New York State Seal
STATE OF NEW YORK
INSURANCE DEPARTMENT

25 BEAVER STREET
NEW YORK, NEW YORK 10004

Eliot Spitzer
Governor
Eric R. Dinallo
Acting Superintendent

The Office of General Counsel issued the following opinion on March 28, 2007, representing the position of the New York State Insurance Department.

Re: Reimbursement for Nursing Services

Questions Presented

1. Is coverage for nursing services under Insurance Law § 3221(l)(9) - which requires every insurer issuing a group accident and health policy for delivery in New York to make available and, if requested by the contract holder, to provide reimbursement for services within the lawful scope of practice of a duly licensed registered processional nurse - limited to situations where such services are not otherwise available through the healthcare facility, or where a hospital contracts with independent nurses for services?

2. Does Insurance Law § 3221(l)(9) limit reimbursement for nursing services if those services are available through the healthcare facility?

Conclusions

1. No.  Insurance Law § 3221(l)(9) precludes reimbursement for nursing services rendered in a hospital, but does not preclude reimbursement for home nursing care supervised or provided by a registered professional nurse, or care delivered in a registered professional nurse’s office.  

2. No.  Insurance Law § 3221(l)(9) does not limit the reimbursement of nursing services if those services are available through the healthcare facility.                                       

Facts:

The inquiry was of a general nature, without reference to particular facts.
           
Analysis:

Insurance Law § 3221(l)(9), which applies to the standard provisions for group accident and health insurance policies, states:

(l)(9) Every insurer issuing a group policy for delivery in this state which policy provides coverage for any service within the lawful scope of practice of a duly licensed registered professional nurse, must make available, and if requested by the contract holder, provide reimbursement for such service when such service is performed by a duly licensed registered professional nurse provided, however, that reimbursement shall not be made for nursing services provided to an insured in a general hospital, nursing home or a facility providing health related services, as such terms are defined in section twenty-eight hundred one of the public health law, or in a facility, as such term is defined in subdivision six of section 1.03 of the mental hygiene law, or in a physician's office.  Such coverage may be subject to annual deductibles and co-insurance as may be deemed appropriate by the superintendent and are consistent with those imposed on other benefits within a given policy. Such coverage shall not replace, restrict or eliminate existing coverage provided by the policy.  Coverage for the services of a duly licensed registered professional nurse need be provided only if the nature of the patient's illness or condition requires nursing care which can appropriately be provided by a person with the education and professional skill of a registered professional nurse and the nursing care is necessary in the treatment of the patient's illness or condition.  Written notice of the availability of such coverage shall be delivered to the policyholder prior to inception of such group policy and annually thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state.

Insurance Law § 3221(l)(9) requires every insurer issuing a group accident and health policy for delivery in this state to make available, and if requested by the contract holder, to provide reimbursement for services within the lawful scope of practice of a duly licensed registered professional nurse.1  The statute does not, however, allow for reimbursement for nursing services rendered in a general hospital, nursing home, or health-related facility as defined in the Public Health Law, in certain facilities defined in the Mental Hygiene Law, or in a physician’s office. 

With regard to the inquirer’s first question, the limitations on reimbursement established by Insurance Law § 3221(l)(9) do not apply to home nursing care supervised or provided by a registered professional nurse, or care delivered in a registered professional nurse’s office.  Circular Letter No. 8 (1985).  An insured is entitled to coverage for these services so long as the service is provided within the lawful scope of practice of the registered professional nurse, and would be covered under the insurance contract had it been furnished by a physician.  Circular Letter No. 8 (1985).

As to the inquirer’s second question, Insurance Law § 3221(l)(9) does not limit the reimbursement for nursing services if those services are available through a healthcare facility.  By broadening an insured’s freedom of choice, Insurance Law § 3221(l)(9) is intended to encourage reliance upon non-institutional and cost-effective options by those who might otherwise be forced to depend upon costly hospital or nursing home care.  Press Release, State of New York Executive Chamber, An Act to Amend the Insurance Law in Relation to Registered Professional Nurses, (Dec. 21, 1984). 

For further information you may contact Associate Attorney Pascale Jean-Baptiste at the New York City Office.

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1 N.Y. Ins. Law § 4303(m) (McKinney 2007) mandates the same requirements for medical expense indemnity corporations and health service corporations.