Bill S1611-2011

Requires medical care insurance policies to include coverage for the care of Alzheimer's and related disease patients upon request

Provides for the coverage of Alzheimer's and related disease patients under group and individual health insurance contracts and non-profit medical or health service corporations; certain terms defined.

Details

Actions

  • Jan 4, 2012: REFERRED TO INSURANCE
  • Jan 10, 2011: REFERRED TO INSURANCE

Memo

BILL NUMBER:S1611

TITLE OF BILL: An act to amend the insurance law, in relation to coverage for the care of Alzheimer's and related disease patients

PURPOSE OF THE BILL: To require all health insurance providers of New York State to make available, when requested by a contract holder, coverage for a designated group of non-health related services provided to Alzheimer's or related diseases. These services are custodial in nature, and include crisis intervention, adult day care, home care, and respite care.

SUMMARY OF SPECIFIC PROVISIONS: This bill adds insurance coverage for non-health related services required by Alzheimer's and related disease victims. Under current Insurance Law there is no provision for that group of services.

Subsection (i) of §3216 of the Insurance Law is amended by adding a new paragraph eleven. Subsection (1) of §3221 of such law is amended by adding a new paragraph eighteen.

JUSTIFICATION: Alzheimer's disease is a progressively degenerative neurological disorder with no known cause or cure. The course of this disease as well as other dementias usually extends over a number of years, necessitating the use of many non-health related services, such as adult day care, home care, and respite care. Because this type of care is considered custodial, victims of Alzheimer's and related dementias do not have access to the traditional funding mechanisms for health care.

Medicare and Medicaid are currently the major sources of financing for both institutional and community based care. Because Medicare does not cover services needed for long-term chronic care, and Medicaid requires that an individual be financially destitute in order to be eligible for coverage, Alzheimer's victims are denied reimbursement for their much needed care. The private/commercial insurers of New York State currently require that care be of a rehabilitative nature further eliminating access to reimbursement for this group of patients. It is time for New York State to require insurers to provide this coverage.

LEGISLATIVE HISTORY: 2009-10: S.4229

FISCAL IMPLICATIONS FOR STATE AND LOCAL GOVERNMENTS: To be determined.

EFFECTIVE DATE: One hundred twenty days after it shall have become a law, with provisions.


Text

STATE OF NEW YORK ________________________________________________________________________ 1611 2011-2012 Regular Sessions IN SENATE January 10, 2011 ___________
Introduced by Sen. SAVINO -- 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 coverage for the care of Alzheimer's and related disease patients 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 28 to read as follows: (28) (A) EVERY POLICY WHICH PROVIDES FOR SURGICAL OR MEDICAL COVERAGE OR IN-PATIENT HOSPITAL CARE AS WELL AS NON-HEALTH RELATED SERVICES, SHALL MAKE AVAILABLE, WHEN REQUESTED BY THE CONTRACT HOLDER, COVERAGE FOR OUT-PATIENT TREATMENT OF ALZHEIMER'S OR RELATED DISEASES. (B) FOR THE PURPOSES OF THIS PARAGRAPH, THE FOLLOWING TERMS SHALL HAVE THE FOLLOWING MEANINGS: (I) "NON-HEALTH RELATED SERVICES" MEANS THOSE OUT-PATIENT SERVICES WHICH MEET THE CARE AND BEHAVIORAL NEEDS OF THE PATIENT, INCLUDING BUT NOT LIMITED TO CRISIS INTERVENTION, ADULT DAY CARE, HOME CARE AND RESPITE CARE. (II) "CARE AND BEHAVIORAL NEEDS OF THE PATIENT" MEANS THE MANIFESTA- TION OF SYMPTOMS WHICH MAY INCLUDE BUT NOT LIMITED TO MEMORY LOSS, APHA- SIA (COMMUNICATION DISORDER), BECOMING LOST OR DISORIENTED, CONFUSION AND AGITATION WITH THE POTENTIAL FOR COMBATIVENESS AND INCONTINENCE. (III) "ALZHEIMER'S OR RELATED DISEASES" MEANS ANY OF THOSE IRREVERS- IBLE BRAIN DISORDERS WHICH RESULT IN THE SYMPTOMS DESCRIBED IN THIS PARAGRAPH BUT NOT LIMITED TO MULTI-INFARCT DEMENTIAS AND PARKINSON'S DISEASE. S 2. Subsection (l) of section 3221 of the insurance law is amended by adding a new paragraph 18 to read as follows: (18) (A) EVERY INSURER DELIVERING A GROUP POLICY OR ISSUING A GROUP POLICY FOR DELIVERY IN THIS STATE WHICH PROVIDES HOSPITAL, SURGICAL OR MEDICAL COVERAGE SHALL, IF REQUESTED BY THE POLICYHOLDER INCLUDE COVER-
AGE FOR THE TREATMENT AND DIAGNOSIS OF ALZHEIMER'S OR RELATED DISEASES. SUCH COVERAGE FOR THE DIAGNOSIS AND TREATMENT SHALL INCLUDE HOSPITAL, SURGICAL OR MEDICAL CARE TO THE SAME EXTENT THAT COVERAGE IS PROVIDED FOR ILLNESS OR DISEASE UNDER THE POLICY. (B) COVERAGE SHALL ALSO INCLUDE NON-HEALTH RELATED SERVICES AS WELL AS BUT NOT LIMITED TO NURSING HOME CARE, LICENSED REGISTERED PROFESSIONAL NURSE, PSYCHIATRISTS OR PSYCHOLOGISTS LICENSED TO PRACTICE IN THIS STATE, HOME HEALTH SERVICES AND ANY OTHER MEDICAL AND REHABILITATIVE TREATMENT. (C) SUCH COVERAGE MAY BE SUBJECT TO ANNUAL DEDUCTIBLES AND COINSURANCE AS MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT. SUCH DEDUCTIBLES AND COINSURANCE MAY BE CONSISTENT WITH THOSE IMPOSED ON OTHER BENEFITS WITHIN A GIVEN POLICY. (D) FOR THE PURPOSES OF THIS PARAGRAPH, THE FOLLOWING TERMS SHALL HAVE THE FOLLOWING MEANINGS: (I) "NON-HEALTH RELATED SERVICES" MEANS THOSE OUT-PATIENT SERVICES WHICH MEET THE CARE AND BEHAVIORAL NEEDS OF THE PATIENT, INCLUDING BUT NOT LIMITED TO CRISIS INTERVENTION, ADULT DAY CARE, HOME CARE AND RESPITE CARE. (II) "CARE AND BEHAVIORAL NEEDS OF THE PATIENT" MEANS THE MANIFESTA- TION OF SYMPTOMS WHICH MAY INCLUDE BUT NOT LIMITED TO MEMORY LOSS, APHA- SIA (COMMUNICATION DISORDER), BECOMING LOST OR DISORIENTED, CONFUSION AND AGITATION WITH THE POTENTIAL FOR COMBATIVENESS AND INCONTINENCE. (III) "ALZHEIMER'S OR RELATED DISEASES" MEANS ANY OF THOSE IRREVERS- IBLE BRAIN DISORDERS WHICH RESULT IN THE SYMPTOMS DESCRIBED IN THIS PARAGRAPH BUT NOT LIMITED TO MULTI-INFARCT DEMENTIAS AND PARKINSON'S DISEASE. S 3. Paragraph 1 of subsection (d) of section 4301 of the insurance law is amended to read as follows: (1) (A) Hospital service shall consist of in-patient hospital care and out-patient hospital care when such hospital care is provided through a hospital which is maintained by the state or any of its political subdi- visions, or maintained by a corporation organized for hospital purposes under the laws of this state, or such other hospitals as shall be desig- nated by the state department of health, and hospitals of other states subject to the supervision of such other state, convalescent care provided by any convalescent institution, or nursing care provided by any nursing home. (B) OUT-PATIENT HOSPITAL CARE SHALL INCLUDE, TO THE SAME EXTENT AS IS PROVIDED FOR ILLNESS OR DISEASE UNDER THE POLICY, THE TREATMENT AND DIAGNOSIS OF ALZHEIMER'S OR RELATED DISEASES AND NON-HEALTH RELATED SERVICES. (C) FOR THE PURPOSES OF THIS PARAGRAPH THE FOLLOWING TERMS SHALL HAVE THE FOLLOWING MEANINGS: (I) "NON-HEALTH RELATED SERVICES" MEANS THOSE OUT-PATIENT SERVICES WHICH MEET THE CARE AND BEHAVIORAL NEEDS OF THE PATIENT, INCLUDING BUT NOT LIMITED TO CRISIS INTERVENTION, ADULT DAY CARE, HOME CARE AND RESPITE CARE. (II) "CARE AND BEHAVIORAL NEEDS OF THE PATIENT" MEANS THE MANIFESTA- TION OF SYMPTOMS WHICH MAY INCLUDE BUT NOT LIMITED TO MEMORY LOSS, APHA- SIA (COMMUNICATION DISORDER), BECOMING LOST OR DISORIENTED, CONFUSION AND AGITATION WITH THE POTENTIAL FOR COMBATIVENESS AND INCONTINENCE. (III) "ALZHEIMER'S OR RELATED DISEASES" MEANS ANY OF THOSE IRREVERS- IBLE BRAIN DISORDERS WHICH RESULT IN THE SYMPTOMS DESCRIBED IN THIS PARAGRAPH BUT NOT LIMITED TO MULTI-INFARCT DEMENTIAS AND PARKINSON'S DISEASE.
S 4. Paragraph 2 of subsection (e) and paragraph 2 of subsection (f) of section 4303 of the insurance law, paragraph 2 of subsection (e) as amended by chapter 593 of the laws of 2000, are amended to read as follows: (2) For the purpose of this subsection, ambulatory care in hospital out-patient facilities shall mean [services]: (A) SERVICES for diagnos- tic x-rays, laboratory and pathological examinations, physical and occu- pational therapy and radiation therapy, and services and medications used for nonexperimental cancer chemotherapy and cancer hormone therapy, provided that such services and medications are (i) related to and necessary for the treatment or diagnosis of the patient's illness or injury, (ii) ordered by a physician and (iii) in the case of physical therapy, services are to be furnished in connection with the same illness for which the patient had been hospitalized or in connection with surgical care, but in no event need benefits for physical therapy be provided which commences more than six months after discharge from a hospital or the date surgical care was rendered, and in no event need benefits for physical therapy be provided after three hundred sixty-five days from the date of discharge from a hospital or the date surgical care was rendered. Such coverage shall be made available at the incep- tion of all new contracts and, with respect to all other contracts, at any anniversary date subject to evidence of insurability. (B) TREATMENT AND DIAGNOSIS OF ALZHEIMER'S OR RELATED DISEASES AND NON-HEALTH RELATED SERVICES. (C) FOR THE PURPOSES OF THIS PARAGRAPH, THE FOLLOWING TERMS SHALL HAVE THE FOLLOWING MEANINGS: (I) "NON-HEALTH RELATED SERVICES" MEANS THOSE OUT-PATIENT SERVICES WHICH MEET THE CARE AND BEHAVIORAL NEEDS OF THE PATIENT, INCLUDING BUT NOT LIMITED TO CRISIS INTERVENTION, ADULT DAY CARE, HOME CARE AND RESPITE CARE. (II) "CARE AND BEHAVIORAL NEEDS OF THE PATIENT" MEANS THE MANIFESTA- TION OF SYMPTOMS WHICH MAY INCLUDE BUT NOT LIMITED TO MEMORY LOSS, APHA- SIA (COMMUNICATION DISORDER), BECOMING LOST OR DISORIENTED, CONFUSION AND AGITATION WITH THE POTENTIAL FOR COMBATIVENESS AND INCONTINENCE. (III) "ALZHEIMER'S OR RELATED DISEASES" MEANS ANY OF THOSE IRREVERS- IBLE BRAIN DISORDERS WHICH RESULT IN THE SYMPTOMS DESCRIBED IN THIS PARAGRAPH BUT NOT LIMITED TO MULTI-INFARCT DEMENTIAS AND PARKINSON'S DISEASE. (2) For the purpose of this subsection, ambulatory care in physi- cians' offices shall mean [services]: (A) SERVICES for diagnostic x-rays, radiation therapy, laboratory and pathological examinations, and services and medications used for nonexperimental cancer chemotherapy and cancer hormone therapy, provided that such services and medications are (i) related to and necessary for the treatment or diagnosis of the patient's illness or injury, and (ii) ordered by a physician. Such coverage shall be made available at the inception of all new contracts and, with respect to all other contracts at any anniversary date subject to evidence of insurability. (B) TREATMENT AND DIAGNOSIS OF ALZHEIMER'S OR RELATED DISEASES AND NON-HEALTH RELATED SERVICES. (C) FOR THE PURPOSES OF THIS PARAGRAPH THE FOLLOWING TERMS SHALL HAVE THE FOLLOWING MEANINGS: (I) "NON-HEALTH RELATED SERVICES" MEANS THOSE OUT-PATIENT SERVICES WHICH MEET THE CARE AND BEHAVIORAL NEEDS OF THE PATIENT, INCLUDING BUT NOT LIMITED TO CRISIS INTERVENTION, ADULT DAY CARE, HOME CARE AND RESPITE CARE.
(II) "CARE AND BEHAVIORAL NEEDS OF THE PATIENT" MEANS THE MANIFESTA- TION OF SYMPTOMS WHICH MAY INCLUDE BUT NOT LIMITED TO MEMORY LOSS, APHA- SIA (COMMUNICATION DISORDER), BECOMING LOST OR DISORIENTED, CONFUSION AND AGITATION WITH THE POTENTIAL FOR COMBATIVENESS AND INCONTINENCE. (III) "ALZHEIMER'S OR RELATED DISEASES" MEANS ANY OF THOSE IRREVERS- IBLE BRAIN DISORDERS WHICH RESULT IN THE SYMPTOMS DESCRIBED IN THIS PARAGRAPH BUT NOT LIMITED TO MULTI-INFARCT DEMENTIAS AND PARKINSON'S DISEASE. S 5. This act shall take effect on the one hundred twentieth day after it shall have become a law, provided however, that effective immediate- ly, the addition, amendment and/or repeal of any rules or regulations necessary for the implementation of the provisions of this act on its effective date are authorized and directed to be made and completed on or before such effective date and shall apply to all policies and contracts issued, renewed, modified, altered or amended on or after such effective date.

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