OGC Op. No. 07-09-29
The Office of General Counsel issued the following opinion on September 27, 2007, representing the position of the New York State Insurance Department.
RE: Coverage by health insurers of chiropractic services
Are insurance companies that issue managed care products required to include coverage for chiropractic care (as defined by New York Education Law § 6551)?
Yes. An insurance company that issues a managed care product is required to include coverage for chiropractice care if the product includes either coverage for physician services in a physician’s office, or major medical or similar comprehensive-type coverage.
The inquiry is of a general nature, without reference to specific facts.
Insurance Law § 3221, styled Group or blanket accident and health insurance policies; standard provisions, requires commercial insurance companies to include chiropractice care coverage. Insurance Law § 3221(k)(11) reads as follows:
(A) Every policy which is a ‘managed care product’1 as defined in subparagraph (D) of this paragraph that includes coverage for physician services in a physician's office, and every ‘managed care product’ that provides major medical or similar comprehensive-type coverage, shall include coverage for chiropractic care, as defined in section six thousand five hundred fifty-one of the education law, provided by a doctor of chiropractic licensed pursuant to article one hundred thirty-two of the education law, in connection with the detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. However, 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 any such amounts, limits and review: (a) shall not function to direct treatment in a manner discriminative against chiropractic care, and (b) individually and collectively shall be no 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 nomenclature is used to describe the condition, injury, complaint, disorder or ailment. Nothing herein contained shall be construed as impeding or preventing either the provision or coverage of chiropractic care and services by duly licensed doctors of chiropractic, within the lawful scope of chiropractic practice, in hospital facilities on a staff or employee basis. . . .
. . .
(E) The coverage required by this subsection shall not be abridged by any regulation promulgated by the superintendent.
Chiropractic care also is encompassed by Insurance Law § 4303(y) (which regulates subscriber contracts of not-for-profit heath insurers and all HMOs), and Insurance Law § 3216(i)(21) (which regulates individual policies of commercial health insurers). Note, however, that Insurance Law § 4322 (standardized individual direct pay insurance) does not mandate coverage for chiropractice care.
Section 1 of 1997 N.Y. Laws 426 sets forth the legislative intent behind Insurance Law §§ 3216(i)(21), 3221(k)(11) and 4303(y):
The legislature recognizes that multiple health professions are trained and licensed to diagnose and treat the same or similar conditions through the use of modalities, therapies, services and philosophies that vary from profession to profession. It is the specific intent of this legislature to assure that health insurance policies, plans and contracts that provide coverage for the diagnosis and treatment of conditions, complaints, ailments, disorders or injuries by any health care profession, that may be diagnosed and treated by a doctor of chiropractic, must provide access to and equivalent coverage for the diagnosis and treatment of those conditions, complaints, ailments, disorders or injuries by a duly licensed doctor of chiropractic, within the lawful scope of chiropractic practice even if different terminology, philosophy, services, treatments or modalities are used by the various health professions; and such equivalent coverage shall not be abridged by any regulation heretofore promulgated or to be promulgated.
The Memorandum in Support of the legislative proposal, Senate Bill 5994 (Sen. Velella), that became 1997 N.Y. Laws 426 similarly provides:
There has been concern expressed about the cost impact of including a mandate for chiropractic services as a required part of a health insurance benefit package. This bill addresses this concern by permitting insurers and HMOs to subject chiropractic coverage to reasonable deductible, co-payment and co-insurance amounts, benefit limits and utilization review requirements. However, such limitations must not operate in a manner discriminative against the chiropractic school of practice.
Sections 3216(i)(21), 3221(k)(11) and 4303(y) of the Insurance Law thus mandate 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 that clearly fall within the definition of chiropractic services could be excluded if deemed not medically necessary. In addition, policies may include limitations that would exclude coverage for pre-existing conditions.
Moreover, Insurance Law §§ 3216(i)(21), 3221(k)(11) and 4303(y) do 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 (1) do not function to steer treatment in a manner discriminatory to chiropractic care, and (2) are not more restrictive than those applied under the same policy to other health professionals for the same or similar services.
For further information, you may contact Associate Tax Counsel Ann H. Logan at the New York City office.
1 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.