The Office of General Counsel issued the following informal opinion on June 10, 2003, representing the position of the New York State Insurance Department.

Re: Blanket Accident and Health Insurance Policy/Limitations on Chiropractic or Physical Therapy Services

Question Presented:

With regard to chiropractic and physical therapy services, what types of limitations are allowed under the Insurance Law and must reimbursements made to chiropractors be the same as reimbursements made to physicians for the same or similar service?

Conclusion:

N.Y. Ins. Law § 3221(k)(11)(A) (McKinney Supp. 2003), as added by Chapter 426 of the Laws of 1997, provides for mandatory chiropractic coverage. However, such coverage may be subject to reasonable deductible, co-payment and co-insurance amounts, reasonable fee or benefit limits, and reasonable utilization review, provided that such amounts, limits and review are not more restrictive than those applied to other health professionals and do not function to direct treatment in a manner discriminative against chiropractic care.

With regard to the question about limitations on physical therapy services, where an insurer provides physical therapy coverage, such insurers may impose limitations on the delivery of such services.

Facts:

The inquiry is general in nature. No specific facts were provided.

Analysis:

Chapter 426 of the Laws of 1997 amended various sections ¹ of the Insurance Law "to expand access to the chiropractic school of practice in major medical and similar comprehensive-type plans, and any plan that provides coverage for physician services in a physician’s office, by requiring such plans to provide coverage for services rendered by a licensed doctor of chiropractic."² It appears that this question relates to blanket accident and health insurance policies. Thus, this opinion will specifically deal with chiropractic coverage under Section 3221 that applies to group or blanket accident and health insurance policies issued by commercial insurers. N.Y. Ins. Law 3221(k)(11)(A) (McKinney Supp. 2003) states in pertinent part:

The inquirer asks whether limitations may be placed on chiropractic services and whether reimbursements to chiropractors must be identical to reimbursements made to physicians for the same or similar service. Under Section 3221(k)(11)(A) chiropractic care and services may be subject to reasonable deductible, co-payment and co-insurance amounts, reasonable fee or benefit limits, and reasonable utilization review, provided that such amounts, limits and review do not function to direct treatment in a manner discriminative against chiropractic care. Further, such amounts, limits and review shall not, individually and collectively, be more restrictive than those applicable under the same policy to care or services provided by other health professionals in the diagnosis, treatment and management of the same or similar conditions, injuries, complaints, disorders or ailments, even if differing categorization is used to describe the condition, injury, complaint, disorder or ailment.

The Department has interpreted Section 3221(k)(11)(A) as mandating coverage for chiropractic services, while allowing an insurer to set certain reasonable and permissible limitations, such as fee and benefit limits, on such coverage. Any limits imposed, however, may not be discriminatory against chiropractic services; neither can such limits be more restrictive than those that are applicable under the same policy to care provided by other health professionals for the same or similar conditions. Thus, an insurance policy may, for example, permissibly include a limitation to exclude coverage for services that are determined not to be "medically necessary." In that case, services which clearly fall within the definition of chiropractic services could then be excluded if deemed not medically necessary. In addition, policies may include limitations that would exclude coverage for pre-existing conditions. See, N.Y. Comp. Codes R. & Regs., tit. 11, Part 52 (2002) (Regulation 62) for a listing of other permissible exclusions.

In addition, Section 3221(k)(11)(A) does not require that reimbursement for chiropractors be identical to that of physicians who deliver the same or similar service. Therefore, having different reimbursement methods for chiropractors is permissible so long as such reimbursement methods do not function to direct treatment in a manner discriminative against chiropractic care and are not more restrictive than those that are applied under the same policy to other health professionals for the same or similar services.

As a final matter, where an insurer provides coverage for physical therapy services, the insurer may impose limitations on the delivery of such services. This opinion does not address issues concerning the Education, Public Health or Workers’ Compensation Laws, or any other law that may impact this issue.

For further information you may contact Associate Attorney D. Monica Marsh at the New York City Office.

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1

Chapter 426 of the Laws of 1997 adds mandatory chiropractic coverage to: paragraph 21 of subsection (i) of Section 3216 (individual policies issued by commercial insurers) and subsection (y) of 4303 (policies issued by not-for-profit insurers and HMOs).

² See, The Governor’s Executive Memorandum on Chapter 426 of the Laws of 1997 dated August 20, 1997.

³ Subparagraph (D) defines managed care product, for the purpose of paragraph (11), to mean a policy which requires that medical or other health care services covered under the policy, other than emergency care services, be provided by, or pursuant to a referral from, a primary care provider, and that services provided pursuant to such referral be rendered by a health care provider participating in the insurer’s managed care provider network. A managed care product shall also mean the in-network portion of a contract which requires that medical or other health care services covered under the contract, other than emergency care services, be provided by, or pursuant to a referral from a primary care provider, and that services provided pursuant to such a referral be rendered by a health care provider participating in the insurer’s managed care provider network, in order for the insured to be entitled to the maximum reimbursement under the contract.

⁴ Subparagraph (C) of paragraph (11) applies to policies that include coverage for physician services in a physician’s office and policies that provide major medical or similar comprehensive-type coverage, other than managed care product and contains similar language.