What's happening
This bill requires all health insurance policies in New York to cover treatment, including reconstructive and habilitative services, for congenital anomalies in children.
Why it matters
Expands the definition of covered treatments. to specifically include reconstructive and habilitative services for children with congenital anomalies, addressing not just life-threatening conditions but also those that impact function or appearance (such as cleft palate, craniofacial malformations, or missing digits).
Requires insurance coverage for a broad range of services. including surgeries, therapies (physical, occupational, speech), dental and orthodontic work, prosthetics, and follow-up care—ensuring comprehensive, ongoing support for affected children and not just one-time procedures.
Prevents insurance discrimination and coverage loopholes. by prohibiting insurers from dropping coverage, refusing enrollment, or incentivizing providers to limit medically necessary care related to congenital anomalies, thereby safeguarding access to essential treatments.
Establishes clearer, faster appeals processes. for families whose claims for reconstructive or habilitative services are denied, including expedited review timelines, which could reduce delays in critical care for children.
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Who cares
Headline styles
Cover Kids' Birth Defects
Plain English, a few words. Used as the page title.
Sponsors
Senator · Senate District 7
History
- 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 Kids' Birth Defects
In Assembly Committee · Insurance · Sponsor Jo Anne Simon
Full text
7 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
7709
IN SENATE
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 Assembly, 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 existing 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 procedures that enhance and reshape structures of the body to improve appearance 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 physical 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, trauma, 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 appearance, as a result of a congenital anomaly and shall not include cosmetic surgery. Inpatient and outpatient care and services shall include treatment 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 procedures;
(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 maintain 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 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.
(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 treating provider, or provide monetary or other incentives to a treating provider to induce the provider to provide care to an individual participant or beneficiary in a manner inconsistent with this subparagraph.
(v) Written notice of the availability of the coverage shall be delivered 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 experimental.
(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 existing 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 procedures that enhance and reshape structures of the body to improve appearance 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 physical 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, trauma, 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, craniofacial 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 appearance, as a result of a congenital anomaly and shall not include cosmetic surgery. Inpatient and outpatient care and services shall include treatment 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 procedures;
(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 maintain 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 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.
(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 treating provider, or provide monetary or other incentives to a treating provider to induce the provider to provide care to an individual participant or beneficiary in a manner inconsistent with this paragraph.
(V) Written notice of the availability of the coverage shall be delivered 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 experimental.
(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 function of the body, whether caused by a hereditary or developmental disability or disease.
2. "Cosmetic surgery" means surgical and nonsurgical elective procedures that enhance and reshape structures of the body to improve appearance 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 physical 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, trauma, 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, craniofacial 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 appearance, as a result of a congenital anomaly and shall not include cosmetic surgery. Inpatient and outpatient care and services shall include treatment 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 procedures;
2. All services, procedures, and adjunctive needs, including prosthetics and appliances, resulting from complications;
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 enacting the "Give Kids a Chance - Carter's Law" mandating health insurance coverage for congenital anomalies
Purpose
To require coverage for medical and dental treatments as well as rehabi- litative therapies (physical, speech, occupational, etc.) to address conditions or illness related to or developed as a result of a congen- ital anomaly.
Summary of provisions
Section 1. Adds 5 new paragraphs 5, 6, 7, 8 and 9 to subsection (a) of § 3216 of the insurance law to require every policy that provides coverage for hospital, surgical, or medical care to provide coverage for the assessment, evaluation, treatment, management, and follow-up care of congenital abnormalities. Such coverage shall not be denied on the grounds that it is for cosmetic purposes or is not for -a functional defect or impairment.
Read the full memo (868 words)
Section 2. Paragraph 4 of Subsection (C) of section § 3216 of the insur- ance law is amended by adding a new subparagraph (D).
Section 3. Adds a new paragraph 5 to subsection (F) of § 4235 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 congen- ital abnormalities. Such coverage shall not be denied on the grounds that it is for cosmetic purposes or is not for a functional defect or impairment.
Section 4. Adds a new subsection (d) to § 4304 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 congen- ital abnormalities. Such coverage shall not be denied on the grounds that it is for cosmetic purposes or is not for a functional defect or impairment.
Section 5. Paragraph 1 of subsection (c) of section § 4305 is amended by adding a new subparagraph (d)
Section 6. Sets forth the effective date.
Justification
For every 38 babies born in New York State one is diagnosed with a congenital anomaly. There are a variety of different congenital anoma- lies New York's children are born with, ranging from atrial septal defect with 11,316 cases annually to trisomy 21 with 2,790 cases annual- ly. Two of the most commonly recognized congenital anomalies are cleft lip and cleft palate. A child would be diagnosed with cleft lip and/or cleft palate where the child is born with an unclosed lip and/or with an unclosed roof of the mouth. Basically, there is a gap in facial struc- ture due to incomplete fusion of skin, muscle and bone. This defect occurs during fetal development. Uncorrected, the defect causes severe eating, breathing, speaking and hearing difficulties and presents gross facial deformities.
With appropriate surgical treatment, bone grafts, orthodontic, prostho- dontic and dental treatment as well as speech, physical and occupational therapies, individuals can gain nearly full function and approximate normal facial appearance. There is currently no New York State require- ment for full coverage (medical, dental and related therapies) for cleft lip, cleft palate or any other congenital anomaly.
Currently, health insurance coverage varies by insurer both as to what is offered and as to how coverage is applied when covering costs related to congenital anomalies. While initial surgeries to close the structural gap for cleft lip and/or cleft palate are often covered, subsequent surgeries, bone grafts, follow up treatment and orthodontic, prosthodon- tic and related care are often not covered at all, are severely restricted in coverage or are subject to individual negotiation or confrontation with insurers.
This lack of coverage consistency is the same when dealing with other congenital anomalies. For example, a 6 month old male with sagittal craniosynostosis (premature closing of a baby's skull) who had to wear a prescribed helmet to protect post-operative treatment was denied cover- age for a second helmet as he continued to grow.
New York law should be clear, comprehensive and consistent. This is a matter of fairness to the citizens of New York. Children should be covered for all procedures and therapies from infancy until they are no longer eligible to be covered on their parents' health insurance.
Correcting this gap in insurance coverage would 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 congenital anomalies.
Other states currently mandate comprehensive coverage for all congenital defects diagnosed by a doctor. Among them, Louisiana, Colorado, New Hampshire, Indiana, and North Carolina have laws specifically requiring comprehensive coverage for any congenital anomaly. New York should join these states and make sure everyone receives comprehensive coverage.
Legislative history
New Bill
Fiscal implications
None
Local 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.