Provides that comprehensive medical insurance policies shall include coverage for regular, non-emergency out-of-network dialysis

3 Co-sponsors

• John J. Bonacic
• Pedro Espada Jr.
• Antoine M. Thompson

BILL NUMBER:S1803C

Title of bill

An act to amend the insurance law, in relation to insurance coverage for out-of-network dialysis

Purpose or general idea of bill

Provides that insured persons receiving dialysis treatment may go out of network to receive their treatment.

Summary of provisions

Amends section 3216, 3221, 4303 and 4332 of the Insurance Law to allow insured persons to receive dialysis treatment out-of-network provided that the out-of-network provider is duly licensed; the out-of-network provider is located outside the service area of the insurer; the in network provider issues a written order for dialysis treatment stating that the treatment is necessary; the insured notifies, in writing, at least thirty days in advance the proposed date or dates of potential out-of-network services; the insurer shall have the right to pre-approve the treatment; such coverage is limited to no greater than ten treat- ments in a calendar year; and no insurers shall be obligated to reim- burse the out-of-network provider at an amount greater than it would have paid for the same treatment within the network.

Such coverage of out-of-network services shall also be otherwise subject to the limitations, exclusions and terms of the policy, including but not limited to, utilization review, annual deductibles, copayments and coinsurance consistent with those required for other similar benefits under the policy.

Justification

Individuals with kidney failure need regular dialysis treatment, often several times a week, in order to survive. Although many health insur- ance plans allow these patients to travel and receive dialysis treatment while they are away from home, this coverage is not granted by all insurance providers. Effectively, this means that some individuals are faced with the prospect of paying expensive medical bills for regular dialysis treatments, or staying home. Some individuals requiring dialy- sis treatment are unable to travel away from home for more than a day or two because they cannot afford the uninsured costs of this treatment. They may be unable to visit family members or grandchildren, attend weddings, graduations or funerals, or make ordinary vacation plans. This legislation would allow these insured's to participate in such important occasions. At the same time, this legislation would not increase costs for insurers. It provides that an insurer is only obligated to pay the amount it would pay for local dialysis treatment, and which it would pay anyway if the insured stayed home. The insured pays not only any regular deductible, but also any amounts in excess of the local cost of treat- ment. The legislation also provides that the insurer may require reason- able notice of travel plans, as approved by the Superintendent of Insur-

ance, so that it can make arrangements, if it wishes, with dialysis providers at the locations where the insured intends to travel.

Prior legislative history

2007-2008: S.2331/A.144 - Remained in Senate Insurance Committee/ Passed Assembly 2005-2006: S.2907-A/A.2501-A - Remained in Senate Insurance Committee/ Passed Assembly

Effective date

This act shall take effect on the first day of January next succeeding the date on which it shall have become a law and shall apply to insur- ance policies and contracts issued, renewed, modified or altered on or after such date.