New health care laws in New York State went into effect on January 1. Under the new laws,h ealth insurers will be required to cover medically necessary EpiPens and cap out-of-pocket costs at $100 per year, breast cancer screening and imaging, and the cost of scalp cooling systems to reduce hair loss during chemotherapy.
“New Yorkers shouldn’t have to choose between putting food on the table or being able to afford life-saving medical devices and procedures,” Governor Hochul said. “With these new laws going into effect, individuals will be able to focus on their health and well-being without having to worry about the financial burdens tied to treatments.”
Insurance Coverage for EpiPens
EpiPen devices are used to treat life-threatening allergic reactions in individuals who are at risk or have a history of anaphylaxis, which can be caused by insect bites or stings, foods, medications, environmental exposures, exercise and other unknown causes.
The cost of EpiPen devices has far outpaced the rate of inflation, with some reports citing a 600 percent increase in price since the medication was first acquired by Mylan in 2007. While EpiPens once cost $60 per device, they can now sell for upwards of $600 for a pack of two pens. EpiPens have a relatively short shelf-life, expiring after 12 months on average, requiring those in need to purchase the medication repeatedly. Adding to their expense, users of EpiPens are also advised to carry two devices at all times, as a single dose of epinephrine may not be enough to treat a serious allergic reaction.
This new law will dramatically reduce the cost of these devices for consumers by requiring health insurers in the individual and group markets, including non-profit insurers and HMOs, to cover medically necessary EpiPens for the emergency treatment of allergic reactions and cap out-of-pocket costs for such coverage at $100 per year.
Expanding Insurance Coverage for Breast Cancer Screening and Imaging
Breast cancer is one of the most common cancers among females in New York State. Each year in New York, at least 17,000 females are diagnosed with breast cancer and nearly 2,400 die from the disease. It is estimated that one in eight females will develop breast cancer during their life. Breast cancer is the second leading cause of cancer-related deaths among females in New York State. It is most often found in females ages 50 and older.
The new law changes parts of the Insurance Law to require individual, group and non-profit (including HMO) health insurance plans to cover breast cancer screening and diagnostic imaging. This coverage applies if a doctor recommends it based on nationally recognized clinical guidelines. The screenings include diagnostic mammograms, breast ultrasounds and MRIs. The new law also clarifies that cost-sharing will not apply to these procedures except to the extent it would result in health savings account ineligibility under IRS guidelines.
Covering Cost of Scalp Cooling Systems
Scalp cooling is covered by Medicaid and Medicare, and three different cooling systems have already been approved by the U.S. Food and Drug Administration. Without insurance coverage, patients must pay out of pocket, which ranges from $1,500 to $3,000 per round of chemotherapy.
The new law requires health insurers in the large group market to provide coverage for scalp cooling systems that are used during chemotherapy treatment. As part of the treatment, patients wear a cooling cap before, during and after each chemotherapy session to reduce the amount of chemotherapy drugs that reach the hair follicles, which helps to preserve a person’s hair.