S T A T E O F N E W Y O R K ________________________________________________________________________ 3131--B 1999-2000 Regular Sessions I N S E N A T E March 2, 1999 ___________ Introduced by Sens. LAVALLE, SPANO, GOODMAN, HOFFMANN, KRUGER, LACHMAN, LARKIN, LEIBELL, MARCELLINO, MARKOWITZ, MORAHAN, PADAVAN, SKELOS, TRUNZO -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said commit- tee -- 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 committee AN ACT to amend the insurance law, in relation to coverage for diagnosis testing for and treatment of infertility; and providing for the repeal of such provisions upon expiration thereof THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: 1 Section 1. Subsection (k) of section 3221 of the insurance law is 2 amended by adding a new paragraph 13 to read as follows: 3 (13)(A) EVERY GROUP OR BLANKET POLICY DELIVERED OR ISSUED FOR DELIVERY 4 IN THIS STATE WHICH PROVIDES MEDICAL COVERAGE THAT INCLUDES COVERAGE FOR 5 PHYSICIAN SERVICES IN A PHYSICIAN'S OFFICE AND EVERY POLICY DELIVERED OR 6 ISSUED FOR DELIVERY IN THIS STATE WHICH PROVIDES HOSPITAL, SURGICAL, 7 MAJOR MEDICAL OR SIMILAR COMPREHENSIVE-TYPE COVERAGE SHALL PROVIDE 8 COVERAGE FOR PERSONS AGES TWENTY-FIVE THROUGH FORTY-FOUR FOR THE DIAGNO- 9 SIS AND TREATMENT OF INFERTILITY IN ACCORDANCE WITH A PHYSICIAN'S PLAN 10 OF CARE AND GENERALLY ACCEPTED CLINICAL GUIDELINES AS ADOPTED BY THE 11 AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS AND THE AMERICAN 12 SOCIETY FOR REPRODUCTIVE MEDICINE. COVERAGE FOR SUCH TREATMENT SHALL 13 INCLUDE PRESCRIPTION DRUGS, BUT ONLY IF THE POLICY OTHERWISE PROVIDES 14 COVERAGE FOR PRESCRIPTION DRUGS. SUCH POLICY SHALL COVER ONLY MEDICAL OR 15 SURGICAL SERVICES OR PROCEDURES THAT ARE CONSISTENT WITH GENERALLY 16 ACCEPTED GUIDELINES TO TREAT INFERTILITY OR INDUCE PREGNANCY BUT, SHALL 17 NOT INCLUDE MEDICAL OR SURGICAL SERVICES OR PROCEDURES THAT ARE DEEMED 18 TO BE EXPERIMENTAL BY THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOL- 19 OGISTS OR THE AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE. SUCH POLICY PAGE-2 1 SHALL COVER ONLY MEDICAL OR SURGICAL SERVICES OR PROCEDURES PERFORMED BY 2 HEALTH CARE PROVIDERS WHOSE TRAINING IS CONSISTENT WITH GUIDELINES 3 ESTABLISHED BY THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS 4 AND THE AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE. SUCH COVERAGE SHALL 5 NOT INCLUDE REVERSAL OF STERILIZATIONS, VASECTOMIES, TUBAL LIGATIONS, OR 6 REVERSAL OF SEX CHANGE PROCEDURES, CLONING, OR EGG AND SPERM RETRIEVAL 7 FROM DECEASED INDIVIDUALS OR COVER PERSONS THAT HAVE UNDERGONE ELECTIVE 8 STERILIZATION. THE USE OF SPERM OR EGGS FROM AN INDIVIDUAL WHO IS 9 DECEASED SHALL ONLY BE COVERED IF SUCH INDIVIDUAL AUTHORIZED SUCH USE IN 10 WRITING PRIOR TO DEATH. IF THE GROUP OR ENTITY, ON WHOSE BEHALF THE 11 POLICY IS ISSUED IS OPERATED, SUPERVISED OR CONTROLLED BY OR IN 12 CONNECTION WITH A RELIGIOUS ORGANIZATION OR DENOMINATIONAL GROUP OR 13 ENTITY, THEN NOTHING IN THIS PARAGRAPH SHALL REQUIRE THE POLICY TO COVER 14 ANY DIAGNOSIS OR TREATMENT THAT IS CONTRARY TO THE RELIGIOUS TENETS OF 15 SUCH GROUP OR ENTITY. IF THE INSURER OR HEALTH MAINTENANCE ORGANIZATION 16 DELIVERING THE POLICY OR ISSUING THE POLICY FOR DELIVERY IN THIS STATE 17 IS OPERATED, SPONSORED OR CONTROLLED BY OR IN CONNECTION WITH A RELI- 18 GIOUS ORGANIZATION OR DENOMINATIONAL GROUP OR ENTITY, THEN NOTHING IN 19 THIS PARAGRAPH SHALL REQUIRE THE POLICY TO COVER ANY DIAGNOSIS OR TREAT- 20 MENT THAT IS CONTRARY TO THE RELIGIOUS TENETS OF SUCH INSURER OR HEALTH 21 MAINTENANCE ORGANIZATION. 22 (B) THE COVERAGE REQUIRED UNDER SUBPARAGRAPH (A) OF THIS PARAGRAPH IS 23 SUBJECT TO THE FOLLOWING CONDITIONS: 24 (I) SUCH COVERAGE MAY BE SUBJECT TO ANNUAL CO-PAYMENTS, CO-INSURANCE 25 AND DEDUCTIBLES AS MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT; 26 PROVIDED, HOWEVER, THAT A LIFETIME LIMIT FOR SUCH COVERAGE UNDER THIS 27 PARAGRAPH SHALL BE SIXTY THOUSAND DOLLARS; PROVIDED, FURTHER, THAT SUCH 28 LIFETIME LIMIT SHALL NOT INCLUDE THE COST OF PRESCRIPTION DRUGS FOR SUCH 29 COVERAGE PROVIDED UNDER THIS PARAGRAPH; 30 (II) COVERAGE FOR PROCEDURES FOR IN VITRO FERTILIZATION, INTRACYTO- 31 PLASMIC SPERM INJECTION, ASSISTED HATCHING, GAMETE DONATION, EMBRYO 32 DONATION, EMBRYO TRANSFER, GAMETE INTRAFALLOPIAN TUBE TRANSFER OR ZYGOTE 33 INTRAFALLOPIAN TUBE TRANSFER SHALL BE REQUIRED ONLY IF: 34 (I) THE COVERED INDIVIDUAL HAS BEEN UNABLE TO ATTAIN OR SUSTAIN A 35 SUCCESSFUL PREGNANCY THROUGH REASONABLE, LESS COSTLY MEDICALLY APPROPRI- 36 ATE INFERTILITY TREATMENTS FOR WHICH COVERAGE IS AVAILABLE UNDER THE 37 POLICY, PLAN OR CONTRACT, 38 (II) THE COVERED INDIVIDUAL HAS NOT UNDERGONE FOUR COMPLETED EMBRYO 39 TRANSFERS, EXCEPT THAT IF A LIVE BIRTH FOLLOWS A COMPLETED EMBRYO TRANS- 40 FER, THEN TWO MORE COMPLETED EMBRYO TRANSFERS SHALL BE COVERED, 41 (III) THE PROCEDURES ARE PERFORMED AT MEDICAL FACILITIES THAT CONFORM 42 TO THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS GUIDELINES 43 FOR IN VITRO FERTILIZATION CLINICS OR TO THE AMERICAN SOCIETY FOR REPRO- 44 DUCTIVE MEDICINE MINIMAL STANDARDS FOR PROGRAMS OF IN VITRO FERTILIZA- 45 TION, AND THE EMBRYO LABORATORIES THAT PARTICIPATE IN EMBRYO TRANSFER 46 PROCEDURES ADHERE TO GUIDELINES ISSUED BY THE CENTERS FOR DISEASE 47 CONTROL AS PART OF THE FEDERAL FERTILITY CLINIC SUCCESS RATE AND CERTIF- 48 ICATION ACT OF 1992, AND 49 (IV) THE COVERED INDIVIDUAL IS AN APPROPRIATE MEDICAL CANDIDATE AND 50 THERE IS A REASONABLE EXPECTATION THAT TREATMENT WILL RESULT IN A HEAL- 51 THY CHILD, AS DETERMINED BY GUIDELINES ESTABLISHED BY THE AMERICAN 52 COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS AND THE AMERICAN SOCIETY FOR 53 REPRODUCTIVE MEDICINE; AND 54 (III) SUCH COVERAGE SHALL BE LIMITED TO THOSE PERSONS COVERED UNDER 55 THE POLICY FOR A PERIOD OF AT LEAST TWELVE MONTHS. FOR THE PURPOSES OF 56 THIS PARAGRAPH, "COVERED UNDER THE POLICY" SHALL MEAN EITHER THE DATE PAGE-3 1 THE INSURED WAS FIRST COVERED UNDER THE EXISTING POLICY OR A PREVIOUSLY 2 IN-FORCE CONVERTED POLICY, WHICHEVER DATE IS EARLIER. 3 (C) FOR PURPOSES OF THIS SECTION, "INFERTILITY" SHALL BE DETERMINED IN 4 ACCORDANCE WITH AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS AND 5 AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE GUIDELINES. 6 § 2. Section 4303 of the insurance law is amended by adding a new 7 subsection (aa) to read as follows: 8 (AA) (1) EVERY CONTRACT ISSUED BY A MEDICAL EXPENSE INDEMNITY CORPO- 9 RATION, A HOSPITAL SERVICE CORPORATION OR A HEALTH SERVICE CORPORATION 10 WHICH PROVIDES MEDICAL COVERAGE THAT INCLUDES COVERAGE FOR PHYSICIAN 11 SERVICES IN A PHYSICIAN'S OFFICE AND EVERY POLICY WHICH PROVIDES MAJOR 12 MEDICAL OR SIMILAR COMPREHENSIVE-TYPE COVERAGE SHALL PROVIDE COVERAGE 13 FOR PERSONS AGES TWENTY-FIVE THROUGH FORTY-FOUR FOR THE DIAGNOSIS AND 14 TREATMENT OF INFERTILITY IN ACCORDANCE WITH A PHYSICIAN'S PLAN OF CARE 15 AND GENERALLY ACCEPTED CLINICAL GUIDELINES ADOPTED BY THE AMERICAN 16 COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS AND THE AMERICAN SOCIETY FOR 17 REPRODUCTIVE MEDICINE. COVERAGE FOR SUCH TREATMENT SHALL INCLUDE 18 PRESCRIPTION DRUGS, BUT ONLY IF THE POLICY OR CONTRACT OTHERWISE 19 PROVIDES COVERAGE FOR PRESCRIPTION DRUGS. SUCH CONTRACT SHALL COVER ONLY 20 MEDICAL OR SURGICAL SERVICES OR PROCEDURES THAT ARE CONSISTENT WITH 21 GENERALLY ACCEPTED GUIDELINES TO TREAT INFERTILITY OR INDUCE PREGNANCY 22 BUT, SHALL NOT INCLUDE MEDICAL OR SURGICAL SERVICES OR PROCEDURES THAT 23 ARE DEEMED TO BE EXPERIMENTAL BY THE AMERICAN COLLEGE OF OBSTETRICIANS 24 AND GYNECOLOGISTS OR THE AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE. 25 SUCH CONTRACT SHALL COVER ONLY MEDICAL OR SURGICAL SERVICES OR PROCE- 26 DURES PERFORMED BY HEALTH CARE PROVIDERS WHOSE TRAINING IS CONSISTENT 27 WITH GUIDELINES ESTABLISHED BY THE AMERICAN COLLEGE OF OBSTETRICIANS AND 28 GYNECOLOGISTS AND THE AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE. SUCH 29 COVERAGE SHALL NOT INCLUDE REVERSAL OF STERILIZATIONS, VASECTOMIES, 30 TUBAL LIGATIONS, REVERSAL OF SEX CHANGE PROCEDURES, CLONING, OR EGG AND 31 SPERM RETRIEVAL FROM DECEASED INDIVIDUALS OR COVER PERSONS THAT HAVE 32 UNDERGONE ELECTIVE STERILIZATION. THE USE OF SPERM OR EGGS FROM AN 33 INDIVIDUAL WHO IS DECEASED SHALL ONLY BE COVERED IF SUCH INDIVIDUAL 34 AUTHORIZED SUCH USE IN WRITING PRIOR TO DEATH. IF THE GROUP OR ENTITY, 35 ON WHOSE BEHALF THE CONTRACT ISSUED IS OPERATED, SUPERVISED OR 36 CONTROLLED BY OR IN CONNECTION WITH A RELIGIOUS ORGANIZATION OR DENOMI- 37 NATIONAL GROUP OR ENTITY, THEN NOTHING IN THIS PARAGRAPH SHALL REQUIRE 38 THE CONTRACT TO COVER ANY DIAGNOSIS OR TREATMENT THAT IS CONTRARY TO THE 39 RELIGIOUS TENETS OF SUCH GROUP OR ENTITY. IF THE INSURER OR HEALTH MAIN- 40 TENANCE ORGANIZATION DELIVERING THE CONTRACT OR ISSUING THE CONTRACT FOR 41 DELIVERY IN THIS STATE IS OPERATED, SPONSORED OR CONTROLLED BY OR IN 42 CONNECTION WITH A RELIGIOUS ORGANIZATION OR DENOMINATIONAL GROUP OR 43 ENTITY, THEN NOTHING IN THIS PARAGRAPH SHALL REQUIRE THE CONTRACT TO 44 COVER ANY DIAGNOSIS OR TREATMENT THAT IS CONTRARY TO THE RELIGIOUS 45 TENETS OF SUCH INSURER OR HEALTH MAINTENANCE ORGANIZATION. 46 (2) THE COVERAGE REQUIRED UNDER PARAGRAPH ONE OF THIS SUBSECTION IS 47 SUBJECT TO THE FOLLOWING CONDITIONS: 48 (A) SUCH COVERAGE MAY BE SUBJECT TO ANNUAL CO-PAYMENTS, CO-INSURANCE 49 AND DEDUCTIBLES AS MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT; 50 PROVIDED, HOWEVER, THAT A LIFETIME LIMIT FOR SUCH COVERAGE UNDER THIS 51 SUBSECTION SHALL BE SIXTY THOUSAND DOLLARS; PROVIDED, FURTHER, THAT SUCH 52 LIFETIME LIMIT SHALL NOT INCLUDE THE COST OF PRESCRIPTION DRUGS FOR SUCH 53 COVERAGE PROVIDED UNDER THIS SUBSECTION; 54 (B) COVERAGE FOR PROCEDURES FOR IN VITRO FERTILIZATION, INTRACYTO- 55 PLASMIC SPERM INJECTION, ASSISTED HATCHING, GAMETE DONATION, EMBRYO PAGE-4 1 DONATION, EMBRYO TRANSFER, GAMETE INTRAFALLOPIAN TUBE TRANSFER OR ZYGOTE 2 INTRAFALLOPIAN TUBE TRANSFER SHALL BE REQUIRED ONLY IF: 3 (I) THE COVERED INDIVIDUAL HAS BEEN UNABLE TO ATTAIN OR SUSTAIN A 4 SUCCESSFUL PREGNANCY THROUGH REASONABLE, LESS COSTLY MEDICALLY APPROPRI- 5 ATE INFERTILITY TREATMENTS FOR WHICH COVERAGE IS AVAILABLE UNDER THE 6 POLICY, PLAN OR CONTRACT, 7 (II) THE COVERED INDIVIDUAL HAS NOT UNDERGONE FOUR COMPLETED EMBRYO 8 TRANSFERS, EXCEPT THAT IF A LIVE BIRTH FOLLOWS A COMPLETED EMBRYO TRANS- 9 FER, THEN TWO MORE COMPLETED EMBRYO TRANSFERS SHALL BE COVERED, 10 (III) THE PROCEDURES ARE PERFORMED AT MEDICAL FACILITIES THAT CONFORM 11 TO THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS GUIDELINES 12 FOR IN VITRO FERTILIZATION CLINICS OR TO THE AMERICAN SOCIETY FOR REPRO- 13 DUCTIVE MEDICINE MINIMAL STANDARDS FOR PROGRAMS OF IN VITRO FERTILIZA- 14 TION, AND THE EMBRYO LABORATORIES THAT PARTICIPATE IN EMBRYO TRANSFER 15 PROCEDURES ADHERE TO GUIDELINES ISSUED BY THE CENTERS FOR DISEASE 16 CONTROL AS PART OF THE FEDERAL FERTILITY CLINIC SUCCESS RATE AND CERTIF- 17 ICATION ACT OF 1992, AND 18 (IV) THE COVERED INDIVIDUAL IS AN APPROPRIATE MEDICAL CANDIDATE AND 19 THERE IS A REASONABLE EXPECTATION THAT TREATMENT WILL RESULT IN A HEAL- 20 THY CHILD, AS DETERMINED BY GUIDELINES ESTABLISHED BY THE AMERICAN 21 COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS AND THE AMERICAN SOCIETY FOR 22 REPRODUCTIVE MEDICINE; AND 23 (C) SUCH COVERAGE SHALL BE LIMITED TO THOSE PERSONS COVERED UNDER THE 24 POLICY OR CONTRACT FOR A PERIOD OF AT LEAST TWELVE MONTHS. FOR THE 25 PURPOSES OF THIS SUBSECTION, "COVERED UNDER THE POLICY OR CONTRACT" 26 SHALL MEAN EITHER THE DATE THE INSURED WAS FIRST COVERED UNDER THE 27 EXISTING POLICY OR CONTRACT OR A PREVIOUSLY IN-FORCE CONVERTED POLICY OR 28 CONTRACT, WHICHEVER DATE IS EARLIER. 29 (3) FOR PURPOSES OF THIS SECTION, "INFERTILITY" SHALL BE DETERMINED IN 30 ACCORDANCE WITH AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS AND 31 AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE GUIDELINES. 32 § 3. The superintendent of insurance shall order the conducting of a 33 study of the utilization trends and experience, and the rate and premium 34 impact to health insurance consumers of paragraph 13 of subsection (k) 35 of section 3221 and subsection (aa) of section 4303 of the insurance law 36 as added by sections one and two of this act. Such study shall be 37 performed by a member of the American Academy of Actuaries. The study 38 shall be completed and a report submitted thereon to the governor, 39 superintendent of insurance, temporary president of the senate and 40 speaker of the assembly on or before March 1, 2002. 41 § 4. This act shall take effect July 1, 2000 and shall expire and be 42 deemed repealed July 1, 2002. This act shall apply to all policies and 43 contracts issued, renewed, altered or modified on any date during the 44 period which the provisions of this act are in effect. Any rules and 45 regulations necessary to implement the provisions of this act on its 46 effective date are authorized and directed to be completed on or before 47 such effective date. .