S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   7709
 
                             I N  S E N A T E
 
                             February 10, 2020
                                ___________
 
 Introduced  by  Sen.  KAPLAN -- read twice and ordered printed, and when
   printed to be committed to the Committee on Insurance
 
 AN ACT to amend the insurance law, in relation  to  enacting  the  "Give
   Kids  a Chance - Carter's Law" mandating health insurance coverage for
   congenital anomalies
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.  Short  title. This act shall be known and may be cited as
 the "Give Kids a Chance - Carter's Law".
   § 2. Subsection (a) of section 3216 of the insurance law is amended by
 adding 5 new paragraphs 5, 6, 7, 8 and 9 to read as follows:
   (5) "CONGENITAL ANOMALY" MEANS A MEDICALLY DIAGNOSED CONDITION  EXIST-
 ING  AT  OR  FROM BIRTH THAT IS A DEVIATION FROM THE COMMON STRUCTURE OR
 FUNCTION OF THE BODY, WHETHER CAUSED BY A  HEREDITARY  OR  DEVELOPMENTAL
 DISABILITY OR DISEASE.
   (6)  "COSMETIC SURGERY" MEANS SURGICAL AND NONSURGICAL ELECTIVE PROCE-
 DURES THAT ENHANCE AND RESHAPE STRUCTURES OF THE BODY TO IMPROVE APPEAR-
 ANCE AND CONFIDENCE, BUT ARE NOT NECESSARY TO IMPROVE BODY STRUCTURE  OR
 FUNCTION.
   (7)  "HABILITATIVE  SERVICES"  MEANS  HEALTHCARE SERVICES THAT HELP AN
 INDIVIDUAL KEEP, LEARN, OR IMPROVE  SKILLS  AND  FUNCTIONING  FOR  DAILY
 LIVING.  HABILITATIVE SERVICES SHALL INCLUDE BUT IS NOT LIMITED TO PHYS-
 ICAL  AND  OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY, AND SERVICES
 FOR PEOPLE WITH DISABILITIES IN A VARIETY OF INPATIENT AND/OR OUTPATIENT
 SETTINGS.
   (8) "RECONSTRUCTIVE SERVICES" MEANS PROCEDURES  OR  SURGERY  THAT  ARE
 PERFORMED  TO  TREAT  STRUCTURES  OF  THE BODY AFFECTED AESTHETICALLY OR
 FUNCTIONALLY BY CONGENITAL ANOMALIES, DEVELOPMENTAL ABNORMALITIES, TRAU-
 MA, INFECTION, TUMORS, OR DISEASE.  RECONSTRUCTIVE SERVICES ARE INTENDED
 TO IMPROVE FUNCTION AND ABILITY, AND MAY ALSO BE PERFORMED TO ACHIEVE  A
 MORE TYPICAL APPEARANCE OF THE AFFECTED STRUCTURE.
   (9) "DEVIATION" MEANS AN ANOMALY THAT IMPAIRS THE FUNCTION OF THE BODY
 AND  INCLUDES  BUT  IS NOT LIMITED TO THE CONDITIONS OF CLEFT LIP, CLEFT
 PALATE, WEBBED FINGERS OR TOES, SUPERNUMERARY TOES OR FINGERS, CRANIOFA-
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                       [ ] is old law to be omitted.
                                                            LBD14264-03-9

 S. 7709                             2
 
 CIAL MALFORMATIONS, DISORDERS OF METABOLISM, AND OTHER  CONDITIONS  THAT
 ARE MEDICALLY DIAGNOSED TO BE CONGENITAL ANOMALIES.
   §  3.  Paragraph  4 of subsection (c) of section 3216 of the insurance
 law is amended by adding a new subparagraph (D) to read as follows:
   (D) (1) FOR THE PURPOSE OF THIS  SUBPARAGRAPH,  THE  TERM  "TREATMENT"
 INCLUDES INPATIENT AND OUTPATIENT CARE AND SERVICES PERFORMED TO IMPROVE
 OR  RESTORE  BODY FUNCTION, OR PERFORMED TO APPROXIMATE A NORMAL APPEAR-
 ANCE, AS A RESULT OF A CONGENITAL ANOMALY AND SHALL NOT INCLUDE COSMETIC
 SURGERY. INPATIENT AND OUTPATIENT CARE AND SERVICES SHALL INCLUDE TREAT-
 MENT TO ANY AND ALL MISSING OR ABNORMAL BODY PARTS, INCLUDING TEETH, THE
 ORAL CAVITY, AND THEIR ASSOCIATED STRUCTURES, THAT  WOULD  OTHERWISE  BE
 PROVIDED  UNDER  THE PLAN OR COVERAGE FOR ANY OTHER INJURY AND SICKNESS,
 INCLUDING:
   (I) ALL INPATIENT AND OUTPATIENT RECONSTRUCTIVE  SERVICES  AND  PROCE-
 DURES;
   (II) ALL SERVICES, PROCEDURES, AND ADJUNCTIVE NEEDS, INCLUDING BUT NOT
 LIMITED TO PROSTHETICS AND APPLIANCES, RESULTING FROM COMPLICATIONS;
   (III)  ADJUNCTIVE  DENTAL,  ORTHODONTIC  OR PROSTHODONTIC SUPPORT FROM
 BIRTH UNTIL THE MEDICAL OR SURGICAL TREATMENT OF THE  ANOMALY  HAS  BEEN
 COMPLETED,  INCLUDING  ONGOING OR SUBSEQUENT TREATMENT REQUIRED TO MAIN-
 TAIN FUNCTION OR APPROXIMATE A NORMAL APPEARANCE;
   (IV) PROCEDURES THAT DO NOT MATERIALLY RESTORE OR IMPROVE THE FUNCTION
 OF THE BODY PART BEING TREATED; AND
   (V) PROCEDURES FOR SECONDARY CONDITIONS AND FOLLOW-UP TREATMENTS.
   (2) (I) EVERY POLICY, PLAN,  CERTIFICATE  OR  CONTRACT  SHALL  PROVIDE
 BENEFITS  FOR  RECONSTRUCTIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL
 TO OR FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER  DISEASES
 OF  THE INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT IS
 PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL  DISEASE  OR
 ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
   (II)  EVERY  POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE BENE-
 FITS FOR HABILITATIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL  TO  OR
 FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES OF THE
 INVOLVED  MISSING  OR  ABNORMAL  BODY  PART  OR  WHEN  SUCH TREATMENT IS
 PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL  DISEASE  OR
 ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
   (III)  EVERY  POLICY,  PLAN, CERTIFICATE OR CONTRACT MAY BE SUBJECT TO
 ANNUAL DEDUCTIBLE, CO-PAYMENT, AND  COINSURANCE  PROVISIONS  AS  MAY  BE
 DEEMED  APPROPRIATE  AND  AS  ARE  CONSISTENT WITH THOSE ESTABLISHED FOR
 OTHER BENEFITS UNDER THE PLAN OR COVERAGE.
   (IV) NO POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL:
   A. DENY TO A PATIENT ELIGIBILITY OR CONTINUED ELIGIBILITY,  TO  ENROLL
 OR  TO  RENEW,  COVERAGE  UNDER  THE  TERMS  OF THE PLAN, SOLELY FOR THE
 PURPOSE OF AVOIDING THE REQUIREMENTS OF THIS SUBPARAGRAPH; OR
   B. PENALIZE OR OTHERWISE REDUCE OR LIMIT THE REIMBURSEMENT OF A TREAT-
 ING PROVIDER, OR PROVIDE MONETARY OR  OTHER  INCENTIVES  TO  A  TREATING
 PROVIDER TO INDUCE THE PROVIDER TO PROVIDE CARE TO AN INDIVIDUAL PARTIC-
 IPANT OR BENEFICIARY IN A MANNER INCONSISTENT WITH THIS SUBPARAGRAPH.
   (V) WRITTEN NOTICE OF THE AVAILABILITY OF THE COVERAGE SHALL BE DELIV-
 ERED TO THE PARTICIPANT UPON ENROLLMENT AND ANNUALLY THEREAFTER.
   (3)  (I)  IN  ACCORDANCE  WITH SECTION FORTY-FOUR HUNDRED EIGHT OF THE
 PUBLIC HEALTH LAW, AN ENROLLEE HAS THE RIGHT TO  APPEAL  ANY  DENIAL  OF
 CARE  THAT  THE  CARRIER DETERMINES IS NOT MEDICALLY NECESSARY OR EXPER-
 IMENTAL.
   (II) AN INTERNAL  APPEAL  OF  DENIAL  FILED  BY  AN  ENROLLEE  OR  THE
 ENROLLEE'S  PROVIDER  TO  THE  INSURANCE  CARRIER REGARDING COVERAGE FOR

 S. 7709                             3
 
 RECONSTRUCTIVE OR HABILITATIVE SERVICES TO TREAT  A  CONGENITAL  ANOMALY
 SHALL  BE EXPEDITED BY THE CARRIER. THE HEALTH PLAN SHALL RESPOND ORALLY
 WITH A DECISION WITHIN FORTY-EIGHT HOURS, FOLLOWED BY A CONFIRMATION  IN
 WRITING WITHIN SEVEN DAYS.
   § 4. Subsection (f) of section 4235 of the insurance law is amended by
 adding a new paragraph 5 to read as follows:
   (5) (A) AS USED IN THIS PARAGRAPH:
   (I)  "CONGENITAL ANOMALY" MEANS A MEDICALLY DIAGNOSED CONDITION EXIST-
 ING AT OR FROM BIRTH THAT IS A DEVIATION FROM THE  COMMON  STRUCTURE  OR
 FUNCTION  OF  THE  BODY, WHETHER CAUSED BY A HEREDITARY OR DEVELOPMENTAL
 DISABILITY OR DISEASE.
   (II) "COSMETIC SURGERY" MEANS SURGICAL AND NONSURGICAL ELECTIVE PROCE-
 DURES THAT ENHANCE AND RESHAPE STRUCTURES OF THE BODY TO IMPROVE APPEAR-
 ANCE AND CONFIDENCE, BUT ARE NOT NECESSARY TO IMPROVE BODY STRUCTURE  OR
 FUNCTION.
   (III)  "HABILITATIVE  SERVICES" MEANS HEALTHCARE SERVICES THAT HELP AN
 INDIVIDUAL KEEP, LEARN, OR IMPROVE  SKILLS  AND  FUNCTIONING  FOR  DAILY
 LIVING.  HABILITATIVE SERVICES SHALL INCLUDE BUT IS NOT LIMITED TO PHYS-
 ICAL  AND  OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY, AND SERVICES
 FOR PEOPLE WITH DISABILITIES IN A VARIETY OF INPATIENT AND/OR OUTPATIENT
 SETTINGS.
   (IV) "RECONSTRUCTIVE SERVICES" MEANS PROCEDURES OR  SURGERY  THAT  ARE
 PERFORMED  TO  TREAT  STRUCTURES  OF  THE BODY AFFECTED AESTHETICALLY OR
 FUNCTIONALLY BY CONGENITAL ANOMALIES, DEVELOPMENTAL ABNORMALITIES, TRAU-
 MA, INFECTION, TUMORS, OR DISEASE.  RECONSTRUCTIVE SERVICES ARE INTENDED
 TO IMPROVE FUNCTION AND ABILITY, AND MAY ALSO BE PERFORMED TO ACHIEVE  A
 MORE TYPICAL APPEARANCE OF THE AFFECTED STRUCTURE.
   (V) "DEVIATION" MEANS AN ANOMALY THAT IMPAIRS THE FUNCTION OF THE BODY
 AND  INCLUDES  BUT  IS NOT LIMITED TO THE CONDITIONS OF CLEFT LIP, CLEFT
 PALATE, WEBBED FINGERS OR TOES, SUPERNUMERARY TOES OR FINGERS, CRANIOFA-
 CIAL MALFORMATIONS, DISORDERS OF METABOLISM, AND OTHER  CONDITIONS  THAT
 ARE MEDICALLY DIAGNOSED TO BE CONGENITAL ANOMALIES.
   (B)  (I)  FOR  THE  PURPOSE  OF  THIS  PARAGRAPH, THE TERM "TREATMENT"
 INCLUDES INPATIENT AND OUTPATIENT CARE AND SERVICES PERFORMED TO IMPROVE
 OR RESTORE BODY FUNCTION, OR PERFORMED TO APPROXIMATE A  NORMAL  APPEAR-
 ANCE, AS A RESULT OF A CONGENITAL ANOMALY AND SHALL NOT INCLUDE COSMETIC
 SURGERY. INPATIENT AND OUTPATIENT CARE AND SERVICES SHALL INCLUDE TREAT-
 MENT TO ANY AND ALL MISSING OR ABNORMAL BODY PARTS, INCLUDING TEETH, THE
 ORAL  CAVITY,  AND  THEIR ASSOCIATED STRUCTURES, THAT WOULD OTHERWISE BE
 PROVIDED UNDER THE PLAN OR COVERAGE FOR ANY OTHER INJURY  AND  SICKNESS,
 INCLUDING:
   (I)  ALL  INPATIENT  AND OUTPATIENT RECONSTRUCTIVE SERVICES AND PROCE-
 DURES;
   (II) ALL SERVICES, PROCEDURES, AND ADJUNCTIVE NEEDS, INCLUDING BUT NOT
 LIMITED TO PROSTHETICS AND APPLIANCES, RESULTING FROM COMPLICATIONS;
   (III) ADJUNCTIVE DENTAL, ORTHODONTIC  OR  PROSTHODONTIC  SUPPORT  FROM
 BIRTH  UNTIL  THE  MEDICAL OR SURGICAL TREATMENT OF THE ANOMALY HAS BEEN
 COMPLETED, INCLUDING ONGOING OR SUBSEQUENT TREATMENT REQUIRED  TO  MAIN-
 TAIN FUNCTION OR APPROXIMATE A NORMAL APPEARANCE;
   (IV) PROCEDURES THAT DO NOT MATERIALLY RESTORE OR IMPROVE THE FUNCTION
 OF THE BODY PART BEING TREATED; AND
   (V) PROCEDURES FOR SECONDARY CONDITIONS AND FOLLOW-UP TREATMENTS.
   (II)  (I)  EVERY  POLICY,  PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE
 BENEFITS FOR RECONSTRUCTIVE SERVICES WHEN SUCH TREATMENT  IS  INCIDENTAL
 TO  OR FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES
 OF THE INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT  IS

 S. 7709                             4
 
 PROVIDED  TO  A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL DISEASE OR
 ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
   (II)  EVERY  POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE BENE-
 FITS FOR HABILITATIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL  TO  OR
 FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES OF THE
 INVOLVED  MISSING  OR  ABNORMAL  BODY  PART  OR  WHEN  SUCH TREATMENT IS
 PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL  DISEASE  OR
 ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
   (III)  EVERY  POLICY,  PLAN, CERTIFICATE OR CONTRACT MAY BE SUBJECT TO
 ANNUAL DEDUCTIBLE, CO-PAYMENT, AND  COINSURANCE  PROVISIONS  AS  MAY  BE
 DEEMED  APPROPRIATE  AND  AS  ARE  CONSISTENT WITH THOSE ESTABLISHED FOR
 OTHER BENEFITS UNDER THE PLAN OR COVERAGE.
   (IV) NO POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL:
   A. DENY TO A PATIENT ELIGIBILITY OR CONTINUED ELIGIBILITY,  TO  ENROLL
 OR  TO  RENEW,  COVERAGE  UNDER  THE  TERMS  OF THE PLAN, SOLELY FOR THE
 PURPOSE OF AVOIDING THE REQUIREMENTS OF THIS PARAGRAPH; OR
   B. PENALIZE OR OTHERWISE REDUCE OR LIMIT THE REIMBURSEMENT OF A TREAT-
 ING PROVIDER, OR PROVIDE MONETARY OR  OTHER  INCENTIVES  TO  A  TREATING
 PROVIDER TO INDUCE THE PROVIDER TO PROVIDE CARE TO AN INDIVIDUAL PARTIC-
 IPANT OR BENEFICIARY IN A MANNER INCONSISTENT WITH THIS PARAGRAPH.
   (V) WRITTEN NOTICE OF THE AVAILABILITY OF THE COVERAGE SHALL BE DELIV-
 ERED TO THE PARTICIPANT UPON ENROLLMENT AND ANNUALLY THEREAFTER.
   (III)  (I)  IN ACCORDANCE WITH SECTION FORTY-FOUR HUNDRED EIGHT OF THE
 PUBLIC HEALTH LAW, AN ENROLLEE HAS THE RIGHT TO  APPEAL  ANY  DENIAL  OF
 CARE  THAT  THE  CARRIER DETERMINES IS NOT MEDICALLY NECESSARY OR EXPER-
 IMENTAL.
   (II) AN INTERNAL  APPEAL  OF  DENIAL  FILED  BY  AN  ENROLLEE  OR  THE
 ENROLLEE'S  PROVIDER  TO  THE  INSURANCE  CARRIER REGARDING COVERAGE FOR
 RECONSTRUCTIVE OR HABILITATIVE SERVICES TO TREAT  A  CONGENITAL  ANOMALY
 SHALL  BE EXPEDITED BY THE CARRIER. THE HEALTH PLAN SHALL RESPOND ORALLY
 WITH A DECISION WITHIN FORTY-EIGHT HOURS, FOLLOWED BY A CONFIRMATION  IN
 WRITING WITHIN SEVEN DAYS.
   §  5.  Paragraph  1 of subsection (d) of section 4304 of the insurance
 law is amended by adding a new subparagraph (D) to read as follows:
   (D) (I) AS USED IN THIS PARAGRAPH:
   1. "CONGENITAL ANOMALY" MEANS A MEDICALLY DIAGNOSED CONDITION EXISTING
 AT OR FROM BIRTH THAT IS A DEVIATION FROM THE COMMON STRUCTURE OR  FUNC-
 TION  OF THE BODY, WHETHER CAUSED BY A HEREDITARY OR DEVELOPMENTAL DISA-
 BILITY OR DISEASE.
   2. "COSMETIC SURGERY" MEANS SURGICAL AND NONSURGICAL  ELECTIVE  PROCE-
 DURES THAT ENHANCE AND RESHAPE STRUCTURES OF THE BODY TO IMPROVE APPEAR-
 ANCE  AND CONFIDENCE, BUT ARE NOT NECESSARY TO IMPROVE BODY STRUCTURE OR
 FUNCTION.
   3. "HABILITATIVE SERVICES" MEANS  HEALTHCARE  SERVICES  THAT  HELP  AN
 INDIVIDUAL  KEEP,  LEARN,  OR  IMPROVE  SKILLS AND FUNCTIONING FOR DAILY
 LIVING.  HABILITATIVE SERVICES SHALL INCLUDE BUT IS NOT LIMITED TO PHYS-
 ICAL AND OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY,  AND  SERVICES
 FOR PEOPLE WITH DISABILITIES IN A VARIETY OF INPATIENT AND/OR OUTPATIENT
 SETTINGS.
   4.  "RECONSTRUCTIVE  SERVICES"  MEANS  PROCEDURES  OR SURGERY THAT ARE
 PERFORMED TO TREAT STRUCTURES OF  THE  BODY  AFFECTED  AESTHETICALLY  OR
 FUNCTIONALLY BY CONGENITAL ANOMALIES, DEVELOPMENTAL ABNORMALITIES, TRAU-
 MA, INFECTION, TUMORS, OR DISEASE.  RECONSTRUCTIVE SERVICES ARE INTENDED
 TO  IMPROVE FUNCTION AND ABILITY, AND MAY ALSO BE PERFORMED TO ACHIEVE A
 MORE TYPICAL APPEARANCE OF THE AFFECTED STRUCTURE.

 S. 7709                             5
 
   5. "DEVIATION" MEANS AN ANOMALY THAT IMPAIRS THE FUNCTION OF THE  BODY
 AND  INCLUDES  BUT  IS NOT LIMITED TO THE CONDITIONS OF CLEFT LIP, CLEFT
 PALATE, WEBBED FINGERS OR TOES, SUPERNUMERARY TOES OR FINGERS, CRANIOFA-
 CIAL MALFORMATIONS, DISORDERS OF METABOLISM, AND OTHER  CONDITIONS  THAT
 ARE MEDICALLY DIAGNOSED TO BE CONGENITAL ANOMALIES.
   (II)  FOR  THE  PURPOSE  OF  THIS  SUBPARAGRAPH,  THE TERM "TREATMENT"
 INCLUDES INPATIENT AND OUTPATIENT CARE AND SERVICES PERFORMED TO IMPROVE
 OR RESTORE BODY FUNCTION, OR PERFORMED TO APPROXIMATE A  NORMAL  APPEAR-
 ANCE, AS A RESULT OF A CONGENITAL ANOMALY AND SHALL NOT INCLUDE COSMETIC
 SURGERY. INPATIENT AND OUTPATIENT CARE AND SERVICES SHALL INCLUDE TREAT-
 MENT TO ANY AND ALL MISSING OR ABNORMAL BODY PARTS, INCLUDING TEETH, THE
 ORAL  CAVITY,  AND  THEIR ASSOCIATED STRUCTURES, THAT WOULD OTHERWISE BE
 PROVIDED UNDER THE PLAN OR COVERAGE FOR ANY OTHER INJURY  AND  SICKNESS,
 INCLUDING:
   1.  ALL  INPATIENT  AND  OUTPATIENT RECONSTRUCTIVE SERVICES AND PROCE-
 DURES;
   2. ALL SERVICES, PROCEDURES, AND ADJUNCTIVE NEEDS, INCLUDING PROSTHET-
 ICS AND APPLIANCES, RESULTING FROM COMPLICATIONS;
   3. ADJUNCTIVE DENTAL, ORTHODONTIC OR PROSTHODONTIC SUPPORT FROM  BIRTH
 UNTIL  THE  MEDICAL  OR  SURGICAL  TREATMENT  OF  THE  ANOMALY  HAS BEEN
 COMPLETED, INCLUDING ONGOING OR SUBSEQUENT TREATMENT REQUIRED  TO  MAIN-
 TAIN FUNCTION OR APPROXIMATE A NORMAL APPEARANCE;
   4.  PROCEDURES  THAT DO NOT MATERIALLY RESTORE OR IMPROVE THE FUNCTION
 OF THE BODY PART BEING TREATED; AND
   5. PROCEDURES FOR SECONDARY CONDITIONS AND FOLLOW-UP TREATMENTS.
   (III) 1. EVERY POLICY, PLAN, CERTIFICATE  OR  CONTRACT  SHALL  PROVIDE
 BENEFITS  FOR  RECONSTRUCTIVE SERVICES WHEN SUCH TREATMENT IS INCIDENTAL
 TO OR FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER  DISEASES
 OF  THE INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT IS
 PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL  DISEASE  OR
 ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
   2.  EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE BENEFITS
 FOR HABILITATIVE SERVICES  WHEN  SUCH  TREATMENT  IS  INCIDENTAL  TO  OR
 FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES OF THE
 INVOLVED  MISSING  OR  ABNORMAL  BODY  PART  OR  WHEN  SUCH TREATMENT IS
 PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL  DISEASE  OR
 ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
   3. EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT MAY BE SUBJECT TO ANNU-
 AL  DEDUCTIBLE,  CO-PAYMENT, AND COINSURANCE PROVISIONS AS MAY BE DEEMED
 APPROPRIATE AND AS ARE CONSISTENT WITH THOSE ESTABLISHED FOR OTHER BENE-
 FITS UNDER THE PLAN OR COVERAGE.
   4. NO POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL:
   A. DENY TO A PATIENT ELIGIBILITY OR CONTINUED ELIGIBILITY,  TO  ENROLL
 OR  TO  RENEW,  COVERAGE  UNDER  THE  TERMS  OF THE PLAN, SOLELY FOR THE
 PURPOSE OF AVOIDING THE REQUIREMENTS OF THIS SUBPARAGRAPH; OR
   B. PENALIZE OR OTHERWISE REDUCE OR LIMIT THE REIMBURSEMENT OF A TREAT-
 ING PROVIDER, OR PROVIDE MONETARY OR  OTHER  INCENTIVES  TO  A  TREATING
 PROVIDER TO INDUCE THE PROVIDER TO PROVIDE CARE TO AN INDIVIDUAL PARTIC-
 IPANT OR BENEFICIARY IN A MANNER INCONSISTENT WITH THIS SUBPARAGRAPH.
   (IV)  WRITTEN  NOTICE  OF  THE  AVAILABILITY  OF THE COVERAGE SHALL BE
 DELIVERED TO THE PARTICIPANT UPON ENROLLMENT AND ANNUALLY THEREAFTER.
   (V) 1. IN ACCORDANCE WITH SECTION  FORTY-FOUR  HUNDRED  EIGHT  OF  THE
 PUBLIC  HEALTH  LAW,  AN  ENROLLEE HAS THE RIGHT TO APPEAL ANY DENIAL OF
 CARE THAT THE CARRIER DETERMINES IS NOT MEDICALLY  NECESSARY  OR  EXPER-
 IMENTAL.

 S. 7709                             6

   2. AN INTERNAL APPEAL OF DENIAL FILED BY AN ENROLLEE OR THE ENROLLEE'S
 PROVIDER  TO THE INSURANCE CARRIER REGARDING COVERAGE FOR RECONSTRUCTIVE
 OR HABILITATIVE SERVICES TO TREAT A CONGENITAL ANOMALY  SHALL  BE  EXPE-
 DITED  BY THE CARRIER. THE HEALTH PLAN SHALL RESPOND ORALLY WITH A DECI-
 SION  WITHIN  FORTY-EIGHT  HOURS,  FOLLOWED BY A CONFIRMATION IN WRITING
 WITHIN SEVEN DAYS.
   § 6. Paragraph 1 of subsection (c) of section 4305  of  the  insurance
 law is amended by adding a new subparagraph (D) to read as follows:
   (D)(I) AS USED IN THIS SUBPARAGRAPH:
   1. "CONGENITAL ANOMALY" MEANS A MEDICALLY DIAGNOSED CONDITION EXISTING
 AT  OR FROM BIRTH THAT IS A DEVIATION FROM THE COMMON STRUCTURE OR FUNC-
 TION OF THE BODY, WHETHER CAUSED BY A HEREDITARY OR DEVELOPMENTAL  DISA-
 BILITY OR DISEASE.
   2.  "COSMETIC  SURGERY" MEANS SURGICAL AND NONSURGICAL ELECTIVE PROCE-
 DURES THAT ENHANCE AND RESHAPE STRUCTURES OF THE BODY TO IMPROVE APPEAR-
 ANCE AND CONFIDENCE, BUT ARE NOT NECESSARY TO IMPROVE BODY STRUCTURE  OR
 FUNCTION.
   3.  "HABILITATIVE  SERVICES"  MEANS  HEALTHCARE  SERVICES THAT HELP AN
 INDIVIDUAL KEEP, LEARN, OR IMPROVE  SKILLS  AND  FUNCTIONING  FOR  DAILY
 LIVING.  HABILITATIVE SERVICES SHALL INCLUDE BUT IS NOT LIMITED TO PHYS-
 ICAL AND OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY,  AND  SERVICES
 FOR PEOPLE WITH DISABILITIES IN A VARIETY OF INPATIENT AND/OR OUTPATIENT
 SETTINGS.
   4.  "RECONSTRUCTIVE  SERVICES"  MEANS  PROCEDURES  OR SURGERY THAT ARE
 PERFORMED TO TREAT STRUCTURES OF  THE  BODY  AFFECTED  AESTHETICALLY  OR
 FUNCTIONALLY BY CONGENITAL ANOMALIES, DEVELOPMENTAL ABNORMALITIES, TRAU-
 MA,  INFECTION, TUMORS, OR DISEASE. RECONSTRUCTIVE SERVICES ARE INTENDED
 TO IMPROVE FUNCTION AND ABILITY, AND MAY ALSO BE PERFORMED TO ACHIEVE  A
 MORE TYPICAL APPEARANCE OF THE AFFECTED STRUCTURE.
   5.  "DEVIATION" MEANS AN ANOMALY THAT IMPAIRS THE FUNCTION OF THE BODY
 AND INCLUDES BUT IS NOT LIMITED TO THE CONDITIONS OF  CLEFT  LIP,  CLEFT
 PALATE, WEBBED FINGERS OR TOES, SUPERNUMERARY TOES OR FINGERS, CRANIOFA-
 CIAL  MALFORMATIONS,  DISORDERS OF METABOLISM, AND OTHER CONDITIONS THAT
 ARE MEDICALLY DIAGNOSED TO BE CONGENITAL ANOMALIES.
   (II) FOR THE  PURPOSE  OF  THIS  SUBPARAGRAPH,  THE  TERM  "TREATMENT"
 INCLUDES INPATIENT AND OUTPATIENT CARE AND SERVICES PERFORMED TO IMPROVE
 OR  RESTORE  BODY FUNCTION, OR PERFORMED TO APPROXIMATE A NORMAL APPEAR-
 ANCE, AS A RESULT OF A CONGENITAL ANOMALY AND SHALL NOT INCLUDE COSMETIC
 SURGERY. INPATIENT AND OUTPATIENT CARE AND SERVICES SHALL INCLUDE TREAT-
 MENT TO ANY AND ALL MISSING OR ABNORMAL BODY PARTS, INCLUDING TEETH, THE
 ORAL CAVITY, AND THEIR ASSOCIATED STRUCTURES, THAT  WOULD  OTHERWISE  BE
 PROVIDED  UNDER  THE PLAN OR COVERAGE FOR ANY OTHER INJURY AND SICKNESS,
 INCLUDING:
   1. ALL INPATIENT AND OUTPATIENT  RECONSTRUCTIVE  SERVICES  AND  PROCE-
 DURES;
   2. ALL SERVICES, PROCEDURES, AND ADJUNCTIVE NEEDS, INCLUDING PROSTHET-
 ICS AND APPLIANCES, RESULTING FROM COMPLICATIONS;
   3.  ADJUNCTIVE DENTAL, ORTHODONTIC OR PROSTHODONTIC SUPPORT FROM BIRTH
 UNTIL THE  MEDICAL  OR  SURGICAL  TREATMENT  OF  THE  ANOMALY  HAS  BEEN
 COMPLETED,  INCLUDING  ONGOING OR SUBSEQUENT TREATMENT REQUIRED TO MAIN-
 TAIN FUNCTION OR APPROXIMATE A NORMAL APPEARANCE;
   4. PROCEDURES THAT DO NOT MATERIALLY RESTORE OR IMPROVE  THE  FUNCTION
 OF THE BODY PART BEING TREATED; AND
   5. PROCEDURES FOR SECONDARY CONDITIONS AND FOLLOW-UP TREATMENTS.
   (III)  1.  EVERY  POLICY,  PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE
 BENEFITS FOR RECONSTRUCTIVE SERVICES WHEN SUCH TREATMENT  IS  INCIDENTAL

 S. 7709                             7
 
 TO  OR FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES
 OF THE INVOLVED MISSING OR ABNORMAL BODY PART OR WHEN SUCH TREATMENT  IS
 PROVIDED  TO  A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL DISEASE OR
 ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
   2.  EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL PROVIDE BENEFITS
 FOR HABILITATIVE SERVICES  WHEN  SUCH  TREATMENT  IS  INCIDENTAL  TO  OR
 FOLLOWS SURGERY RESULTING FROM INJURY, SICKNESS OR OTHER DISEASES OF THE
 INVOLVED  MISSING  OR  ABNORMAL  BODY  PART  OR  WHEN  SUCH TREATMENT IS
 PROVIDED TO A COVERED DEPENDENT CHILD BECAUSE OF CONGENITAL  DISEASE  OR
 ANOMALY AS DETERMINED BY THE TREATING PHYSICIAN.
   3. EVERY POLICY, PLAN, CERTIFICATE OR CONTRACT MAY BE SUBJECT TO ANNU-
 AL  DEDUCTIBLE,  CO-PAYMENT, AND COINSURANCE PROVISIONS AS MAY BE DEEMED
 APPROPRIATE AND AS ARE CONSISTENT WITH THOSE ESTABLISHED FOR OTHER BENE-
 FITS UNDER THE PLAN OR COVERAGE.
   4. NO POLICY, PLAN, CERTIFICATE OR CONTRACT SHALL:
   A. DENY TO A PATIENT ELIGIBILITY OR CONTINUED ELIGIBILITY,  TO  ENROLL
 OR  TO  RENEW,  COVERAGE  UNDER  THE  TERMS  OF THE PLAN, SOLELY FOR THE
 PURPOSE OF AVOIDING THE REQUIREMENTS OF THIS SUBPARAGRAPH; OR
   B. PENALIZE OR OTHERWISE REDUCE OR LIMIT THE REIMBURSEMENT OF A TREAT-
 ING PROVIDER OR PROVIDE MONETARY  OR  OTHER  INCENTIVES  TO  A  TREATING
 PROVIDER TO INDUCE THE PROVIDER TO PROVIDE CARE TO AN INDIVIDUAL PARTIC-
 IPANT OR BENEFICIARY IN A MANNER INCONSISTENT WITH THIS SUBPARAGRAPH.
   (IV)  WRITTEN  NOTICE  OF  THE  AVAILABILITY  OF THE COVERAGE SHALL BE
 DELIVERED TO THE PARTICIPANT UPON ENROLLMENT AND ANNUALLY THEREAFTER.
   (V) 1. IN ACCORDANCE WITH SECTION  FORTY-FOUR  HUNDRED  EIGHT  OF  THE
 PUBLIC  HEALTH  LAW,  AN  ENROLLEE HAS THE RIGHT TO APPEAL ANY DENIAL OF
 CARE THAT THE CARRIER DETERMINES IS NOT MEDICALLY  NECESSARY  OR  EXPER-
 IMENTAL.
   2. AN INTERNAL APPEAL OF DENIAL FILED BY AN ENROLLEE OR THE ENROLLEE'S
 PROVIDER  TO THE INSURANCE CARRIER REGARDING COVERAGE FOR RECONSTRUCTIVE
 OR HABILITATIVE SERVICES TO TREAT A CONGENITAL ANOMALY  SHALL  BE  EXPE-
 DITED  BY THE CARRIER. THE HEALTH PLAN SHALL RESPOND ORALLY WITH A DECI-
 SION WITHIN FORTY-EIGHT HOURS, FOLLOWED BY  A  CONFIRMATION  IN  WRITING
 WITHIN SEVEN DAYS.
   §  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 date.