Provides that health insurers may not deny reimbursements to insureds because the registered pharmacy providing pharmaceutical products has not been approved by the insurer or other entity.

---

S166A-2011 Actions

• Jan 18, 2012: PRINT NUMBER 166A
• Jan 18, 2012: AMEND AND RECOMMIT TO INSURANCE
• Jan 4, 2012: REFERRED TO INSURANCE
• Jan 5, 2011: REFERRED TO INSURANCE

S166A-2011 Memo

BILL NUMBER:S166A

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

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, 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.648/A.3375  of 1997-1998; Referred to Insurance
S.8155/A.5906 of 1999-2000; Referred to Insurance
S.3208/A.1025 of 2001-2002; Referred to Insurance
S.559/A.1915  of 2003-2004; Referred to Insurance
S.3235/A.843  of 2005-2006; Referred to Insurance
S.27          of 2007-2008; Referred to Insurance
S.1449/A.7930 of 2009-2010; Referred to Insurance

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.

S166A-2011 Text

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

                                   166--A

                         2011-2012 Regular Sessions

                              I N  SENATE

                                 (PREFILED)

                               January 5, 2011
                                 ___________

  Introduced  by  Sens.  MAZIARZ, GOLDEN, GRISANTI, LITTLE, PARKER -- read
    twice and ordered printed, and when printed to  be  committed  to  the
    Committee on Insurance -- recommitted to the Committee on Insurance in
    accordance  with  Senate  Rule 6, sec. 8 -- committee discharged, bill
    amended, ordered reprinted as amended and recommitted to said  commit-
    tee

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

    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 29 to read as follows:

    (29) NO SUCH POLICY SHALL LIMIT BENEFITS  OR  DENY  REIMBURSEMENT  FOR
  BENEFITS  TO  ANY  INSURED ON THE BASIS THAT THE PHARMACY PROVIDING SUCH
  BENEFITS HAS NOT BEEN SPECIFICALLY SELECTED OR APPROVED. IF THE INSURED,
  HIS DEPENDENTS OR BOTH RECEIVE SERVICES FROM A  PHARMACY  OF  THEIR  OWN
  CHOOSING,  SUCH  INSURED  SHALL  PAY  THE  COST  OF  SUCH PHARMACEUTICAL
  PRODUCTS 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  PHARMACY  FROM
  PROVIDING  SERVICES,  PROVIDED  SUCH  PHARMACY  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 (k) 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 PHARMACY
  PROVIDING SUCH BENEFITS HAS NOT BEEN SPECIFICALLY SELECTED  OR  APPROVED
  BY  THE  GROUP OR BLANKET POLICY. IF THE INSURED, HIS DEPENDENTS OR BOTH

   EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                        [ ] is old law to be omitted.
                                                             LBD01652-03-2

 S. 166--A                           2

  RECEIVE SERVICES FROM A PHARMACY OF THEIR  OWN  CHOOSING,  SUCH  INSURED
  SHALL  PAY  THE  COST OF SUCH PHARMACEUTICAL PRODUCTS TO THE EXTENT THAT
  SUCH COST EXCEEDS THE BENEFITS PROVIDED UNDER THE GROUP OR BLANKET POLI-
  CY WITHOUT FORFEITURE OF THE BENEFITS PROVIDED UNDER SUCH GROUP OR BLAN-
  KET POLICY. NO SUCH GROUP OR BLANKET POLICY SHALL PROHIBIT A DULY REGIS-
  TERED PHARMACY FROM PROVIDING SERVICES, PROVIDED SUCH PHARMACY AGREES TO
  PROVIDE  SUCH  SERVICES  IN  ACCORDANCE  WITH  THE MINIMUM STANDARDS AND
  CONDITIONS FOR SIMILAR PROVIDERS THAT  HAVE  BEEN  ESTABLISHED  BY  SUCH
  GROUP OR BLANKET POLICY.
    S  3.  Section  4303  of  the insurance law is amended by adding a new
  subsection (ii) to read as follows:

    (II) 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 PHARMACY PROVIDING SUCH BENEFITS  HAS  NOT  BEEN  SPECIF-
  ICALLY  SELECTED  OR APPROVED BY THE THIRD PARTY BENEFIT PROGRAM. IF THE
  INSURED, HIS DEPENDENTS OR BOTH RECEIVE  SERVICES  FROM  A  PHARMACY  OF
  THEIR OWN CHOOSING, SUCH INSURED SHALL PAY THE COST OF SUCH TREATMENT TO
  THE EXTENT THAT SUCH COST EXCEEDS THE BENEFITS PROVIDED UNDER THE POLICY
  WITHOUT  FORFEITURE  OF THE BENEFITS PROVIDED UNDER SUCH POLICY. NO SUCH
  THIRD PARTY BENEFIT PROGRAM SHALL PROHIBIT A  DULY  REGISTERED  PHARMACY
  FROM  PROVIDING  SERVICES,  PROVIDED  SUCH  PHARMACY  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 PHARMACY, 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
  PHARMACY 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 DEPENDENTS OR BOTH RECEIVE SERVICES FROM A PHAR-
  MACY 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 PHARMACY   FROM PROVIDING  EMPLOYEE  BENEFITS,  PROVIDED
  SUCH  PHARMACY  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 PHARMACY SERVICES, PRESCRIPTION DRUGS OR FOR  PARTICIPATION
  IN  A  PRESCRIPTION DRUG PLAN, ANY PHARMACY WILLING TO PARTICIPATE UNDER
  THE TERMS OF THE CONTRACT SHALL NOT BE DENIED  ACCESS  TO  THE  PROVIDER
  PANEL.

 S. 166--A                           3

    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.