Bill S1106-2013

Provides that health insurance coverage may not deny reimbursements because the registered laboratory providing laboratory services has not been approved

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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  • Jan 8, 2014: REFERRED TO INSURANCE
  • Jan 9, 2013: REFERRED TO INSURANCE

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.


Text

STATE OF NEW YORK ________________________________________________________________________ 1106 2013-2014 Regular Sessions IN 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
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.

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