S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   5476
 
                        2019-2020 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             February 12, 2019
                                ___________
 
 Introduced  by M. of A. ORTIZ -- read once and referred to the Committee
   on Insurance
 
 AN ACT to amend the insurance law, in relation to  coverage  for  eating
   disorders
 
   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 35 to read as follows:
   (35)  (A)  EVERY  POLICY WHICH PROVIDES MEDICAL COVERAGE THAT INCLUDES
 COVERAGE FOR PHYSICIAN SERVICES IN A PHYSICIAN'S OFFICE AND EVERY POLICY
 WHICH PROVIDES MAJOR  MEDICAL  OR  SIMILAR  COMPREHENSIVE-TYPE  COVERAGE
 SHALL INCLUDE COVERAGE FOR INPATIENT HOSPITALIZATION, PARTIAL HOSPITALI-
 ZATION,  RESIDENTIAL  CARE,  INTENSIVE  OUTPATIENT  TREATMENT, FOLLOW UP
 OUTPATIENT CARE AND COUNSELING  FOR  ADULTS  AND  CHILDREN  WITH  EATING
 DISORDERS.  SUCH  COVERAGE  SHALL BE PROVIDED UNDER THE TERMS AND CONDI-
 TIONS OTHERWISE APPLICABLE UNDER THE POLICY, INCLUDING  NETWORK  LIMITA-
 TIONS  OR  VARIATIONS,  EXCLUSIONS, CO-PAYS, COINSURANCE, DEDUCTIBLES OR
 OTHER SPECIFIC COST SHARING MECHANISMS. PROVIDED FURTHER, WHERE A POLICY
 PROVIDES BOTH IN-NETWORK AND OUT-OF-NETWORK BENEFITS, THE OUT-OF-NETWORK
 BENEFITS MAY HAVE DIFFERENT COINSURANCE, CO-PAYS, OR  DEDUCTIBLES,  THAN
 THE  IN-NETWORK  BENEFITS,  REGARDLESS  OF WHETHER THE POLICY IS WRITTEN
 UNDER ONE LICENSE OR TWO LICENSES.
   (B) COVERAGE FOR TREATMENT OF AN EATING DISORDER PROVIDED  UNDER  THIS
 PARAGRAPH  IS  LIMITED TO MEDICALLY NECESSARY TREATMENT THAT IS PROVIDED
 BY A LICENSED TREATING  PHYSICIAN,  PSYCHIATRIST,  PSYCHOLOGIST,  MENTAL
 HEALTH COUNSELOR, CLINICAL SOCIAL WORKER, OR LICENSED MARRIAGE AND FAMI-
 LY THERAPIST, IN ACCORDANCE WITH A TREATMENT PLAN.  SUCH TREATMENT PLAN,
 UPON  REQUEST  BY  THE INSURER, SHALL INCLUDE ALL ELEMENTS NECESSARY FOR
 SUCH INSURER TO PAY CLAIMS. SUCH ELEMENTS INCLUDE, BUT ARE  NOT  LIMITED
 TO,  A  DIAGNOSIS, PROPOSED TREATMENT BY TYPE, FREQUENCY AND DURATION OF
 TREATMENT, AND GOALS.
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD08518-02-9

 A. 5476                             2
 
   (C) MEDICAL NECESSITY  DETERMINATIONS  AND  CARE  MANAGEMENT  FOR  THE
 TREATMENT  OF  EATING  DISORDERS  SHALL CONSIDER THE OVERALL MEDICAL AND
 MENTAL HEALTH NEEDS OF THE INDIVIDUAL WITH AN EATING DISORDER, SHALL NOT
 BE BASED SOLELY ON WEIGHT, AND SHALL TAKE INTO  CONSIDERATION  THE  MOST
 RECENT  PRACTICE  GUIDELINE  FOR  THE  TREATMENT OF PATIENTS WITH EATING
 DISORDERS ADOPTED BY THE AMERICAN PSYCHIATRIC ASSOCIATION IN ADDITION TO
 CURRENT STANDARDS BASED UPON THE MEDICAL LITERATURE GENERALLY RECOGNIZED
 AS AUTHORITATIVE IN THE MEDICAL COMMUNITY.
   (D) FOR PURPOSES OF THIS PARAGRAPH, THE TERM "EATING  DISORDER"  MEANS
 PICA,  RUMINATION  DISORDER,  AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER,
 ANOREXIA NERVOSA, BULIMIA NERVOSA, BINGE EATING DISORDER,  OTHER  SPECI-
 FIED FEEDING OR EATING DISORDER, AND ANY OTHER EATING DISORDER CONTAINED
 IN  THE  MOST RECENT VERSION OF THE DIAGNOSTIC AND STATISTICAL MANUAL OF
 MENTAL DISORDERS PUBLISHED BY THE AMERICAN PSYCHIATRIC ASSOCIATION.
   § 2. Subparagraph (B) of paragraph 5 of subsection (l) of section 3221
 of the insurance law, as amended by chapter 502 of the laws of 2007,  is
 amended to read as follows:
   (B)  (i)  Every insurer delivering a group or school blanket policy or
 issuing a group or school blanket policy for delivery,  in  this  state,
 which  provides  coverage  for  inpatient  hospital care or coverage for
 physician services, shall provide comparable  coverage  for  adults  and
 children  with  biologically  based  mental illness. Such group policies
 issued or delivered in this state shall  also  provide  such  comparable
 coverage for children with serious emotional disturbances. Such coverage
 shall  be  provided  under the terms and conditions otherwise applicable
 under the policy, including network limitations  or  variations,  exclu-
 sions,  co-pays, coinsurance, deductibles or other specific cost sharing
 mechanisms. Provided further, where a policy  provides  both  in-network
 and  out-of-network  benefits,  the  out-of-network  benefits  may  have
 different coinsurance, co-pays,  or  deductibles,  than  the  in-network
 benefits,  regardless of whether the policy is written under one license
 or two licenses.
   (ii) For purposes of this  paragraph,  the  term  "biologically  based
 mental  illness" means a mental, nervous, or emotional condition that is
 caused by a biological disorder of the brain and results in a clinically
 significant, psychological syndrome or pattern that substantially limits
 the functioning of the person with the illness. Such biologically  based
 mental illnesses are defined as schizophrenia/psychotic disorders, major
 depression,  bipolar  disorder,  delusional  disorders,  panic disorder,
 obsessive compulsive disorders[, bulimia, and  anorexia]  OR  AN  EATING
 DISORDER.
   (III)  (I) FOR PURPOSES OF THIS SUBSECTION, THE TERM "EATING DISORDER"
 MEANS PICA, RUMINATION DISORDER, AVOIDANT/RESTRICTIVE FOOD INTAKE DISOR-
 DER, ANOREXIA NERVOSA, BULIMIA NERVOSA,  BINGE  EATING  DISORDER,  OTHER
 SPECIFIED  FEEDING  OR  EATING  DISORDER,  AND ANY OTHER EATING DISORDER
 CONTAINED IN THE MOST RECENT VERSION OF THE DIAGNOSTIC  AND  STATISTICAL
 MANUAL OF MENTAL DISORDERS PUBLISHED BY THE AMERICAN PSYCHIATRIC ASSOCI-
 ATION.
   (II)  NOTWITHSTANDING  ANY  PROVISION OF THIS SECTION TO THE CONTRARY,
 COVERAGE FOR  TREATMENT  OF  AN  EATING  DISORDER  PROVIDED  UNDER  THIS
 SUBSECTION SHALL INCLUDE INPATIENT HOSPITALIZATION, PARTIAL HOSPITALIZA-
 TION, RESIDENTIAL CARE, INTENSIVE OUTPATIENT TREATMENT, FOLLOW UP OUTPA-
 TIENT  CARE AND COUNSELING, PROVIDED, HOWEVER, SUCH TREATMENT IS LIMITED
 TO MEDICALLY NECESSARY TREATMENT THAT IS PROVIDED BY A LICENSED TREATING
 PHYSICIAN, PSYCHIATRIST, PSYCHOLOGIST, MENTAL HEALTH COUNSELOR, CLINICAL
 SOCIAL WORKER, OR LICENSED MARRIAGE AND FAMILY THERAPIST, IN  ACCORDANCE

 A. 5476                             3
 
 WITH  A TREATMENT PLAN. SUCH TREATMENT PLAN, UPON REQUEST BY THE MEDICAL
 EXPENSE INDEMNITY  CORPORATION  OR  HEALTH  SERVICE  CORPORATION,  SHALL
 INCLUDE  ALL ELEMENTS NECESSARY FOR SUCH CORPORATION TO PAY CLAIMS. SUCH
 ELEMENTS  INCLUDE,  BUT ARE NOT LIMITED TO, A DIAGNOSIS, PROPOSED TREAT-
 MENT BY TYPE, FREQUENCY AND DURATION OF TREATMENT, AND GOALS.
   (III) MEDICAL NECESSITY DETERMINATIONS AND  CARE  MANAGEMENT  FOR  THE
 TREATMENT  OF  EATING  DISORDERS  SHALL CONSIDER THE OVERALL MEDICAL AND
 MENTAL HEALTH NEEDS OF THE INDIVIDUAL WITH AN EATING DISORDER, SHALL NOT
 BE BASED SOLELY ON WEIGHT, AND SHALL TAKE INTO  CONSIDERATION  THE  MOST
 RECENT  PRACTICE  GUIDELINE  FOR  THE  TREATMENT OF PATIENTS WITH EATING
 DISORDERS ADOPTED BY THE AMERICAN PSYCHIATRIC ASSOCIATION IN ADDITION TO
 CURRENT STANDARDS BASED UPON THE MEDICAL LITERATURE GENERALLY RECOGNIZED
 AS AUTHORITATIVE IN THE MEDICAL COMMUNITY.
   § 3. Paragraph 2 of subsection (g) of section 4303  of  the  insurance
 law,  as  amended by chapter 502 of the laws of 2007, is amended to read
 as follows:
   (2) (A) A hospital service corporation  or  a  health  service  corpo-
 ration,  which provides group, group remittance or school blanket cover-
 age for inpatient hospital care, shall provide comparable  coverage  for
 adults  and children with biologically based mental illness. Such hospi-
 tal service corporation or health service corporation shall also provide
 such comparable coverage for children with  serious  emotional  disturb-
 ances.  Such  coverage  shall be provided under the terms and conditions
 otherwise applicable under the contract, including  network  limitations
 or  variations,  exclusions,  co-pays, coinsurance, deductibles or other
 specific cost sharing mechanisms. Provided  further,  where  a  contract
 provides both in-network and out-of-network benefits, the out-of-network
 benefits  may  have different coinsurance, co-pays, or deductibles, than
 the in-network benefits, regardless of whether the contract  is  written
 under one license or two licenses.
   (B)  For  purposes  of  this  subsection, the term "biologically based
 mental illness" means a mental, nervous, or emotional condition that  is
 caused by a biological disorder of the brain and results in a clinically
 significant, psychological syndrome or pattern that substantially limits
 the  functioning of the person with the illness. Such biologically based
 mental illnesses are defined as schizophrenia/psychotic disorders, major
 depression, bipolar  disorder,  delusional  disorders,  panic  disorder,
 obsessive  compulsive  disorders[,  anorexia,  and bulimia] OR AN EATING
 DISORDER.
   (C) (I) FOR PURPOSES OF THIS SUBSECTION, THE  TERM  "EATING  DISORDER"
 MEANS PICA, RUMINATION DISORDER, AVOIDANT/RESTRICTIVE FOOD INTAKE DISOR-
 DER,  ANOREXIA  NERVOSA,  BULIMIA  NERVOSA, BINGE EATING DISORDER, OTHER
 SPECIFIED FEEDING OR EATING DISORDER,  AND  ANY  OTHER  EATING  DISORDER
 CONTAINED  IN  THE MOST RECENT VERSION OF THE DIAGNOSTIC AND STATISTICAL
 MANUAL OF MENTAL DISORDERS PUBLISHED BY THE AMERICAN PSYCHIATRIC ASSOCI-
 ATION.
   (II) NOTWITHSTANDING ANY PROVISION OF THIS SECTION  TO  THE  CONTRARY,
 COVERAGE  FOR  TREATMENT  OF  AN  EATING  DISORDER  PROVIDED  UNDER THIS
 SUBSECTION SHALL INCLUDE INPATIENT HOSPITALIZATION, PARTIAL HOSPITALIZA-
 TION, RESIDENTIAL CARE, INTENSIVE OUTPATIENT TREATMENT, FOLLOW UP OUTPA-
 TIENT CARE AND COUNSELING, PROVIDED, HOWEVER, SUCH TREATMENT IS  LIMITED
 TO MEDICALLY NECESSARY TREATMENT THAT IS PROVIDED BY A LICENSED TREATING
 PHYSICIAN, PSYCHIATRIST, PSYCHOLOGIST, MENTAL HEALTH COUNSELOR, CLINICAL
 SOCIAL  WORKER, OR LICENSED MARRIAGE AND FAMILY THERAPIST, IN ACCORDANCE
 WITH A TREATMENT PLAN. SUCH TREATMENT PLAN, UPON REQUEST BY THE  MEDICAL
 EXPENSE  INDEMNITY  CORPORATION  OR  HEALTH  SERVICE  CORPORATION, SHALL

 A. 5476                             4
 
 INCLUDE ALL ELEMENTS NECESSARY FOR SUCH CORPORATION TO PAY CLAIMS.  SUCH
 ELEMENTS  INCLUDE,  BUT ARE NOT LIMITED TO, A DIAGNOSIS, PROPOSED TREAT-
 MENT BY TYPE, FREQUENCY AND DURATION OF TREATMENT, AND GOALS.
   (III)  MEDICAL  NECESSITY  DETERMINATIONS  AND CARE MANAGEMENT FOR THE
 TREATMENT OF EATING DISORDERS SHALL CONSIDER  THE  OVERALL  MEDICAL  AND
 MENTAL HEALTH NEEDS OF THE INDIVIDUAL WITH AN EATING DISORDER, SHALL NOT
 BE  BASED  SOLELY  ON WEIGHT, AND SHALL TAKE INTO CONSIDERATION THE MOST
 RECENT PRACTICE GUIDELINE FOR THE  TREATMENT  OF  PATIENTS  WITH  EATING
 DISORDERS ADOPTED BY THE AMERICAN PSYCHIATRIC ASSOCIATION IN ADDITION TO
 CURRENT STANDARDS BASED UPON THE MEDICAL LITERATURE GENERALLY RECOGNIZED
 AS AUTHORITATIVE IN THE MEDICAL COMMUNITY.
   §  4.  Paragraph  2 of subsection (h) of section 4303 of the insurance
 law, as amended by chapter 502 of the laws of 2007, is amended  to  read
 as follows:
   (2)  (A)  A  medical expense indemnity corporation or a health service
 corporation, which provides group, group remittance  or  school  blanket
 coverage  for  physician services, shall provide comparable coverage for
 adults and children with biologically based mental illness. Such medical
 expense indemnity corporation or health service corporation  shall  also
 provide  such  comparable  coverage  for children with serious emotional
 disturbances. Such coverage shall be provided under the terms and condi-
 tions otherwise applicable under the contract, including network limita-
 tions or variations, exclusions, co-pays,  coinsurance,  deductibles  or
 other  specific  cost  sharing  mechanisms.  Provided  further,  where a
 contract provides both in-network and out-of-network benefits, the  out-
 of-network  benefits may have different coinsurance, co-pays, or deduct-
 ibles, than the in-network benefits, regardless of whether the  contract
 is written under one license or two licenses.
   (B)  For  purposes  of  this  subsection, the term "biologically based
 mental illness" means a mental, nervous, or emotional condition that  is
 caused by a biological disorder of the brain and results in a clinically
 significant, psychological syndrome or pattern that substantially limits
 the  functioning of the person with the illness. Such biologically based
 mental illnesses are defined as schizophrenia/psychotic disorders, major
 depression, bipolar  disorder,  delusional  disorders,  panic  disorder,
 obsessive  compulsive  disorder[,  anorexia,  and  bulimia] OR AN EATING
 DISORDER.
   (C) (I) FOR PURPOSES OF THIS SUBSECTION, THE  TERM  "EATING  DISORDER"
 MEANS PICA, RUMINATION DISORDER, AVOIDANT/RESTRICTIVE FOOD INTAKE DISOR-
 DER,  ANOREXIA  NERVOSA,  BULIMIA  NERVOSA, BINGE EATING DISORDER, OTHER
 SPECIFIED FEEDING OR EATING DISORDER,  AND  ANY  OTHER  EATING  DISORDER
 CONTAINED  IN  THE MOST RECENT VERSION OF THE DIAGNOSTIC AND STATISTICAL
 MANUAL OF MENTAL DISORDERS PUBLISHED BY THE AMERICAN PSYCHIATRIC ASSOCI-
 ATION.
   (II) NOTWITHSTANDING ANY PROVISION OF THIS SECTION  TO  THE  CONTRARY,
 COVERAGE  FOR  TREATMENT  OF  AN  EATING  DISORDER  PROVIDED  UNDER THIS
 SUBSECTION SHALL INCLUDE INPATIENT HOSPITALIZATION, PARTIAL HOSPITALIZA-
 TION, RESIDENTIAL CARE, INTENSIVE OUTPATIENT TREATMENT, FOLLOW UP OUTPA-
 TIENT CARE AND COUNSELING, PROVIDED, HOWEVER, SUCH TREATMENT IS  LIMITED
 TO MEDICALLY NECESSARY TREATMENT THAT IS PROVIDED BY A LICENSED TREATING
 PHYSICIAN, PSYCHIATRIST, PSYCHOLOGIST, MENTAL HEALTH COUNSELOR, CLINICAL
 SOCIAL  WORKER, OR LICENSED MARRIAGE AND FAMILY THERAPIST, IN ACCORDANCE
 WITH A TREATMENT PLAN. SUCH TREATMENT PLAN, UPON REQUEST BY THE  MEDICAL
 EXPENSE  INDEMNITY  CORPORATION  OR  HEALTH  SERVICE  CORPORATION, SHALL
 INCLUDE ALL ELEMENTS NECESSARY FOR SUCH CORPORATION TO PAY CLAIMS.  SUCH

 A. 5476                             5
 
 ELEMENTS  INCLUDE,  BUT ARE NOT LIMITED TO, A DIAGNOSIS, PROPOSED TREAT-
 MENT BY TYPE, FREQUENCY AND DURATION OF TREATMENT, AND GOALS.
   (III)  MEDICAL  NECESSITY  DETERMINATIONS  AND CARE MANAGEMENT FOR THE
 TREATMENT OF EATING DISORDERS SHALL CONSIDER  THE  OVERALL  MEDICAL  AND
 MENTAL HEALTH NEEDS OF THE INDIVIDUAL WITH AN EATING DISORDER, SHALL NOT
 BE  BASED  SOLELY  ON WEIGHT, AND SHALL TAKE INTO CONSIDERATION THE MOST
 RECENT PRACTICE GUIDELINE FOR THE  TREATMENT  OF  PATIENTS  WITH  EATING
 DISORDERS ADOPTED BY THE AMERICAN PSYCHIATRIC ASSOCIATION IN ADDITION TO
 CURRENT STANDARDS BASED UPON THE MEDICAL LITERATURE GENERALLY RECOGNIZED
 AS AUTHORITATIVE IN THE MEDICAL COMMUNITY.
   §  5.  This  act shall take effect on the ninetieth day after it shall
 have become a law; provided, however, that the provisions  of  this  act
 shall apply to policies and contracts issued, renewed, modified, altered
 or amended on or after such effective date.