Provides that health insurance coverage may not deny reimbursements because the registered laboratory providing laboratory services has not been approved by the insurer or other entity; provides that in such case the insured pays excess costs therefor above the covered benefit.

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S1106-2013 Actions

• Jan 9, 2013: REFERRED TO INSURANCE

S1106-2013 Memo

BILL NUMBER:S1106

TITLE OF BILL:
An act
to amend the insurance law, in relation to health insurance coverage and
eligibility for employee benefits provided by employee welfare funds for
laboratory services

PURPOSE:
To prohibit the denial of health insurance coverage for
pharmaceuticals strictly because the registered pharmacy providing
the pharmaceutical products has not been approved by the health
insurance plan.

SUMMARY OF PROVISIONS:
Amends sections 3216, 3221, 4301, 4303, 4402
and 4413 of the New York State Insurance Law to provide that health
insurance coverage providers may not deny reimbursements because the
registered pharmacy providing pharmaceutical products has not been
approved by the insurer or other entity.

This amendment would require individuals who select a pharmacy that is
not part of the insurer's panel to be responsible for paying any
differential between the benefits provided under the health care
insurance contract and the cost of the services selected.. The fund,
employer' or union would be precluded from denying eligibility for
reimbursement to any registered pharmacy which is willing to meet
minimum standard conditions per participation requirements of the fund.

JUSTIFICATION:
Individuals and families should not be denied the
ability to obtain services from a registered pharmacy of their choice
simply on the basis of their membership in the health insurance plan
made available to them. A personal choice is being taken away from
an insured when they are directed to only obtain services from a
specified pharmacy rather than to the pharmacist they have sought
services from their entire lives. The insured may be more comfortable
with a pharmacist that he/she has come to know and rely upon and who
is familiar with their health history. Further, limiting
participating pharmacies is particularly difficult for insureds
living in rural areas who may have to travel miles to a pharmacy and
for the homebound.

This bill ensures that insureds will be able to access any registered
pharmacy that is willing to provide service in accordance with the
minimum criteria established by the health insurance contract.

This bill allows the insured freedom of choice and limits the
financial exposure of the insurer as well as that of an employee
welfare fund to the level of benefits agreed to between the
bargaining agent of the employee and the employer. The insurer would
not be required to provide the benefit to anyone that is not already
insured, nor would the insurer be required to reimburse pharmacies at
a higher rate than it reimburses participating providers. This bill
would simply require the insurer to reimburse any "duly registered


pharmacy" of the insured's choosing, instead of a limited number of
pharmacies of the insurance company's choosing.

LEGISLATIVE HISTORY:
S.176 of 2011/2012; Referred to Senate Insurance Committee
S.1053/A.509D of 2009/2010; Referred to Senate Insurance Committee
S.48/A.6728 of 2007/2008; Referred to Senate Insurance Committee
S19132/A.10403 of 2005/2006; Referred to Senate Insurance Committee
S.5878/A.4439 of 2003/2004; Referred to Senate Insurance Committee

FISCAL IMPLICATIONS:
None.

EFFECTIVE DATE:
Effective on January 1, next succeeding passage, and
shall apply to all policies and contracts issued, modified, altered
or amended thereafter.

S1106-2013 Text

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

                                    1106

                         2013-2014 Regular Sessions

                              I N  SENATE

                                 (PREFILED)

                               January 9, 2013
                                 ___________

  Introduced  by  Sen. MAZIARZ -- read twice and ordered printed, and when
    printed to be committed to the Committee on Insurance

  AN ACT to amend the insurance  law,  in  relation  to  health  insurance
    coverage  and  eligibility  for employee benefits provided by employee
    welfare funds for laboratory services

    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 30 to read as follows:

    (30) NO SUCH POLICY SHALL LIMIT BENEFITS  OR  DENY  REIMBURSEMENT  FOR
  BENEFITS  TO ANY INSURED ON THE BASIS THAT THE LABORATORY PROVIDING SUCH
  BENEFITS HAS NOT BEEN SPECIFICALLY SELECTED OR APPROVED. IF THE INSURED,
  HIS OR HER DEPENDENTS OR BOTH RECEIVE  SERVICES  FROM  A  LABORATORY  OF
  THEIR  OWN  CHOOSING, SUCH INSURED SHALL PAY THE COST OF SUCH LABORATORY
  SERVICES TO THE EXTENT THAT SUCH  COST  EXCEEDS  THE  BENEFITS  PROVIDED
  UNDER  THE POLICY WITHOUT FORFEITURE OF THE BENEFITS PROVIDED UNDER SUCH
  POLICY. NO SUCH POLICY SHALL PROHIBIT A DULY REGISTERED LABORATORY  FROM
  PROVIDING  SERVICES,  PROVIDED  SUCH  LABORATORY  AGREES TO PROVIDE SUCH
  SERVICES IN ACCORDANCE WITH THE MINIMUM  STANDARDS  AND  CONDITIONS  FOR
  SIMILAR PROVIDERS THAT HAVE BEEN ESTABLISHED BY SUCH POLICY.
    S 2. Subsection (e) of section 3221 of the insurance law is amended by
  adding a new paragraph 13 to read as follows:

    (13)  NO  SUCH  GROUP  OR  BLANKET POLICY SHALL LIMIT BENEFITS OR DENY
  REIMBURSEMENT FOR BENEFITS TO ANY INSURED ON THE BASIS THAT THE  LABORA-
  TORY  PROVIDING  SUCH  BENEFITS  HAS  NOT  BEEN SPECIFICALLY SELECTED OR
  APPROVED BY THE GROUP OR BLANKET POLICY. IF  THE  INSURED,  HIS  OR  HER
  DEPENDENTS  OR  BOTH  RECEIVE  SERVICES  FROM  A LABORATORY OF THEIR OWN
  CHOOSING, SUCH INSURED SHALL PAY THE COST OF SUCH LABORATORY SERVICES TO
  THE EXTENT THAT SUCH COST EXCEEDS THE BENEFITS PROVIDED UNDER THE  GROUP
  OR BLANKET POLICY WITHOUT FORFEITURE OF THE BENEFITS PROVIDED UNDER SUCH

   EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                        [ ] is old law to be omitted.
                                                             LBD02288-01-3

 S. 1106                             2

  GROUP  OR BLANKET POLICY. NO SUCH GROUP OR BLANKET POLICY SHALL PROHIBIT
  A DULY REGISTERED LABORATORY  FROM  PROVIDING  SERVICES,  PROVIDED  SUCH
  LABORATORY  AGREES TO PROVIDE SUCH SERVICES IN ACCORDANCE WITH THE MINI-
  MUM STANDARDS AND CONDITIONS FOR SIMILAR PROVIDERS THAT HAVE BEEN ESTAB-
  LISHED BY SUCH GROUP OR BLANKET POLICY.
    S  3.  Section  4303  of  the insurance law is amended by adding a new
  subsection (jj) to read as follows:

    (JJ) NO SUCH POLICY ISSUED BY A  THIRD  PARTY  BENEFIT  PROGRAM  SHALL
  LIMIT  BENEFITS OR DENY REIMBURSEMENT FOR SERVICES TO ANY INSURED ON THE
  BASIS THAT THE LABORATORY PROVIDING SUCH BENEFITS HAS NOT  BEEN  SPECIF-
  ICALLY  SELECTED  OR APPROVED BY THE THIRD PARTY BENEFIT PROGRAM. IF THE
  INSURED, HIS OR HER DEPENDENTS OR BOTH RECEIVE SERVICES FROM A LABORATO-
  RY OF THEIR OWN CHOOSING, SUCH INSURED SHALL PAY THE COST OF SUCH TREAT-
  MENT TO THE EXTENT THAT SUCH COST EXCEEDS THE  BENEFITS  PROVIDED  UNDER
  THE  POLICY WITHOUT FORFEITURE OF THE BENEFITS PROVIDED UNDER SUCH POLI-
  CY. NO SUCH THIRD PARTY BENEFIT PROGRAM SHALL PROHIBIT A DULY REGISTERED
  LABORATORY FROM PROVIDING SERVICES, PROVIDED SUCH LABORATORY  AGREES  TO
  PROVIDE SERVICES IN ACCORDANCE WITH THE MINIMUM STANDARDS AND CONDITIONS
  FOR  SIMILAR  PROVIDERS  THAT  HAVE BEEN ESTABLISHED BY SUCH THIRD PARTY
  BENEFIT PROGRAM.
    S 4. Subsection (b) of section 4402 of the insurance law is amended to
  read as follows:

    (b) "Employee benefits" means one or more  benefits  or  services  for
  employees  or  their families or dependents, or for both, including, but
  not limited to, medical, surgical or hospital care or benefits  PROVIDED
  BY  OR  PERFORMED  BY ANY LABORATORY, benefits in the event of sickness,
  accident, disability or death, benefits in the event of unemployment, or
  retirement benefits.
    S 5. Subsection (b) of section 4413 of the insurance law is amended by
  adding a new paragraph 1-a to read as follows:

    (1-A) NO SUCH FUND SHALL LIMIT EMPLOYEE BENEFITS OR DENY REIMBURSEMENT
  FOR EMPLOYEE BENEFITS TO ANY ELIGIBLE EMPLOYEE ON  THE  BASIS  THAT  THE
  LABORATORY PROVIDING SUCH BENEFITS HAS NOT BEEN SPECIFICALLY SELECTED OR
  APPROVED  BY  THE  WELFARE  FUND, THE EMPLOYER OR THE LABOR ORGANIZATION
  REPRESENTING THE EMPLOYEES ELIGIBLE FOR SUCH EMPLOYEE BENEFITS.  IF  THE
  ELIGIBLE EMPLOYEE, HIS OR HER DEPENDENTS OR BOTH RECEIVE SERVICES FROM A
  LABORATORY  OF  THEIR  OWN CHOOSING, SUCH EMPLOYEE SHALL PAY THE COST OF
  SUCH TREATMENT TO  THE  EXTENT  THAT  SUCH  COST  EXCEEDS  THE  BENEFITS
  PROVIDED  UNDER  THE  PLAN  WITHOUT  FORFEITURE OF THE BENEFITS PROVIDED
  UNDER SUCH PLAN.  NO SUCH FUND, EMPLOYER  OR  LABOR  ORGANIZATION  SHALL
  PROHIBIT  A DULY REGISTERED LABORATORY FROM PROVIDING EMPLOYEE BENEFITS,
  PROVIDED SUCH LABORATORY AGREES TO PROVIDE SUCH SERVICES  IN  ACCORDANCE
  WITH  THE  MINIMUM  STANDARDS  AND CONDITIONS FOR SIMILAR PROVIDERS THAT
  HAVE BEEN ESTABLISHED BY SUCH FUND, EMPLOYER OR LABOR ORGANIZATION.
    S 6. Subsection (b) of section 4301 of the insurance law is amended by
  adding a new paragraph 4 to read as follows:

    (4) IF A CONTRACT ISSUED BY A THIRD  PARTY  BENEFIT  PROGRAM  PROVIDES
  BENEFITS  FOR LABORATORY SERVICES, ANY LABORATORY WILLING TO PARTICIPATE
  UNDER THE TERMS OF THE CONTRACT  SHALL  NOT  BE  DENIED  ACCESS  TO  THE
  PROVIDER PANEL.
    S  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 effective date.