Requires health insurance policies and contracts shall provide coverage for the diagnosis and treatment of lymphedema, both primary and secondary lymphedema; requires such coverage shall include benefits for equipment, supplies, devices, complex decongestive therapy and out-patient self-management training and education for the treatment of lymphedema, both primary and secondary lymphedema.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A1713
SPONSOR: Rosenthal (MS) TITLE OF BILL:
An act to amend the insurance law, in relation to requiring certain
health insurance coverage for lymphedema
PURPOSE:
This bill requires health insurance providers to cover the differential
diagnosis and treatment of lymphedema.
SUMMARY OF SPECIFIC PROVISIONS:
Section one amends Clause (ii) of subparagraph (A) of paragraph 20 of
subsection (i) of section 3216 of the insurance law, as added by chapter
21 of the laws of 1997; and adds a new clause (iii).
Section two amends Subsection (i) of section 3216 of the insurance law
by adding two new paragraphs 32 and 33.
Section three amends Clause (ii) of subparagraph (A) of paragraph 10 of
subsection (k) section 3221 of the insurance law, as added by chapter 21
of the laws of 1997; and adds a new clause (iii).
Section four amends Subsection (k) of section 3221 of the insurance law
by adding two new paragraphs 20 and 21.
Section five amends Subparagraph (B) of paragraph 1 of subsection (x) of
section 4303 of the insurance law, as added by chapter 21 of the laws of
1997; and adds a new subparagraph (C).
Section six amends Section 4303 of the insurance law by adding two new
subsections (oo) and (pp). Section seven sets forth the effective date.
JUSTIFICATION:
This bill requires insurers to cover equipment, supplies, devices,
complex decongestive therapy, and outpatient self-management training
and education for the treatment of lymphedema which are not necessarily
uniformly covered by them.
Lymphedema is an accumulation of lymphatic fluid in the interstitial
tissue that causes swelling, most often in the arm(s) or leg(s), and
occasionally in other parts of the body. Lymphedema can develop when
lymphatic vessels are missing or impaired (primary), or when lymph
vessels are damaged or lymph nodes removed (secondary).
Radiation therapy, used in the treatment of various cancers and some
AIDS-related diseases can damage otherwise healthy lymph nodes and
vessels, causing scar tissue to form which interrupts the normal flow of
the lymphatic fluid.
Moreover, untreated, lymphedema can lead into a decrease or loss of
functioning of the' limbs, skin breakdown, and chronic infections. In
the most severe cases, untreated lymphedema can develop into a rare form
of lymphatic cancer.
LEGISLATIVE HISTORY:
2023-24: A.1876 - Referred to Insurance
2021-22: A.491-A - Referred to Insurance; S.4867 - Referred to Insurance
2019-20: A.2816 - Referred to Insurance; S.3321 Referred to Insurance
2017-18: A.2271 - Referred to Insurance; S.4292 - Referred to Insurance
2015-16: A.436 - Referred to Insurance; S.252 - Referred to Insurance
2013-14: A.8363 - Referred to Insurance; S.3474-A - Referred to Insur-
ance
FISCAL IMPLICATIONS:
None to the State.
EFFECTIVE DATE:
This bill shall take effect on the first of January next succeeding the
date on which it shall have become a law and shall apply to all insur-
ance policies, contracts and plans issued, renewed, modified, altered or
amended on or after such date.
STATE OF NEW YORK
________________________________________________________________________
1713
2025-2026 Regular Sessions
IN ASSEMBLY
January 14, 2025
___________
Introduced by M. of A. ROSENTHAL, LAVINE, SANTABARBARA, STECK, RAGA --
Multi-Sponsored by -- M. of A. COOK -- read once and referred to the
Committee on Insurance
AN ACT to amend the insurance law, in relation to requiring certain
health insurance coverage for lymphedema
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Clauses (i) and (ii) of subparagraph (A) of paragraph 20 of
2 subsection (i) of section 3216 of the insurance law, as amended by chap-
3 ter 571 of the laws of 2022, are amended and a new clause (iii) is added
4 to read as follows:
5 (i) all stages of reconstruction of the breast or chest wall on which
6 the mastectomy or partial mastectomy has been performed; [and]
7 (ii) surgery and reconstruction of the other breast or chest wall to
8 produce a symmetrical appearance;
9 in the manner determined by the attending physician and the patient to
10 be appropriate. Chest wall reconstruction surgery shall include aesthet-
11 ic flat closure as such term is defined by the National Cancer Insti-
12 tute. Such coverage may be subject to annual deductibles and coinsurance
13 provisions as may be deemed appropriate by the superintendent and as are
14 consistent with those established for other benefits within a given
15 policy. Written notice of the availability of such coverage shall be
16 delivered to the policyholder prior to inception of such policy and
17 annually thereafter[.]; and
18 (iii) prostheses and physical complications of all stages of mastecto-
19 my, including lymphedema;
20 § 2. Subsection (i) of section 3216 of the insurance law is amended by
21 adding two new paragraphs 40 and 41 to read as follows:
22 (40) Every policy which provides hospital, surgical, medical or major
23 medical coverage shall provide coverage for the differential diagnosis
24 and treatment of lymphedema, both primary and secondary lymphedema.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD04176-01-5
A. 1713 2
1 Such coverage shall include, in addition to benefits for a course of
2 manual lymph drainage whose frequency and duration is determined by the
3 treating physician or therapist based on medical necessity and not based
4 on physical therapy and rehabilitation standards, benefits for equip-
5 ment, supplies, devices, complex decongestive therapy, and out-patient
6 self-management training and education for the treatment of lymphedema,
7 if prescribed by a health care professional legally authorized to
8 prescribe or provide such items under title eight of the education law.
9 Lymphedema therapy administered under this section shall be administered
10 only by a therapist certified to perform lymphedema treatment by the
11 Lymphology Association of North America (LANA) or certified in accord-
12 ance with standards equivalent to the certification standards of LANA.
13 Such equipment, supplies or devices shall include, but not be limited
14 to, bandages, compression garments, pads, orthotic shoes and devices,
15 with replacements when required to maintain compressive function or to
16 accommodate changes in the patient's dimensions. Coverage shall be
17 provided for follow-up treatments when medically required or to period-
18 ically validate home techniques, to monitor progress against the written
19 treatment plan and to modify the treatment plan as required. No individ-
20 ual, other than a licensed physician or surgeon competent to evaluate
21 the specific clinical issues involved in the care requested, may deny
22 requests for authorization of health care services pursuant to this
23 section.
24 (A) A policy which is a managed health care product may require such
25 health care professional be a member of such managed health care plan's
26 provider network, provided that such network includes sufficient health
27 care professionals who are qualified by specific education, experience
28 and credentials to provide the covered benefits described in this para-
29 graph.
30 (B) No insurer, corporation, or health maintenance organization shall
31 impose upon any person receiving benefits pursuant to this paragraph any
32 copayment, fee, policy year or calendar year, or durational benefit
33 limitation or maximum for benefits or services that is not equally
34 imposed upon all individuals in the same benefit category.
35 (C) This paragraph shall not apply to short-term travel, accident
36 only, limited or specified disease, or individual conversion policies or
37 contracts, nor to policies or contracts designed for issuance to persons
38 eligible for coverage under Title XVIII of the Social Security Act,
39 known as Medicare, or any other similar coverage under state or federal
40 governmental plans.
41 (D) For purposes of this paragraph, a "managed care product" shall
42 mean a policy which requires that medical or other health care services
43 covered under the policy, other than emergency care services, be
44 provided by, or pursuant to a referral from a primary care provider, and
45 that services provided pursuant to such a referral be rendered by a
46 health care provider participating in the insurer's managed care provid-
47 er network. In addition, a managed care product shall also mean the
48 in-network portion of a contract which requires that medical or other
49 health care services covered under the contract, other than emergency
50 care services, be provided by, or pursuant to a referral from a primary
51 care provider, and that services provided pursuant to such a referral be
52 rendered by a health care provider participating in the insurer's
53 managed care provider network, in order for the insured to be entitled
54 to the maximum reimbursement under the contract.
55 (41) Patients undergoing any surgery or radiotherapy procedure shall
56 be provided information on the risk of lymphedema associated with that
A. 1713 3
1 procedure, and the potential post-procedure symptoms of lymphedema.
2 Informed consent agreements for all surgeries and radiation therapies
3 shall include information on the risk of lymphedema associated with the
4 alternative procedures.
5 § 3. Clauses (i) and (ii) of subparagraph (A) of paragraph 10 of
6 subsection (k) of section 3221 of the insurance law, as amended by chap-
7 ter 571 of the laws of 2022, are amended and a new clause (iii) is added
8 to read as follows:
9 (i) all stages of reconstruction of the breast or chest wall on which
10 the mastectomy or partial mastectomy has been performed; [and]
11 (ii) surgery and reconstruction of the other breast or chest wall to
12 produce a symmetrical appearance;
13 in the manner determined by the attending physician and the patient to
14 be appropriate. Chest wall reconstruction surgery shall include aesthet-
15 ic flat closure as such term is defined by the National Cancer Insti-
16 tute. Such coverage may be subject to annual deductibles and coinsurance
17 provisions as may be deemed appropriate by the superintendent and as are
18 consistent with those established for other benefits within a given
19 policy. Written notice of the availability of such coverage shall be
20 delivered to the policyholder prior to inception of such policy and
21 annually thereafter[.]; and
22 (iii) prostheses and physical complications of all stages of mastecto-
23 my, including lymphedema;
24 § 4. Subsection (k) of section 3221 of the insurance law is amended by
25 adding two new paragraphs 24 and 25 to read as follows:
26 (24) Every group policy issued or issued for delivery in this state
27 which provides hospital, surgical, medical or major medical coverage
28 shall provide coverage for the differential diagnosis and treatment of
29 lymphedema, both primary and secondary lymphedema. Such coverage shall
30 include, in addition to benefits for a course of manual lymph drainage
31 whose frequency and duration is determined by the treating physician or
32 therapist based on medical necessity and not based on physical therapy
33 and rehabilitation standards, benefits for equipment, supplies, devices,
34 complex decongestive therapy, and out-patient self-management training
35 and education for the treatment of lymphedema, if prescribed by a health
36 care professional legally authorized to prescribe or provide such items
37 under title eight of the education law. Lymphedema therapy administered
38 under this section shall be administered only by a therapist certified
39 to perform lymphedema treatment by the Lymphology Association of North
40 America (LANA) or certified in accordance with standards equivalent to
41 the certification standards of LANA. Such equipment, supplies or
42 devices shall include, but not be limited to, bandages, compression
43 garments, pads, orthotic shoes and devices, with replacements when
44 required to maintain compressive function or to accommodate changes in
45 the patient's dimensions. Coverage shall be provided for follow-up
46 treatments when medically required or to periodically validate home
47 techniques, to monitor progress against the written treatment plan and
48 to modify the treatment plan as required. No individual, other than a
49 licensed physician or surgeon competent to evaluate the specific clin-
50 ical issues involved in the care requested, may deny requests for
51 authorization of health care services pursuant to this section.
52 (A) A policy which is a managed health care product may require such
53 health care professional be a member of such managed health care plan's
54 provider network, provided that such network includes sufficient health
55 care professionals who are qualified by specific education, experience
A. 1713 4
1 and credentials to provide the covered benefits described in this para-
2 graph.
3 (B) No insurer, corporation, or health maintenance organization shall
4 impose upon any person receiving benefits pursuant to this paragraph any
5 copayment, fee, policy year or calendar year, or durational benefit
6 limitation or maximum for benefits or services that is not equally
7 imposed upon all individuals in the same benefit category.
8 (C) This paragraph shall not apply to short-term travel, accident
9 only, limited or specified disease, or individual conversion policies or
10 contracts, nor to policies or contracts designed for issuance to persons
11 eligible for coverage under Title XVIII of the Social Security Act,
12 known as Medicare, or any other similar coverage under state or federal
13 governmental plans.
14 (D) For purposes of this paragraph, a "managed care product" shall
15 mean a policy which requires that medical or other health care services
16 covered under the policy, other than emergency care services, be
17 provided by, or pursuant to a referral from a primary care provider, and
18 that services provided pursuant to such a referral be rendered by a
19 health care provider participating in the insurer's managed care provid-
20 er network. In addition, a managed care product shall also mean the
21 in-network portion of a contract which requires that medical or other
22 health care services covered under the contract, other than emergency
23 care services, be provided by, or pursuant to a referral from a primary
24 care provider, and that services provided pursuant to such a referral be
25 rendered by a health care provider participating in the insurer's
26 managed care provider network, in order for the insured to be entitled
27 to the maximum reimbursement under the contract.
28 (25) Patients undergoing any surgery or radiotherapy procedure shall
29 be provided information on the risk of lymphedema associated with that
30 procedure, and the potential post-procedure symptoms of lymphedema.
31 Informed consent agreements for all surgeries and radiation therapies
32 shall include information on the risk of lymphedema associated with the
33 alternative procedures.
34 § 5. Subparagraphs (A) and (B) of paragraph 1 of subsection (x) of
35 section 4303 of the insurance law, as amended by chapter 571 of the laws
36 of 2022, are amended and a new subparagraph (C) is added to read as
37 follows:
38 (A) all stages of reconstruction of the breast or chest wall on which
39 the mastectomy or partial mastectomy has been performed; [and]
40 (B) surgery and reconstruction of the other breast or chest wall to
41 produce a symmetrical appearance; and
42 (C) prostheses and physical complications of all stages of mastectomy,
43 including lymphedema;
44 in the manner determined by the attending physician and the patient to
45 be appropriate. Chest wall reconstruction surgery shall include aesthet-
46 ic flat closure as such term is defined by the National Cancer insti-
47 tute. Such coverage may be subject to annual deductibles or coinsurance
48 provisions as may be deemed appropriate by the superintendent and as are
49 consistent with those established for other benefits within a given
50 policy. Written notice of the availability of such coverage shall be
51 delivered to the group remitting agent or group contract holder prior to
52 the inception of such contract and annually thereafter.
53 § 6. Section 4303 of the insurance law is amended by adding two new
54 subsections (ww) and (xx) to read as follows:
55 (ww) Every contract issued by a hospital service corporation or health
56 service corporation which provides hospital, surgical, medical or major
A. 1713 5
1 medical coverage shall provide coverage for the differential diagnosis
2 and treatment of lymphedema, both primary and secondary lymphedema.
3 Such coverage shall include, in addition to benefits for a course of
4 manual lymph drainage whose frequency and duration is determined by the
5 treating physician or therapist based on medical necessity and not based
6 on physical therapy and rehabilitation standards, benefits for equip-
7 ment, supplies, devices, complex decongestive therapy, and out-patient
8 self-management training and education for the treatment of lymphedema,
9 if prescribed by a health care professional legally authorized to
10 prescribe or provide such items under title eight of the education law.
11 Lymphedema therapy administered under this section shall be administered
12 only by a therapist certified to perform lymphedema treatment by the
13 Lymphology Association of North America (LANA) or certified in accord-
14 ance with standards equivalent to the certification standards of LANA.
15 Such equipment, supplies or devices shall include, but not be limited
16 to, bandages, compression garments, pads, orthotic shoes and devices,
17 with replacements when required to maintain compressive function or to
18 accommodate changes in the patient's dimensions. Coverage shall be
19 provided for follow-up treatments when medically required or to period-
20 ically validate home techniques, to monitor progress against the written
21 treatment plan and to modify the treatment plan as required. No individ-
22 ual, other than a licensed physician or surgeon competent to evaluate
23 the specific clinical issues involved in the care requested, may deny
24 requests for authorization of health care services pursuant to this
25 section.
26 (1) A policy which is a managed health care product may require such
27 health care professional be a member of such managed health care plan's
28 provider network, provided that such network includes sufficient health
29 care professionals who are qualified by specific education, experience
30 and credentials to provide the covered benefits described in this
31 subsection.
32 (2) No insurer, corporation, or health maintenance organization shall
33 impose upon any person receiving benefits pursuant to this subsection
34 any copayment, fee, policy year or calendar year, or durational benefit
35 limitation or maximum for benefits or services that is not equally
36 imposed upon all individuals in the same benefit category.
37 (3) This subsection shall not apply to short-term travel, accident
38 only, limited or specified disease, or individual conversion policies or
39 contracts, nor to policies or contracts designed for issuance to persons
40 eligible for coverage under Title XVIII of the Social Security Act,
41 known as Medicare, or any other similar coverage under state or federal
42 governmental plans.
43 (4) For purposes of this subsection, a "managed care product" shall
44 mean a policy which requires that medical or other health care services
45 covered under the policy, other than emergency care services, be
46 provided by, or pursuant to a referral from a primary care provider, and
47 that services provided pursuant to such a referral be rendered by a
48 health care provider participating in the insurer's managed care provid-
49 er network. In addition, a managed care product shall also mean the
50 in-network portion of a contract which requires that medical or other
51 health care services covered under the contract, other than emergency
52 care services, be provided by, or pursuant to a referral from a primary
53 care provider, and that services provided pursuant to such a referral be
54 rendered by a health care provider participating in the insurer's
55 managed care provider network, in order for the insured to be entitled
56 to the maximum reimbursement under the contract.
A. 1713 6
1 (xx) Patients undergoing any surgery or radiotherapy procedure shall
2 be provided information on the risk of lymphedema associated with that
3 procedure, and the potential post-procedure symptoms of lymphedema.
4 Informed consent agreements for all surgeries and radiation therapies
5 shall include information on the risk of lymphedema associated with the
6 alternative procedures.
7 § 7. This act shall take effect on the first of January next succeed-
8 ing the date on which it shall have become a law and shall apply to all
9 insurance policies, contracts and plans issued, renewed, modified,
10 altered or amended on or after such effective date.
