
(V) INSTRUCTION TO THE ENROLLEE ON USING THE DEVICE; AND
(VI) WITH RESPECT TO THE PROSTHESES AND ORTHOSES COVERED UNDER ITEMS
(I), (II), AND (III) OF THIS SUBPARAGRAPH, THE MEDICALLY NECESSARY
REPAIR OR REPLACEMENT OF SUCH PROSTHETIC OR ORTHOTIC DEVICE.
(C) FOR AN ENROLLEE TO RECEIVE A PROSTHESIS OR ORTHOSIS UNDER ITEMS
(I), (II), AND (III) OF SUBPARAGRAPH (B) OF THIS PARAGRAPH, THE TREATING
HEALTH CARE PROVIDER SHALL BE REQUIRED TO DETERMINE WHETHER THE ADDI-
TIONAL PROSTHETIC OR CUSTOM ORTHOTIC DEVICE IS NECESSARY TO ENABLE SUCH
ENROLLEE TO ENGAGE IN PHYSICAL ACTIVITIES, AS APPLICABLE, INCLUDING, BUT
NOT LIMITED TO, RUNNING, BIKING, SWIMMING, STRENGTH TRAINING, SHOWERING,
BATHING, AND TO MAXIMIZE ENROLLEE'S WHOLE-BODY HEALTH AND LOWER AND/OR
UPPER LIMB FUNCTION.
(D) EVERY POLICY THAT IS DELIVERED, ISSUED FOR DELIVERY OR RENEWED IN
THIS STATE THAT PROVIDES COVERAGE FOR PROSTHETIC AND CUSTOM ORTHOTIC
DEVICES SHALL CONSIDER SUCH DEVICES HABILITATIVE OR REHABILITATIVE BENE-
FITS FOR THE PURPOSES OF ANY STATE OR FEDERAL REQUIREMENT FOR COVERAGE
OF ESSENTIAL HEALTH BENEFITS.
(E) AN INSURER SHALL NOT DENY A PROSTHETIC OR ORTHOTIC BENEFIT FOR AN
INDIVIDUAL WITH LIMB LOSS OR ABSENCE THAT WOULD OTHERWISE BE COVERED FOR
A NON-DISABLED INDIVIDUAL SEEKING MEDICAL OR SURGICAL INTERVENTION TO
RESTORE OR MAINTAIN THE ABILITY TO PERFORM THE SAME PHYSICAL ACTIVITY.
(F) PROSTHETIC AND CUSTOM ORTHOTIC DEVICE COVERAGE SHALL NOT BE
SUBJECT TO SEPARATE FINANCIAL REQUIREMENTS THAT ARE APPLICABLE ONLY WITH
RESPECT TO THAT COVERAGE. COST-SHARING MAY BE IMPOSED ON PROSTHETIC OR
CUSTOM ORTHOTIC DEVICES; PROVIDED, HOWEVER, THAT ANY COST-SHARING
REQUIREMENTS SHALL NOT BE MORE RESTRICTIVE THAN THE COST-SHARING
REQUIREMENTS APPLICABLE TO COVERAGE FOR INPATIENT PHYSICIAN AND SURGICAL
SERVICES.
(G) (I) IF COVERAGE FOR PROSTHETIC OR CUSTOM ORTHOTIC DEVICES IS
PROVIDED, PAYMENT SHALL BE MADE FOR THE REPLACEMENT OF SUCH PROSTHETIC
OR CUSTOM ORTHOTIC DEVICE OR FOR THE REPLACEMENT OF ANY PART OF SUCH
DEVICES, WITHOUT REGARD TO CONTINUOUS USE OR USEFUL LIFETIME
RESTRICTIONS, IF AN ORDERING HEALTH CARE PROVIDER DETERMINES THAT THE
PROVISION OF A REPLACEMENT DEVICE, OR A REPLACEMENT PART OF SUCH A
DEVICE, IS NECESSARY BECAUSE OF ANY OF THE FOLLOWING:
(1) A CHANGE IN THE PHYSIOLOGICAL CONDITION OF THE ENROLLEE;
(2) AN IRREPARABLE CHANGE IN THE CONDITION OF THE DEVICE OR IN A PART
OF SUCH DEVICE; OR
(3) THE CONDITION OF THE DEVICE, OR THE PART OF THE DEVICE REQUIRES
REPAIRS AND THE COST OF SUCH REPAIRS WOULD BE MORE THAN SIXTY PERCENT OF
THE COST OF A REPLACEMENT DEVICE OR OF THE PART BEING REPLACED.
(II) CONFIRMATION FROM A PRESCRIBING HEALTH CARE PROVIDER MAY BE
REQUIRED IF THE PROSTHETIC OR CUSTOM ORTHOTIC DEVICE OR PART BEING
REPLACED IS LESS THAN THREE YEARS OLD.
§ 2. Subsection (l) of section 3221 of the insurance law is amended by
adding a new paragraph 24 to read as follows:
(24) (A) EVERY GROUP OR BLANKET POLICY DELIVERED OR ISSUED FOR DELIV-
ERY IN THIS STATE THAT PROVIDES COVERAGE FOR HOSPITAL, MEDICAL OR SURGI-
CAL EXPENSES SHALL INCLUDE COVERAGE FOR PROSTHETIC AND ORTHOTIC DEVICES
THAT EQUALS THE COVERAGE AND PAYMENT PROVIDED FOR BY FEDERAL LAWS AND
REGULATIONS FOR THE AGED AND DISABLED PURSUANT TO 42 U.S.C., SECTIONS
1395K, 1395L AND 1395M AND 42 C.F.R., SECTIONS 414.202, 414.210, 414.228
AND 410.100, AND ANY SUCCESSOR REGULATIONS, INCLUDING PAYMENT AT A RATE
NO LESS THAN THE CURRENT QUARTER'S MEDICARE DURABLE MEDICAL EQUIPMENT,
A. 11406 3
PROSTHETICS, ORTHOTICS AND SUPPLIES FEE SCHEDULE ESTABLISHED BY THE
CENTERS FOR MEDICARE AND MEDICAID SERVICES FOR PROSTHETIC AND ORTHOTIC
DEVICES AND SERVICES.
(B) COVERAGE PROVIDED UNDER THIS PARAGRAPH SHALL INCLUDE:
(I) A PROSTHETIC OR ORTHOTIC DEVICE DETERMINED BY THE ENROLLEE'S
HEALTH CARE PROVIDER TO BE THE MOST APPROPRIATE MODEL THAT ADEQUATELY
MEETS THE MEDICAL NEEDS OF SUCH ENROLLEE;
(II) A PROSTHETIC OR CUSTOM ORTHOTIC DEVICE DETERMINED BY THE
ENROLLEE'S HEALTH CARE PROVIDER TO BE THE MOST APPROPRIATE MODEL THAT
MEETS THE MEDICAL NEEDS OF SUCH ENROLLEE FOR PURPOSES OF PERFORMING
PHYSICAL ACTIVITIES, INCLUDING, BUT NOT LIMITED TO, RUNNING, BIKING,
SWIMMING, STRENGTH TRAINING, AND TO MAXIMIZE SUCH ENROLLEE'S WHOLE-BODY
HEALTH AND LOWER AND/OR UPPER LIMB FUNCTION;
(III) A PROSTHETIC OR CUSTOM ORTHOTIC DEVICE DETERMINED BY THE
ENROLLEE'S HEALTH CARE PROVIDER TO BE THE MOST APPROPRIATE MODEL THAT
MEETS THE MEDICAL NEEDS OF SUCH ENROLLEE FOR PURPOSES OF SHOWERING OR
BATHING;
(IV) ALL MATERIALS AND COMPONENTS NECESSARY FOR THE USE OF THE
PROSTHESES AND ORTHOSES;
(V) INSTRUCTION TO THE ENROLLEE ON USING THE DEVICE; AND
(VI) WITH RESPECT TO THE PROSTHESES AND ORTHOSES COVERED UNDER ITEMS
(I), (II), AND (III) OF THIS SUBPARAGRAPH, THE MEDICALLY NECESSARY
REPAIR OR REPLACEMENT OF SUCH PROSTHETIC OR ORTHOTIC DEVICE.
(C) FOR AN ENROLLEE TO RECEIVE A PROSTHESIS OR ORTHOSIS UNDER ITEMS
(I), (II), AND (III) OF SUBPARAGRAPH (B) OF THIS PARAGRAPH, THE TREATING
HEALTH CARE PROVIDER SHALL BE REQUIRED TO DETERMINE WHETHER THE ADDI-
TIONAL PROSTHETIC OR CUSTOM ORTHOTIC DEVICE IS NECESSARY TO ENABLE SUCH
ENROLLEE TO ENGAGE IN PHYSICAL ACTIVITIES, AS APPLICABLE, INCLUDING, BUT
NOT LIMITED TO, RUNNING, BIKING, SWIMMING, STRENGTH TRAINING, SHOWERING,
BATHING, AND TO MAXIMIZE ENROLLEE'S WHOLE-BODY HEALTH AND LOWER AND/OR
UPPER LIMB FUNCTION.
(D) EVERY GROUP OR BLANKET POLICY DELIVERED, ISSUED FOR DELIVERY OR
RENEWED IN THIS STATE THAT PROVIDES COVERAGE FOR PROSTHETIC AND CUSTOM
ORTHOTIC DEVICES SHALL CONSIDER SUCH DEVICES HABILITATIVE OR REHABILITA-
TIVE BENEFITS FOR THE PURPOSES OF ANY STATE OR FEDERAL REQUIREMENT FOR
COVERAGE OF ESSENTIAL HEALTH BENEFITS.
(E) AN INSURER SHALL NOT DENY A PROSTHETIC OR ORTHOTIC BENEFIT FOR AN
INDIVIDUAL WITH LIMB LOSS OR ABSENCE THAT WOULD OTHERWISE BE COVERED FOR
A NON-DISABLED INDIVIDUAL SEEKING MEDICAL OR SURGICAL INTERVENTION TO
RESTORE OR MAINTAIN THE ABILITY TO PERFORM THE SAME PHYSICAL ACTIVITY.
(F) PROSTHETIC AND CUSTOM ORTHOTIC DEVICE COVERAGE SHALL NOT BE
SUBJECT TO SEPARATE FINANCIAL REQUIREMENTS THAT ARE APPLICABLE ONLY WITH
RESPECT TO THAT COVERAGE. COST-SHARING MAY BE IMPOSED ON PROSTHETIC OR
CUSTOM ORTHOTIC DEVICES; PROVIDED, HOWEVER, THAT ANY COST-SHARING
REQUIREMENTS SHALL NOT BE MORE RESTRICTIVE THAN THE COST-SHARING
REQUIREMENTS APPLICABLE TO COVERAGE FOR INPATIENT PHYSICIAN AND SURGICAL
SERVICES.
(G) (I) IF COVERAGE FOR PROSTHETIC OR CUSTOM ORTHOTIC DEVICES IS
PROVIDED, PAYMENT SHALL BE MADE FOR THE REPLACEMENT OF SUCH PROSTHETIC
OR CUSTOM ORTHOTIC DEVICE OR FOR THE REPLACEMENT OF ANY PART OF SUCH
DEVICES, WITHOUT REGARD TO CONTINUOUS USE OR USEFUL LIFETIME
RESTRICTIONS, IF AN ORDERING HEALTH CARE PROVIDER DETERMINES THAT THE
PROVISION OF A REPLACEMENT DEVICE, OR A REPLACEMENT PART OF SUCH A
DEVICE, IS NECESSARY BECAUSE OF ANY OF THE FOLLOWING:
(1) A CHANGE IN THE PHYSIOLOGICAL CONDITION OF THE ENROLLEE;
A. 11406 4
(2) AN IRREPARABLE CHANGE IN THE CONDITION OF THE DEVICE OR IN A PART
OF SUCH DEVICE; OR
(3) THE CONDITION OF THE DEVICE, OR THE PART OF THE DEVICE REQUIRES
REPAIRS AND THE COST OF SUCH REPAIRS WOULD BE MORE THAN SIXTY PERCENT OF
THE COST OF A REPLACEMENT DEVICE OR OF THE PART BEING REPLACED.
(II) CONFIRMATION FROM A PRESCRIBING HEALTH CARE PROVIDER MAY BE
REQUIRED IF THE PROSTHETIC OR CUSTOM ORTHOTIC DEVICE OR PART BEING
REPLACED IS LESS THAN THREE YEARS OLD.
§ 3. Section 4303 of the insurance law is amended by adding a new
subsection (yy) to read as follows:
(YY) (1) EVERY POLICY THAT PROVIDES COVERAGE FOR HOSPITAL, MEDICAL OR
SURGICAL EXPENSES SHALL INCLUDE COVERAGE FOR PROSTHETIC AND ORTHOTIC
DEVICES THAT EQUALS THE COVERAGE AND PAYMENT PROVIDED FOR BY FEDERAL
LAWS AND REGULATIONS FOR THE AGED AND DISABLED PURSUANT TO 42 U.S.C.,
SECTIONS 1395K, 1395L AND 1395M AND 42 C.F.R., SECTIONS 414.202,
414.210, 414.228 AND 410.100, AND ANY SUCCESSOR REGULATIONS, INCLUDING
PAYMENT AT A RATE NO LESS THAN THE CURRENT QUARTER'S MEDICARE DURABLE
MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES FEE SCHEDULE
ESTABLISHED BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES FOR PROS-
THETIC AND ORTHOTIC DEVICES AND SERVICES.
(2) COVERAGE PROVIDED UNDER THIS SUBSECTION SHALL INCLUDE:
(A) A PROSTHETIC OR ORTHOTIC DEVICE DETERMINED BY THE ENROLLEE'S
HEALTH CARE PROVIDER TO BE THE MOST APPROPRIATE MODEL THAT ADEQUATELY
MEETS THE MEDICAL NEEDS OF SUCH ENROLLEE;
(B) A PROSTHETIC OR CUSTOM ORTHOTIC DEVICE DETERMINED BY THE
ENROLLEE'S HEALTH CARE PROVIDER TO BE THE MOST APPROPRIATE MODEL THAT
MEETS THE MEDICAL NEEDS OF SUCH ENROLLEE FOR PURPOSES OF PERFORMING
PHYSICAL ACTIVITIES, INCLUDING, BUT NOT LIMITED TO, RUNNING, BIKING,
SWIMMING, STRENGTH TRAINING, AND TO MAXIMIZE SUCH ENROLLEE'S WHOLE-BODY
HEALTH AND LOWER AND/OR UPPER LIMB FUNCTION;
(C) A PROSTHETIC OR CUSTOM ORTHOTIC DEVICE DETERMINED BY THE
ENROLLEE'S HEALTH CARE PROVIDER TO BE THE MOST APPROPRIATE MODEL THAT
MEETS THE MEDICAL NEEDS OF SUCH ENROLLEE FOR PURPOSES OF SHOWERING OR
BATHING;
(D) ALL MATERIALS AND COMPONENTS NECESSARY FOR THE USE OF THE
PROSTHESES AND ORTHOSES;
(E) INSTRUCTION TO THE ENROLLEE ON USING THE DEVICE; AND
(F) WITH RESPECT TO THE PROSTHESES AND ORTHOSES COVERED UNDER SUBPARA-
GRAPHS (A), (B), AND (C) OF THIS PARAGRAPH, THE MEDICALLY NECESSARY
REPAIR OR REPLACEMENT OF SUCH PROSTHETIC OR ORTHOTIC DEVICE.
(3) FOR AN ENROLLEE TO RECEIVE A PROSTHESIS OR ORTHOSIS UNDER SUBPARA-
GRAPHS (A), (B), AND (C) OF PARAGRAPH TWO OF THIS SUBSECTION, THE TREAT-
ING HEALTH CARE PROVIDER SHALL BE REQUIRED TO DETERMINE WHETHER THE
ADDITIONAL PROSTHETIC OR CUSTOM ORTHOTIC DEVICE IS NECESSARY TO ENABLE
SUCH ENROLLEE TO ENGAGE IN PHYSICAL ACTIVITIES, AS APPLICABLE, INCLUD-
ING, BUT NOT LIMITED TO, RUNNING, BIKING, SWIMMING, STRENGTH TRAINING,
SHOWERING, BATHING, AND TO MAXIMIZE ENROLLEE'S WHOLE-BODY HEALTH AND
LOWER AND/OR UPPER LIMB FUNCTION.
(4) EVERY POLICY DELIVERED, ISSUED FOR DELIVERY OR RENEWED IN THIS
STATE THAT PROVIDES COVERAGE FOR PROSTHETIC AND CUSTOM ORTHOTIC DEVICES
SHALL CONSIDER SUCH DEVICES HABILITATIVE OR REHABILITATIVE BENEFITS FOR
THE PURPOSES OF ANY STATE OR FEDERAL REQUIREMENT FOR COVERAGE OF ESSEN-
TIAL HEALTH BENEFITS.
(5) AN INSURER SHALL NOT DENY A PROSTHETIC OR ORTHOTIC BENEFIT FOR AN
INDIVIDUAL WITH LIMB LOSS OR ABSENCE THAT WOULD OTHERWISE BE COVERED FOR
A. 11406 5
A NON-DISABLED INDIVIDUAL SEEKING MEDICAL OR SURGICAL INTERVENTION TO
RESTORE OR MAINTAIN THE ABILITY TO PERFORM THE SAME PHYSICAL ACTIVITY.
(6) PROSTHETIC AND CUSTOM ORTHOTIC DEVICE COVERAGE SHALL NOT BE
SUBJECT TO SEPARATE FINANCIAL REQUIREMENTS THAT ARE APPLICABLE ONLY WITH
RESPECT TO THAT COVERAGE. COST-SHARING MAY BE IMPOSED ON PROSTHETIC OR
CUSTOM ORTHOTIC DEVICES; PROVIDED, HOWEVER, THAT ANY COST-SHARING
REQUIREMENTS SHALL NOT BE MORE RESTRICTIVE THAN THE COST-SHARING
REQUIREMENTS APPLICABLE TO COVERAGE FOR INPATIENT PHYSICIAN AND SURGICAL
SERVICES.
(7) (A) IF COVERAGE FOR PROSTHETIC OR CUSTOM ORTHOTIC DEVICES IS
PROVIDED, PAYMENT SHALL BE MADE FOR THE REPLACEMENT OF SUCH PROSTHETIC
OR CUSTOM ORTHOTIC DEVICE OR FOR THE REPLACEMENT OF ANY PART OF SUCH
DEVICES, WITHOUT REGARD TO CONTINUOUS USE OR USEFUL LIFETIME
RESTRICTIONS, IF AN ORDERING HEALTH CARE PROVIDER DETERMINES THAT THE
PROVISION OF A REPLACEMENT DEVICE, OR A REPLACEMENT PART OF SUCH A
DEVICE, IS NECESSARY BECAUSE OF ANY OF THE FOLLOWING:
(I) A CHANGE IN THE PHYSIOLOGICAL CONDITION OF THE ENROLLEE;
(II) AN IRREPARABLE CHANGE IN THE CONDITION OF THE DEVICE OR IN A PART
OF SUCH DEVICE; OR
(III) THE CONDITION OF THE DEVICE, OR THE PART OF THE DEVICE REQUIRES
REPAIRS AND THE COST OF SUCH REPAIRS WOULD BE MORE THAN SIXTY PERCENT OF
THE COST OF A REPLACEMENT DEVICE OR OF THE PART BEING REPLACED.
(B) CONFIRMATION FROM A PRESCRIBING HEALTH CARE PROVIDER MAY BE
REQUIRED IF THE PROSTHETIC OR CUSTOM ORTHOTIC DEVICE OR PART BEING
REPLACED IS LESS THAN THREE YEARS OLD.
§ 4. Subdivision 4 of section 364-j of the social services law is
amended by adding a new paragraph (x) to read as follows:
(X) A MANAGED CARE PROVIDER SHALL PROVIDE OR ARRANGE, DIRECTLY OR
INDIRECTLY, INCLUDING BY REFERRAL, FOR ACCESS TO AND COVERAGE OF
SERVICES FOR THE PROVISION OF PROSTHETIC AND ORTHOTIC DEVICES TO ENSURE
ACCESS TO MEDICALLY NECESSARY CLINICAL CARE. SUCH ACCESS SHALL INCLUDE,
BUT NOT BE LIMITED TO, PROSTHETIC AND CUSTOM ORTHOTIC DEVICES AND TECH-
NOLOGY FROM NO LESS THAN TWO DISTINCT PROSTHETIC AND CUSTOM ORTHOTIC
PROVIDERS WITHIN THE MANAGED CARE PROVIDER'S NETWORK. IN THE EVENT THAT
MEDICALLY NECESSARY COVERED PROSTHETICS AND ORTHOTICS ARE NOT AVAILABLE
FROM AN IN-NETWORK PROVIDER, SUCH MANAGED CARE PROVIDER SHALL ESTABLISH
AND MAINTAIN PROCESSES TO REFER A PARTICIPANT TO AN OUT-OF-NETWORK
PROVIDER AND SHALL FULLY REIMBURSE SUCH OUT-OF-NETWORK PROVIDER AT A
MUTUALLY AGREED UPON RATE REDUCED BY ANY PARTICIPANT COST-SHARING DETER-
MINED ON AN IN-NETWORK BASIS.
§ 5. Subsection (a) of section 4902 of the insurance law is amended by
adding a new paragraph 17 to read as follows:
(17) WHEN CONDUCTING UTILIZATION REVIEW FOR THE PURPOSES OF DETERMIN-
ING HEALTH CARE COVERAGE FOR PROSTHETIC AND ORTHOTIC DEVICES, A UTILIZA-
TION REVIEW AGENT SHALL CONDUCT SUCH REVIEW IN A NONDISCRIMINATORY
MANNER AND NOT DENY COVERAGE FOR HABILITATIVE OR REHABILITATIVE BENE-
FITS, INCLUDING PROSTHETICS OR ORTHOTICS, SOLELY ON THE BASIS OF AN
INSURED'S ACTUAL OR PERCEIVED DISABILITY.
§ 6. The public health law is amended by adding a new section 4406-j
to read as follows:
§ 4406-J. PROSTHETIC AND ORTHOTIC DEVICE COVERAGE. NO HEALTH MAINTE-
NANCE ORGANIZATION SUBJECT TO THIS ARTICLE SHALL, BY CONTRACT, WRITTEN
POLICY, OR PROCEDURE, LIMIT A PATIENT ENROLLEE'S ACCESS TO AND COVERAGE
OF SERVICES FOR THE PROVISION OF PROSTHETIC AND ORTHOTIC DEVICES IF SUCH
SERVICES ARE COVERED PURSUANT TO PARAGRAPH FORTY-TWO OF SUBSECTION (I)
OF SECTION THREE THOUSAND TWO HUNDRED SIXTEEN OF THE INSURANCE LAW,
A. 11406 6
PARAGRAPH TWENTY-FOUR OF SUBSECTION (L) OF SECTION THREE THOUSAND TWO
HUNDRED TWENTY-ONE OF THE INSURANCE LAW, OR SUBSECTION (YY) OF SECTION
FOUR THOUSAND THREE HUNDRED THREE OF THE INSURANCE LAW; PROVIDED, HOWEV-
ER, THAT SUCH PATIENT ENROLLEE'S ACCESS TO SUCH SERVICES ARE OTHERWISE
SUBJECT TO THE TERMS AND CONDITIONS OF THE PLAN UNDER WHICH SUCH PATIENT
ENROLLEE IS COVERED.
§ 7. Section 345 of the insurance law, as added by section 12 of part
YY of chapter 56 of the laws of 2020, is amended to read as follows:
§ 345. Health care claims reports. An insurer authorized to write
accident and health insurance in the state, a corporation organized
pursuant to article forty-three of this chapter, or a health maintenance
organization certified pursuant to article forty-four of the public
health law shall report to the superintendent quarterly and annually on
health care claims payment performance with respect to comprehensive
health insurance coverage. The reports shall be submitted in the manner
and form prescribed by the superintendent after consultation with repre-
sentatives of insurers and health care providers but at minimum shall
include the number and dollar value of health care claims by major line
of business and categorized as follows: health care claims received,
health care claims paid, health care claims pended and health care
claims denied during the respective quarter or year. SUCH REPORTS SHALL
ALSO INCLUDE THE NUMBER OF CLAIMS FILED AND THE TOTAL AMOUNT OF CLAIMS
PAID IN THE STATE OF NEW YORK FOR THE SERVICES REQUIRED BY PARAGRAPH
FORTY-TWO OF SUBSECTION (I) OF SECTION THREE THOUSAND TWO HUNDRED
SIXTEEN OF THIS CHAPTER, PARAGRAPH TWENTY-FOUR OF SUBSECTION (L) OF
SECTION THREE THOUSAND TWO HUNDRED TWENTY-ONE OF THIS CHAPTER,
SUBSECTION (YY) OF SECTION FOUR THOUSAND THREE HUNDRED THREE OF THIS
CHAPTER, OR SECTION FORTY-FOUR HUNDRED SIX-J OF THE PUBLIC HEALTH LAW.
The data shall be provided in the aggregate and by major category of
health care provider. The reports should address any patterns or
suspected areas of revenue maximization that may have contributed to the
number of denials. The reports shall be due to the superintendent no
later than forty-five days after the end of the respective quarter or
year and shall be made publicly available including on the department's
website. The superintendent, in conjunction with the commissioner of
health, may promulgate regulations requiring additional reporting
requirements on insurers, corporations, or health maintenance organiza-
tions or health care providers to assess the effectiveness of the
payment policies set forth in this section, which may be informed by the
administrative simplification workgroup authorized by subsection (k) of
section three thousand two hundred twenty-four-a of this chapter.
§ 8. This act shall take effect January 1, 2027 and shall apply to all
policies and contracts issued, renewed, modified, altered or amended on
or after such date; provided, however, that the amendments to section
364-j of the social services law made by section four of this act, shall
not affect the repeal of such section and shall be deemed repealed ther-
ewith. Effective immediately, the addition, amendment and/or repeal of
any rule or regulation necessary for the implementation of this act on
its effective date are authorized to be made and completed on or before
such effective date.