S T A T E O F N E W Y O R K
________________________________________________________________________
8441--B
I N S E N A T E
May 7, 2018
___________
Introduced by Sens. PHILLIPS, HELMING, AKSHAR, BONACIC, LITTLE,
MARCHIONE, O'MARA, YOUNG -- 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 committee -- committee discharged, bill amended, ordered
reprinted as amended and recommitted to said committee
AN ACT to amend the insurance law, in relation to insurance coverage of
in vitro fertilization and other fertility preservation treatments;
and to amend part K of chapter 82 of the laws of 2002 amending the
insurance law and the public health law relating to coverage for the
diagnosis and treatment of infertility, in relation to grants for
infertility services
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Paragraph 13 of subsection (i) of section 3216 of the
insurance law is amended by adding three new subparagraphs (C), (D) and
(E) to read as follows:
(C) EVERY POLICY DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE THAT
PROVIDES COVERAGE FOR HOSPITAL, SURGICAL OR MEDICAL CARE SHALL PROVIDE A
MAXIMUM LIFETIME LIMIT OF FIFTY THOUSAND DOLLARS COVERAGE FOR:
(I) IN VITRO FERTILIZATION USED IN THE TREATMENT OF INFERTILITY; AND
(II) STANDARD FERTILITY PRESERVATION SERVICES WHEN A NECESSARY MEDICAL
TREATMENT MAY DIRECTLY OR INDIRECTLY CAUSE IATROGENIC INFERTILITY TO A
COVERED PERSON.
(D) FOR THE PURPOSES OF SUBPARAGRAPH (C) OF THIS PARAGRAPH:
(I) "INFERTILITY" MEANS A CONDITION OR DISEASE CHARACTERIZED BY THE
INCAPACITY TO IMPREGNATE ANOTHER PERSON OR TO CONCEIVE, AS DIAGNOSED OR
DETERMINED (I) BY A PHYSICIAN LICENSED TO PRACTICE MEDICINE IN THIS
STATE, OR (II) BY THE FAILURE TO ESTABLISH A CLINICAL PREGNANCY AFTER
TWELVE MONTHS OF REGULAR, UNPROTECTED SEXUAL INTERCOURSE, OR AFTER SIX
MONTHS OF REGULAR, UNPROTECTED SEXUAL INTERCOURSE IN THE CASE OF A
FEMALE OVER AGE THIRTY-FIVE.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD04562-13-8
S. 8441--B 2
(II) "IATROGENIC INFERTILITY" MEANS AN IMPAIRMENT OF FERTILITY BY
SURGERY, RADIATION, CHEMOTHERAPY OR OTHER MEDICAL TREATMENT AFFECTING
REPRODUCTIVE ORGANS OR PROCESSES.
(III) COVERAGE FOR PRESCRIPTION DRUGS NECESSARY AS PART OF IN VITRO
FERTILIZATION OR STANDARD FERTILITY PRESERVATION SERVICES IS ONLY AVAIL-
ABLE WHERE THE POLICY OTHERWISE PROVIDES COVERAGE FOR PRESCRIPTION
DRUGS.
(IV) NOTWITHSTANDING ANY OTHER PROVISION OF LAW, A POLICY MAY IMPOSE
COST SHARING, DEDUCTIBLES OR COINSURANCE OBLIGATIONS THAT EXCEED THE
DOLLAR AMOUNT OF COST SHARING, DEDUCTIBLES OR COINSURANCE OBLIGATIONS
FOR NON-PREFERRED BRAND NAME DRUGS OR THEIR EQUIVALENT.
(E) FOR SERVICES PROVIDED PURSUANT TO SUBPARAGRAPH (C) OF THIS PARA-
GRAPH, POLICIES MAY:
(I) REQUIRE THAT SERVICES BE PERFORMED BY CLINICS OR MEDICAL CENTERS
THAT CONFORM TO GUIDELINES ISSUED BY THE AMERICAN SOCIETY FOR REPRODUC-
TIVE MEDICINE OR THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS
(ACOG);
(II) REQUIRE, NOTWITHSTANDING NETWORK ADEQUACY REQUIREMENTS, THAT ALL
SERVICES BE PERFORMED AT DESIGNATED PROVIDERS IDENTIFIED BY THE INSURER
AS MEETING SPECIFIED CREDENTIALING AND QUALITY STANDARDS AND WHICH
PARTICIPATE IN THE INSURER'S PROVIDER NETWORK;
(III) LIMIT COVERAGE FOR IN VITRO FERTILIZATION TO THOSE INDIVIDUALS
WHO HAVE BEEN UNABLE TO CONCEIVE OR PRODUCE CONCEPTION THROUGH LESS
EXPENSIVE AND MEDICALLY VIABLE INFERTILITY TREATMENT OR PROCEDURES
COVERED UNDER SUCH POLICY. NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED
TO DENY THE COVERAGE REQUIRED BY THIS SECTION TO ANY INDIVIDUAL WHO
FOREGOES A PARTICULAR INFERTILITY TREATMENT OR PROCEDURE IF THE INDIVID-
UAL'S PHYSICIAN DETERMINES THAT SUCH TREATMENT OR PROCEDURE IS LIKELY TO
BE UNSUCCESSFUL;
(IV) FOR PURPOSES OF CALCULATING THE LIFETIME LIMIT, REQUIRE DISCLO-
SURE BY THE INDIVIDUAL SEEKING SUCH COVERAGE TO SUCH INDIVIDUAL'S EXIST-
ING HEALTH INSURANCE CARRIER OF ANY PREVIOUS INFERTILITY TREATMENT OR
PROCEDURES FOR WHICH SUCH INDIVIDUAL RECEIVED COVERAGE UNDER A DIFFERENT
HEALTH INSURANCE POLICY ISSUED BY THE SAME INSURER OR BY ANOTHER INSUR-
ER; OR
(V) LIMIT COVERAGE RELATED TO IN VITRO FERTILIZATION SERVICES TO
PERSONS WHOSE AGES RANGE FROM TWENTY-ONE THROUGH FORTY-FOUR YEARS.
§ 2. Paragraph 6 of subsection (k) of section 3221 of the insurance
law is amended by adding four new subparagraphs (E), (F), (G) and (H) to
read as follows:
(E) EVERY GROUP POLICY DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE
THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL COVERAGE SHALL PROVIDE A
MAXIMUM LIFETIME LIMIT OF FIFTY THOUSAND DOLLARS OF COVERAGE FOR:
(I) IN VITRO FERTILIZATION USED IN THE TREATMENT OF INFERTILITY; AND
(II) STANDARD FERTILITY PRESERVATION SERVICES WHEN A NECESSARY MEDICAL
TREATMENT MAY DIRECTLY OR INDIRECTLY CAUSE IATROGENIC INFERTILITY TO A
COVERED PERSON.
(F) FOR THE PURPOSES OF SUBPARAGRAPH (E) OF THIS PARAGRAPH:
(I) "INFERTILITY" MEANS A CONDITION OR DISEASE CHARACTERIZED BY THE
INCAPACITY TO IMPREGNATE ANOTHER PERSON OR TO CONCEIVE, AS DIAGNOSED OR
DETERMINED (I) BY A PHYSICIAN LICENSED TO PRACTICE MEDICINE IN THIS
STATE, OR (II) BY THE FAILURE TO ESTABLISH A CLINICAL PREGNANCY AFTER
TWELVE MONTHS OF REGULAR, UNPROTECTED SEXUAL INTERCOURSE, OR AFTER SIX
MONTHS OF REGULAR, UNPROTECTED SEXUAL INTERCOURSE IN THE CASE OF A
FEMALE OVER AGE THIRTY-FIVE.
S. 8441--B 3
(II) "IATROGENIC INFERTILITY" MEANS AN IMPAIRMENT OF FERTILITY BY
SURGERY, RADIATION, CHEMOTHERAPY OR OTHER MEDICAL TREATMENT AFFECTING
REPRODUCTIVE ORGANS OR PROCESSES.
(III) COVERAGE FOR PRESCRIPTION DRUGS NECESSARY AS PART OF IN VITRO
FERTILIZATION OR STANDARD FERTILITY PRESERVATION SERVICES IS ONLY AVAIL-
ABLE WHERE THE POLICY OTHERWISE PROVIDES COVERAGE FOR PRESCRIPTION
DRUGS.
(IV) NOTWITHSTANDING ANY OTHER PROVISION OF LAW, A POLICY MAY IMPOSE
COST SHARING, DEDUCTIBLES OR COINSURANCE OBLIGATIONS THAT EXCEED THE
DOLLAR AMOUNT OF COST SHARING, DEDUCTIBLES OR COINSURANCE OBLIGATIONS
FOR NON-PREFERRED BRAND NAME DRUGS OR THEIR EQUIVALENT.
(G) NOTWITHSTANDING ANY OTHER PROVISION OF THIS SUBSECTION, A RELI-
GIOUS EMPLOYER MAY REQUEST A CONTRACT WITHOUT COVERAGE FOR IN VITRO
FERTILIZATION USED IN THE TREATMENT OF INFERTILITY AND STANDARD FERTILI-
TY PRESERVATION SERVICES THAT ARE CONTRARY TO THE RELIGIOUS EMPLOYER'S
RELIGIOUS TENETS. IF SO REQUESTED, SUCH CONTRACT SHALL BE PROVIDED WITH-
OUT COVERAGE FOR SERVICES.
(I) FOR PURPOSES OF THIS SUBSECTION, A "RELIGIOUS EMPLOYER" IS A GROUP
OR ENTITY FOR WHICH EACH OF THE FOLLOWING IS TRUE:
(I) THE INCULCATION OF RELIGIOUS VALUES IS THE PURPOSE OF THE GROUP OR
ENTITY.
(II) THE GROUP OR ENTITY PRIMARILY EMPLOYS PERSONS WHO SHARE THE RELI-
GIOUS TENETS OF THE GROUP OR ENTITY.
(III) THE GROUP OR ENTITY SERVES PRIMARILY PERSONS WHO SHARE THE RELI-
GIOUS TENETS OF THE GROUP OR ENTITY.
(IV) THE GROUP OR ENTITY IS A NONPROFIT ORGANIZATION AS DESCRIBED IN
SECTION 6033(A)(2)(A)I OR III, OF THE INTERNAL REVENUE CODE OF 1986, AS
AMENDED.
(II) EVERY RELIGIOUS EMPLOYER THAT INVOKES THE EXEMPTION PROVIDED
UNDER THIS SUBPARAGRAPH SHALL PROVIDE WRITTEN NOTICE TO PROSPECTIVE
ENROLLEES PRIOR TO ENROLLMENT WITH THE PLAN, LISTING THE TREATMENT OF
INFERTILITY AND STANDARD FERTILITY PRESERVATION SERVICES THE EMPLOYER
REFUSES TO COVER FOR RELIGIOUS REASONS.
(H) FOR SERVICES PROVIDED PURSUANT TO SUBPARAGRAPH (E) OF THIS PARA-
GRAPH, POLICIES MAY:
(I) REQUIRE THAT SERVICES BE PERFORMED BY CLINICS OR MEDICAL CENTERS
THAT CONFORM TO GUIDELINES ISSUED BY THE AMERICAN SOCIETY FOR REPRODUC-
TIVE MEDICINE OR THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS
(ACOG);
(II) REQUIRE, NOTWITHSTANDING NETWORK ADEQUACY REQUIREMENTS, THAT ALL
SERVICES BE PERFORMED AT DESIGNATED PROVIDERS IDENTIFIED BY THE INSURER
AS MEETING SPECIFIED CREDENTIALING AND QUALITY STANDARDS AND WHICH
PARTICIPATE IN THE INSURER'S PROVIDER NETWORK;
(III) LIMIT COVERAGE FOR IN VITRO FERTILIZATION TO THOSE INDIVIDUALS
WHO HAVE BEEN UNABLE TO CONCEIVE OR PRODUCE CONCEPTION THROUGH LESS
EXPENSIVE AND MEDICALLY VIABLE INFERTILITY TREATMENT OR PROCEDURES
COVERED UNDER SUCH POLICY. NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED
TO DENY THE COVERAGE REQUIRED BY THIS SECTION TO ANY INDIVIDUAL WHO
FOREGOES A PARTICULAR INFERTILITY TREATMENT OR PROCEDURE IF THE INDIVID-
UAL'S PHYSICIAN DETERMINES THAT SUCH TREATMENT OR PROCEDURE IS LIKELY TO
BE UNSUCCESSFUL;
(IV) FOR PURPOSES OF CALCULATING THE LIFETIME LIMIT, REQUIRE DISCLO-
SURE BY THE INDIVIDUAL SEEKING SUCH COVERAGE TO SUCH INDIVIDUAL'S EXIST-
ING HEALTH INSURANCE CARRIER OF ANY PREVIOUS INFERTILITY TREATMENT OR
PROCEDURES FOR WHICH SUCH INDIVIDUAL RECEIVED COVERAGE UNDER A DIFFERENT
S. 8441--B 4
HEALTH INSURANCE POLICY ISSUED BY THE SAME INSURER OR BY ANOTHER INSUR-
ER; OR
(V) LIMIT COVERAGE RELATED TO IN VITRO FERTILIZATION SERVICES TO
PERSONS WHOSE AGES RANGE FROM TWENTY-ONE THROUGH FORTY-FOUR YEARS.
§ 3. Subsection (s) of section 4303 of the insurance law, as amended
by section 2 of part F of chapter 82 of the laws of 2002, is amended by
adding four new paragraphs 5, 6, 7 and 8 to read as follows:
(5) EVERY CONTRACT ISSUED BY A MEDICAL EXPENSE INDEMNITY CORPORATION,
HOSPITAL SERVICE CORPORATION OR HEALTH SERVICE CORPORATION FOR DELIVERY
IN THIS STATE THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL COVERAGE SHALL
PROVIDE A MAXIMUM LIFETIME LIMIT OF FIFTY THOUSAND DOLLARS OF COVERAGE
FOR:
(A) IN VITRO FERTILIZATION USED IN THE TREATMENT OF INFERTILITY; AND
(B) STANDARD FERTILITY PRESERVATION SERVICES WHEN A NECESSARY MEDICAL
TREATMENT MAY DIRECTLY OR INDIRECTLY CAUSE IATROGENIC INFERTILITY TO A
COVERED PERSON.
(6) FOR THE PURPOSES OF PARAGRAPH FIVE OF THIS SUBSECTION:
(A) "INFERTILITY" MEANS A CONDITION OR DISEASE CHARACTERIZED BY THE
INCAPACITY TO IMPREGNATE ANOTHER PERSON OR TO CONCEIVE, AS DIAGNOSED OR
DETERMINED (I) BY A PHYSICIAN LICENSED TO PRACTICE MEDICINE IN THIS
STATE, OR (II) BY THE FAILURE TO ESTABLISH A CLINICAL PREGNANCY AFTER
TWELVE MONTHS OF REGULAR, UNPROTECTED SEXUAL INTERCOURSE, OR AFTER SIX
MONTHS OF REGULAR, UNPROTECTED SEXUAL INTERCOURSE IN THE CASE OF A
FEMALE OVER AGE THIRTY-FIVE.
(B) "IATROGENIC INFERTILITY" MEANS AN IMPAIRMENT OF FERTILITY BY
SURGERY, RADIATION, CHEMOTHERAPY OR OTHER MEDICAL TREATMENT AFFECTING
REPRODUCTIVE ORGANS OR PROCESSES.
(C) COVERAGE FOR PRESCRIPTION DRUGS NECESSARY AS PART OF IN VITRO
FERTILIZATION OR STANDARD FERTILITY PRESERVATION SERVICES IS ONLY AVAIL-
ABLE WHERE THE POLICY OTHERWISE PROVIDES COVERAGE FOR PRESCRIPTION
DRUGS.
(D) NOTWITHSTANDING ANY OTHER PROVISION OF LAW, A POLICY MAY IMPOSE
COST SHARING, DEDUCTIBLES OR COINSURANCE OBLIGATIONS THAT EXCEED THE
DOLLAR AMOUNT OF COST SHARING, DEDUCTIBLES OR COINSURANCE OBLIGATIONS
FOR NON-PREFERRED BRAND NAME DRUGS OR THEIR EQUIVALENT.
(7) NOTWITHSTANDING ANY OTHER PROVISION OF THIS SUBSECTION, A RELI-
GIOUS EMPLOYER MAY REQUEST A CONTRACT WITHOUT COVERAGE FOR IN VITRO
FERTILIZATION USED IN THE TREATMENT OF INFERTILITY AND STANDARD FERTILI-
TY PRESERVATION SERVICES THAT ARE CONTRARY TO THE RELIGIOUS EMPLOYER'S
RELIGIOUS TENETS. IF SO REQUESTED, SUCH CONTRACT SHALL BE PROVIDED WITH-
OUT COVERAGE FOR SERVICES.
(A) FOR PURPOSES OF THIS SUBSECTION, A "RELIGIOUS EMPLOYER" IS A GROUP
OR ENTITY FOR WHICH EACH OF THE FOLLOWING IS TRUE:
(I) THE INCULCATION OF RELIGIOUS VALUES IS THE PURPOSE OF THE GROUP OR
ENTITY.
(II) THE GROUP OR ENTITY PRIMARILY EMPLOYS PERSONS WHO SHARE THE RELI-
GIOUS TENETS OF THE GROUP OR ENTITY.
(III) THE GROUP OR ENTITY SERVES PRIMARILY PERSONS WHO SHARE THE RELI-
GIOUS TENETS OF THE GROUP OR ENTITY.
(IV) THE GROUP OR ENTITY IS A NONPROFIT ORGANIZATION AS DESCRIBED IN
SECTION 6033(A)(2)(A)I OR III, OF THE INTERNAL REVENUE CODE OF 1986, AS
AMENDED.
(B) EVERY RELIGIOUS EMPLOYER THAT INVOKES THE EXEMPTION PROVIDED UNDER
THIS PARAGRAPH SHALL PROVIDE WRITTEN NOTICE TO PROSPECTIVE ENROLLEES
PRIOR TO ENROLLMENT WITH THE PLAN, LISTING THE TREATMENT OF INFERTILITY
S. 8441--B 5
AND STANDARD FERTILITY PRESERVATION SERVICES THE EMPLOYER REFUSES TO
COVER FOR RELIGIOUS REASONS.
(8) FOR SERVICES PROVIDED PURSUANT TO PARAGRAPH FIVE OF THIS
SUBSECTION, POLICIES MAY:
(A) REQUIRE THAT SERVICES BE PERFORMED BY CLINICS OR MEDICAL CENTERS
THAT CONFORM TO GUIDELINES ISSUED BY THE AMERICAN SOCIETY FOR REPRODUC-
TIVE MEDICINE OR THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS
(ACOG);
(B) REQUIRE, NOTWITHSTANDING NETWORK ADEQUACY REQUIREMENTS, THAT ALL
SERVICES BE PERFORMED AT DESIGNATED PROVIDERS IDENTIFIED BY THE INSURER
AS MEETING SPECIFIED CREDENTIALING AND QUALITY STANDARDS AND WHICH
PARTICIPATE IN THE INSURER'S PROVIDER NETWORK;
(C) LIMIT COVERAGE FOR IN VITRO FERTILIZATION TO THOSE INDIVIDUALS WHO
HAVE BEEN UNABLE TO CONCEIVE OR PRODUCE CONCEPTION THROUGH LESS EXPEN-
SIVE AND MEDICALLY VIABLE INFERTILITY TREATMENT OR PROCEDURES COVERED
UNDER SUCH POLICY. NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO DENY
THE COVERAGE REQUIRED BY THIS SECTION TO ANY INDIVIDUAL WHO FOREGOES A
PARTICULAR INFERTILITY TREATMENT OR PROCEDURE IF THE INDIVIDUAL'S PHYSI-
CIAN DETERMINES THAT SUCH TREATMENT OR PROCEDURE IS LIKELY TO BE UNSUC-
CESSFUL;
(D) FOR PURPOSES OF CALCULATING THE LIFETIME LIMIT, REQUIRE DISCLOSURE
BY THE INDIVIDUAL SEEKING SUCH COVERAGE TO SUCH INDIVIDUAL'S EXISTING
HEALTH INSURANCE CARRIER OF ANY PREVIOUS INFERTILITY TREATMENT OR PROCE-
DURES FOR WHICH SUCH INDIVIDUAL RECEIVED COVERAGE UNDER A DIFFERENT
HEALTH INSURANCE POLICY ISSUED BY THE SAME INSURER OR BY ANOTHER INSUR-
ER; OR
(E) LIMIT COVERAGE RELATED TO IN VITRO FERTILIZATION SERVICES TO
PERSONS WHOSE AGES RANGE FROM TWENTY-ONE THROUGH FORTY-FOUR YEARS.
§ 4. Subparagraph (C) of paragraph 6 of subsection (k) of section 3221
of the insurance law, as amended by section 1 of part K of chapter 82 of
the laws of 2002, is amended to read as follows:
(C) Coverage of diagnostic and treatment procedures, including
prescription drugs, used in the diagnosis and treatment of infertility
as required by subparagraphs (A) and (B) of this paragraph shall be
provided in accordance with the provisions of this subparagraph.
(i) Coverage shall be provided for persons whose ages range from twen-
ty-one through forty-four years, provided that nothing herein shall
preclude the provision of coverage to persons whose age is below or
above such range.
(ii) Diagnosis and treatment of infertility shall be prescribed as
part of a physician's overall plan of care and consistent with the
guidelines for coverage as referenced in this subparagraph.
(iii) Coverage may be subject to co-payments, coinsurance and deduct-
ibles as may be deemed appropriate by the superintendent and as are
consistent with those established for other benefits within a given
policy.
(iv) [Coverage shall be limited to those individuals who have been
previously covered under the policy for a period of not less than twelve
months, provided that for the purposes of this subparagraph "period of
not less than twelve months" shall be determined by calculating such
time from either the date the insured was first covered under the exist-
ing policy or from the date the insured was first covered by a previous-
ly in-force converted policy, whichever is earlier.
(v)] Coverage shall not be required to include the diagnosis and
treatment of infertility in connection with: (I) [in vitro fertiliza-
tion,] gamete intrafallopian tube transfers or zygote intrafallopian
S. 8441--B 6
tube transfers; (II) the reversal of elective sterilizations; (III) sex
change procedures; (IV) cloning; or (V) medical or surgical services or
procedures that are deemed to be experimental in accordance with clin-
ical guidelines referenced in clause [(vi)] (V) of this subparagraph.
[(vi)] (V) The superintendent, in consultation with the commissioner
of health, shall promulgate regulations which shall stipulate the guide-
lines and standards which shall be used in carrying out the provisions
of this subparagraph, which shall include:
(I) The determination of "infertility" in accordance with the stand-
ards and guidelines established and adopted by the American College of
Obstetricians and Gynecologists and the American Society for Reproduc-
tive Medicine;
(II) The identification of experimental procedures and treatments not
covered for the diagnosis and treatment of infertility determined in
accordance with the standards and guidelines established and adopted by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine;
(III) The identification of the required training, experience and
other standards for health care providers for the provision of proce-
dures and treatments for the diagnosis and treatment of infertility
determined in accordance with the standards and guidelines established
and adopted by the American College of Obstetricians and Gynecologists
and the American Society for Reproductive Medicine; and
(IV) The determination of appropriate medical candidates by the treat-
ing physician in accordance with the standards and guidelines estab-
lished and adopted by the American College of Obstetricians and Gynecol-
ogists and/or the American Society for Reproductive Medicine.
§ 5. Paragraph 3 of subsection (s) of section 4303 of the insurance
law, as amended by section 2 of part K of chapter 82 of the laws of
2002, is amended to read as follows:
(3) Coverage of diagnostic and treatment procedures, including
prescription drugs used in the diagnosis and treatment of infertility as
required by paragraphs one and two of this subsection shall be provided
in accordance with this paragraph.
(A) Coverage shall be provided for persons whose ages range from twen-
ty-one through forty-four years, provided that nothing herein shall
preclude the provision of coverage to persons whose age is below or
above such range.
(B) Diagnosis and treatment of infertility shall be prescribed as part
of a physician's overall plan of care and consistent with the guidelines
for coverage as referenced in this paragraph.
(C) Coverage may be subject to co-payments, coinsurance and deduct-
ibles as may be deemed appropriate by the superintendent and as are
consistent with those established for other benefits within a given
policy.
[(D) Coverage shall be limited to those individuals who have been
previously covered under the policy for a period of not less than twelve
months, provided that for the purposes of this paragraph "period of not
less than twelve months" shall be determined by calculating such time
from either the date the insured was first covered under the existing
policy or from the date the insured was first covered by a previously
in-force converted policy, whichever is earlier.
(E)] (D) Coverage shall not be required to include the diagnosis and
treatment of infertility in connection with: (i) [in vitro fertiliza-
tion,] gamete intrafallopian tube transfers or zygote intrafallopian
tube transfers; (ii) the reversal of elective sterilizations; (iii) sex
S. 8441--B 7
change procedures; (iv) cloning; or (v) medical or surgical services or
procedures that are deemed to be experimental in accordance with clin-
ical guidelines referenced in subparagraph [(F)] (E) of this paragraph.
[(F)] (E) The superintendent, in consultation with the commissioner of
health, shall promulgate regulations which shall stipulate the guide-
lines and standards which shall be used in carrying out the provisions
of this paragraph, which shall include:
(i) The determination of "infertility" in accordance with the stand-
ards and guidelines established and adopted by the American College of
Obstetricians and Gynecologists and the American Society for Reproduc-
tive Medicine;
(ii) The identification of experimental procedures and treatments not
covered for the diagnosis and treatment of infertility determined in
accordance with the standards and guidelines established and adopted by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine;
(iii) The identification of the required training, experience and
other standards for health care providers for the provision of proce-
dures and treatments for the diagnosis and treatment of infertility
determined in accordance with the standards and guidelines established
and adopted by the American College of Obstetricians and Gynecologists
and the American Society for Reproductive Medicine; and
(iv) The determination of appropriate medical candidates by the treat-
ing physician in accordance with the standards and guidelines estab-
lished and adopted by the American College of Obstetricians and Gynecol-
ogists and/or the American Society for Reproductive Medicine.
§ 6. Section 4 of part K of chapter 82 of the laws of 2002, amending
the insurance law and the public health law relating to coverage for the
diagnosis and treatment of infertility, is amended to read as follows:
§ 4. The commissioner of health, subject to the availability of funds
pursuant to section 2807-v of the public health law, shall establish a
program to provide grants to health care providers for the purpose of
improving access to infertility services, treatments and procedures. At
least one such provider shall be located in the city of New York and one
such provider shall be located in an upstate region.
Such program shall be targeted to assist individuals in meeting the
cost of infertility services not covered pursuant to sections 3221 and
4303 of the insurance law as such sections are amended by sections one
and two of this act relating to expanded coverage of infertility
services. Services, treatments and procedures paid for pursuant to the
grant program shall be limited to: (A) those who meet the criteria for
such expanded coverage provided pursuant to the insurance law but for
whom the covered services are not effective for treating infertility,
AND THOSE WHO ARE UNABLE TO ACCESS COVERAGE FOR THE EXPANDED PROCEDURES
ENACTED PURSUANT TO A CHAPTER OF THE LAWS OF 2018; AND (B) THOSE WHO ARE
NOT ENROLLED IN A COMMERCIAL HEALTH CARE PLAN BUT WHO WOULD OTHERWISE
MEET THE CRITERIA OF SUBDIVISION (A) OF THIS SECTION. Services, treat-
ments and procedures paid for pursuant to the grant program shall be
further limited to assisted reproductive technology utilizing in vitro
fertilization and gamete intrafallopian tube transfer, and shall be made
available only in accordance with standards, protocols and other parame-
ters as shall be established by the commissioner, which shall include
but not be limited to ASRM and ACOG standards for the appropriateness of
individuals, providers and treatments, and standards relating to cost-
sharing based on income. Services, treatments and procedures under the
grant program, except for those specified herein, shall not include
S. 8441--B 8
those services, treatments and procedures explicitly excluded under the
expanded coverage provided for in the insurance law as amended by
sections one and two of this act. Notwithstanding sections 112 and 163
of the state finance law, grants provided pursuant to such program may
be made without competitive bid or request for proposal.
The commissioner of health shall promote public awareness of this
program.
§ 7. The superintendent of financial services in consultation with
the commissioner of health, shall reassess the coverage requirements of
this act and regulations promulgated thereunder pursuant to a review of
the comprehensive report funded pursuant to appropriation by chapter 50
of the laws of 2018 and the request for quote number C000457.
§ 8. This act shall take effect January 1, 2020 and shall apply to all
policies issued, renewed, altered or modified on or after such date;
provided, however, that should this act be determined to be a mandate
pursuant to section 1311 (d)(3)(B) of the Patient Protection and Afford-
able Care Act, then this act shall not apply to coverage offered in the
individual and small group market unless the state appropriates funds
sufficient to cover the full cost of such coverage, as determined by the
department of financial services and independently verified by an inde-
pendent actuarial firm certified by the American academy of actuaries.
In addition, the superintendent of financial services shall permit
insurers and other organizations subject to this act to establish a
minimum factor attributable to the services covered pursuant to this
chapter that may be incorporated into rates for large group policies
issued on or after January 1, 2020. Provided further, however, that
should this act be determined not to be a mandate pursuant to section
1311(d)(3)(B) of the Patient Protection and Affordable Care Act, then
the superintendent of financial services shall include in the approved
small group and individual rates a factor attributable to the cost of
services covered pursuant to this chapter and consistent with the actu-
arial cost, as projected by the applicant, of such coverage that shall
be incorporated into rates for policies issued on or after January 1,
2020.
