What's happening
This bill requires all health insurance policies in New York to cover assessment, treatment, and related care for cleft lip and cleft palate, including conditions considered cosmetic.
Why it matters
Expands access to necessary care. By mandating insurance coverage for all aspects of cleft lip and palate treatment—including assessment, management, and follow-up—this bill ensures that patients can receive comprehensive care without facing prohibitive out-of-pocket costs.
Addresses related health issues. The coverage requirement extends to any condition or illness that results from or is associated with cleft lip or palate, which means patients can access treatment for complications (such as speech, dental, or hearing problems) that often arise from these conditions.
Eliminates insurer discretion on “cosmetic” care. The bill specifically prohibits insurance companies from denying claims on the grounds that a procedure is cosmetic or not related to a functional defect, ensuring patients can obtain reconstructive or appearance-related surgeries that are vital for social and psychological well-being.
Reduces inequities in care. By standardizing coverage across all insurance policies in New York, the bill helps to prevent disparities where only some patients—based on their insurer or plan—can access the full range of required treatments for cleft conditions.
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Who cares
Headline styles
Cover Cleft Lip, Palate Care
Plain English, a few words. Used as the page title.
Sponsors
History
- Recommit, enacting clause stricken
- Referred to insurance
- Referred to insurance
Companion bill
The same bill in the other chamber. A bill becomes law when one version passes both houses and the governor signs it, so either number can carry it.
Require Cleft Coverage
Stricken · Sponsor Jo Anne Simon
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
1965
2019-2020 Regular Sessions
IN SENATE
January 18, 2019
Introduced by Sens. LITTLE, AKSHAR, AMEDORE, BROOKS, FELDER, RITCHIE -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 mandatory health insurance coverage for cleft lip and cleft palate
The People of the State of New York, represented in Senate and Assembly, 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) Every policy which provides medical, major medical, or similar comprehensive-type coverage shall include coverage for the assessment, evaluation, treatment, management, and follow-up care of cleft lip and cleft palate. Such coverage shall include but not be limited to treatment for any condition or illness which is related to or developed as a result of cleft lip and/or palate. Coverage shall not be denied on the ground that it is for cosmetic purposes or is not for a functional defect or impairment.
§ 2. Subsection (l) of section 3221 of the insurance law is amended by adding a new paragraph 21 to read as follows:
(21) Every policy which provides medical, major medical, or similar comprehensive-type coverage shall include coverage for the assessment, evaluation, treatment, management, and follow-up care of cleft lip and cleft palate. Such coverage shall include but not be limited to treatment for any condition or illness which is related to or developed as a result of cleft lip and/or palate. Coverage shall not be denied on the ground that it is for cosmetic purposes or is not for a functional defect or impairment.
§ 3. Section 4303 of the insurance law is amended by adding a new subsection (ss) to read as follows:
(ss) Every policy which provides medical, major medical, or similar comprehensive-type coverage shall include coverage for the assessment,
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD01784-01-9
S. 1965 2
evaluation, treatment, management, and follow-up care of cleft lip and cleft palate. Such coverage shall include but not be limited to treatment for any condition or illness which is related to or developed as a result of cleft lip and/or palate. Coverage shall not be denied on the ground that it is for cosmetic purposes or is not for a functional defect or impairment.
§ 4. This act shall take effect on the ninetieth day after it shall have become a law and shall apply to policies and contracts issued, renewed, modified, altered or amended on or after such date.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
Title of bill
An act to amend the insurance law, in relation to mandatory health insurance coverage for cleft lip and cleft palate
Purpose
To require coverage for treatment of conditions or illness related to or developed as a result of cleft lip and/or palate.
Summary of provisions
Section 1. Adds a new paragraph 34 to subsection (i) of § 3216 of the insurance law to require every policy that provides coverage for hospi- tal, surgical, or medical care to provide coverage for the assessment, evaluation, treatment, management, and follow-up care of cleft lip and cleft palate. Such coverage shall not be denied on the grounds that it is for cosmetic purposes or is not for -a functional defect or impair- ment.
Read the full memo (651 words)
Section 2. Adds a new paragraph 20 to subsection (1) of § 3221 of the insurance law to require every group or blanket policy that provides coverage for hospital, surgical, or medical care to provide coverage for hospital, surgical, or medical care to provide coverage for the assess- ment, evaluation, treatment, management, and follow-up care of cleft lip and cleft palate. Such coverage shall not be denied on the grounds that it is for cosmetic purposes or is not for a functional defect or impair- ment.
Section 3. Adds a new subsection (oo) to § 4303 of the insurance law to require every medical expense indemnity corporation, hospital service corporation or health service corporation that provides coverage for hospital, surgical or medical care to provide coverage for the assess- ment, evaluation, treatment, management, and follow-up care of cleft lip and cleft palate. Such coverage shall not be denied on the grounds that it is for cosmetic purposes or is not for a functional defect or impair- ment.
Section 4. Sets forth the effective date.
Justification
Cleft lip and/or cleft palate is a congenital birth defect in which a child is born with an unclosed lip and/or with the roof of the mouth unclosed. That is, there is a gap in facial structure due to incomplete fusion of skin, muscle and bone. This defect occurs during fetal devel- opment. It cannot be prevented and there are no specific prenatal tests to detect the abnormality. Uncorrected, the defect causes severe diffi- culties with eating, breathing, speaking and hearing and presents gross facial deformities.
With appropriate surgical treatment, bone grafts or orthodontic, pros- thodontic and dental treatment and speech and hearing intervention, individuals gain nearly full function and approximate normal facial appearance. There is now no New York State requirement for full coverage for cleft lip and/or palate. Currently, health insurance coverage varies by insurer both as to what is offered and as to how coverage is applied. While initial surgeries to close the structural gaps are often covered, subsequent surgeries, bone grafts, follow up treatment and orthodontic, prosthodontic and related care are often not covered at all, are severely restricted in coverage or are subject to individual negotiation or confrontation with insurers.
New York law should be clear, comprehensive and consistent. This is a matter of fairness to the citizens of New York. It would also provide a prudent investment in our most important resource: our children.
Passage of the bill would also provide equity to insurers who are now forced to compete with each other on a field where they are forced to guess how their competitors will apply coverage for cleft lip and/or palate.
Other states currently mandate comprehensive coverage for cleft lip and/or palate. Among them, Louisiana, Colorado, Maryland, Indiana, and North Carolina have laws specifically requiring comprehensive coverage for cleft lip and/or palate. New York should provide its citizens with comprehensive coverage.
Legislative history
2017-18: S.3171A/A.6397A: Referred Insurance; Referred Insurance
Fiscal implications
None.
Effective date
Ninety days after it shall have become a law and shall apply to policies and contracts issued, renewed, modified, altered or amended on or after such date.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.