Bill S166A-2011

Provides that health insurance coverage may not deny reimbursements because the registered pharmacy providing pharmaceutical products has not been approved

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.

Details

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

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.


Text

STATE OF NEW YORK ________________________________________________________________________ 166--A 2011-2012 Regular Sessions IN 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
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 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.

Comments

Open Legislation comments facilitate discussion of New York State legislation. All comments are subject to moderation. Comments deemed off-topic, commercial, campaign-related, self-promotional; or that contain profanity or hate speech; or that link to sites outside of the nysenate.gov domain are not permitted, and will not be published. Comment moderation is generally performed Monday through Friday.

By contributing or voting you agree to the Terms of Participation and verify you are over 13.

Discuss!

blog comments powered by Disqus