Provides that health insurance coverage may not deny reimbursements because the registered pharmacy providing pharmaceutical products has not been approved

4 Co-sponsors

• Martin J. Golden
• Mark Grisanti
• Betty Little
• Kevin S. Parker

BILL NUMBER:S166A

Title of bill

An act to amend the insurance law, in relation to health insurance coverage and to eligibility for employee benefits provided by employee welfare funds

Purpose

To prohibit the denial of health insurance coverage for pharmaceuticals strictly because the registered pharmacy providing the pharmaceutical products has not been approved by the health insurance plan.

Summary of provisions

Amends sections 3216, 3221, 4303, 4402 and 4413 of the New York State Insurance Law to provide that health insurance coverage providers may not deny reimbursements because the registered pharmacy providing pharmaceutical products has not been approved by the insurer or other entity.

This amendment would require individuals who select a pharmacy that is not part of the insurer's panel to be responsible for paying any differential between the benefits provided under the health care insurance contract and the cost of the services selected. The fund, employer or union would be precluded from denying eligibility for reimbursement to any registered pharmacy which is willing to meet minimum standard conditions per participation requirements of the fund.

Justification

Individuals and families should not be denied the ability to obtain services from a registered pharmacy of their choice simply on the basis of their membership in the health insurance plan made available to them. A personal choice is being taken away from an insured when they are directed to only obtain services from a specified pharmacy rather than to the pharmacist they have sought services from their entire lives. The insured may be more comfortable with a pharmacist that he/she has come to know and rely upon and who is familiar with their health history. Further, limiting participating pharmacies is particularly difficult for insureds living in rural areas who may have to travel miles to a pharmacy and for the homebound.

This bill ensures that insureds will be able to access any registered pharmacy that is willing to provide service in accordance with the minimum criteria established by the health insurance contract.

This bill allows the insured freedom of choice and limits the financial exposure of the insurer as well as that of an employee welfare fund to the level of benefits agreed to between the bargaining agent of the employee and the employer. The insurer would not be required to provide the benefit to anyone that is not already insured, nor would the insurer be required to reimburse pharmacies at a higher rate than it reimburses participating providers. This bill would simply require

the insurer to reimburse any "duly registered pharmacy" of the insured's choosing, instead of a limited number of pharmacies of the insurance company's choosing.

Legislative history

S.648/A.3375 of 1997-1998; Referred to Insurance S.8155/A.5906 of 1999-2000; Referred to Insurance S.3208/A.1025 of 2001-2002; Referred to Insurance S.559/A.1915 of 2003-2004; Referred to Insurance S.3235/A.843 of 2005-2006; Referred to Insurance S.27 of 2007-2008; Referred to Insurance S.1449/A.7930 of 2009-2010; Referred to Insurance

Fiscal implications

None.

Effective date

Effective on January 1, next succeeding passage, and shall apply to all policies and contracts issued, modified, altered or amended thereafter.