What's happening
This bill expands insurance coverage for eating disorders in New York, requiring comprehensive treatment options and updated definitions across policies.
Why it matters
Broader and modernized definition of eating disorders. The bill updates the legal definition to include a wider array of diagnoses (such as pica, rumination disorder, avoidant/restrictive food intake disorder, binge eating disorder, and others listed in the latest DSM), not just anorexia and bulimia. This ensures that more people with diverse eating disorder diagnoses are eligible for insurance-covered treatment.
Mandated comprehensive levels of care. Insurers must cover a full spectrum of medically necessary treatments—including inpatient hospitalization, partial hospitalization, residential care, intensive outpatient treatment, and follow-up outpatient care/counseling—for both adults and children. This addresses gaps where only limited forms of treatment may have been covered previously, enabling appropriate care for varying severity and stages of recovery.
Medical necessity standards refocused. Decisions about what treatment is “medically necessary” can no longer be based solely on weight or BMI. Insurers must consider the individual’s overall medical and mental health needs and follow up-to-date clinical guidelines from the American Psychiatric Association, promoting evidence-based and individualized treatment rather than outdated or restrictive criteria.
Expanded provider eligibility and accountability. Coverage is extended to treatments provided by a broad range of licensed mental health professionals (not just physicians), and treatment plans must include clear diagnostic and therapeutic details. This could improve access by allowing more qualified providers to deliver reimbursable care, while also giving insurers information necessary for claim payments—potentially streamlining the approval process.
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Require Eating Disorder Coverage
Plain English, a few words. Used as the page title.
Sponsors
No co-sponsors yet.
History
- 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.
Cover Eating Disorder Treatment
In Assembly Committee · Insurance · Sponsor Felix Ortiz
Full text
5 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
4929
2019-2020 Regular Sessions
IN SENATE
March 29, 2019
Introduced by Sen. RIVERA -- 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 coverage for eating disorders
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) (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 hospitalization, 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 conditions otherwise applicable under the policy, including network limitations 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 family 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
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(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 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 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, 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.
(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 disorder, 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 Association.
(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 hospitalization, residential care, intensive outpatient treatment, follow up outpatient 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
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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 treatment 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 corporation, which provides group, group remittance or school blanket coverage for inpatient hospital care, shall provide comparable coverage for adults and children with biologically based mental illness. Such hospital service 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 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 disorder, 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 Association.
(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 hospitalization, residential care, intensive outpatient treatment, follow up outpatient 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
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include all elements necessary for such corporation to pay claims. Such elements include, but are not limited to, a diagnosis, proposed treatment 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 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 outof-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 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 disorder, 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 Association.
(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 hospitalization, residential care, intensive outpatient treatment, follow up outpatient 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
S. 4929 5
elements include, but are not limited to, a diagnosis, proposed treatment 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.
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 coverage for eating disorders
Purpose or general idea of bill
This legislation will require insurance companies to cover all facets of eating disorder treatment and determination of care be based on the needs of the individual with the eating disorder.
Summary of provisions
The amendments will require the insurance law to include and define the term eating disorder and insurance companies to provide medically neces- sary treatment including inpatient hospitalization, partial hospitaliza- tion, residential care, intensive outpatient treatment, follow up outpa- tient care and counseling for adults and children with eating disorders. The medical necessity determinations and care management will consider the overall medical and mental health needs of the individual and shall not be based solely on weight.
Justification
Eating disorders have the highest mortality rate of any psychiatric disorder; successful treatment is long lasting and costly. Inpatient facilities can cost approximately $30,000 a month and outpatient treat- ment can exceed $100,000 yearly. Often times, insurance companies will only cover certain aspects of treatment or stop treatment all together if the patient reaches a certain weight, risking a relapse. The bulk of treatment costs have fallen on the patients and their families, even with mental health parity laws, forcing many to go without potentially life saving treatment.
This legislation will require insurance companies in New York State to cover all facets of eating disorder treatment, giving those struggling with the disease proper treatment covered by their insurance.
Prior legislative history
New Bill
Fiscal implications for state and local governments
To be determined.
Effective date
This act shall take effect on the ninetieth day after it shall have
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.