N.Y. Insurance Law § 3216: Individual accident and health insurance policy provisions

§ 3216. Individual accident and health insurance policy provisions.

(a) In this section the term:

(1) "Policy of accident and health insurance" includes any individual

policy or contract covering the kind or kinds of insurance described in

paragraph three of subsection (a) of section one thousand one hundred

thirteen of this chapter.

(2) "Indemnity" means benefits promised.

(3) "Family" may include the policyholder's spouse, or dependent

children, or any other person dependent upon the policyholder.

(4) "Dependent children" (A) shall include any children under a

specified age which shall not exceed age nineteen except:

(i) Any unmarried dependent child, regardless of age, who is incapable

of self-sustaining employment by reason of mental illness, or

developmental disability as defined in the mental hygiene law, or

physical handicap and who became so incapable prior to the age at which

dependent coverage would otherwise terminate, shall be included in

coverage subject to any pre-existing conditions limitation applicable to

other dependents; or

(ii) Any unmarried student at an accredited institution of learning

may be considered a dependent child until attaining age twenty-three for

a policy other than hospital, medical, surgical, or prescription drug

expense insurance; or

(iii) Any married or unmarried child shall be considered a dependent

child until attaining age twenty-six without regard to financial

dependence, residency with the policyholder, student status, or

employment, for a policy of hospital, medical, surgical, or prescription

drug expense insurance.

(B) may include, at the option of the insurer, any unmarried child

until attaining age twenty-five for a policy other than hospital,

medical, surgical, or prescription drug expense insurance.

(C) In addition to the requirements of subparagraphs (A) and (B) of

this paragraph, every insurer issuing a policy of hospital, medical, or

surgical expense insurance pursuant to this section that provides

coverage for dependent children must make available and, if requested by

the policyholder, extend coverage under the policy to an unmarried child

through age twenty-nine, without regard to financial dependence who is

not insured by or eligible for coverage under an employer health benefit

plan as an employee or member, whether insured or self-insured, and who

lives, works or resides in New York state or the service area of the

insurer. Such coverage shall be made available at the inception of all

new policies. Written notice of the availability of such coverage shall

be delivered to the policyholder thirty days prior to the inception of

such policy.

(b) No policy of accident and health insurance, including

non-cancellable disability insurance, except as provided in subsection

(h) hereof, shall be delivered or issued for delivery in this state

until the rate manual showing rates, rules and classifications of risks

for use in connection with such accident and health insurance policies

or with riders or endorsements thereon, has been filed with the

superintendent.

(c) No policy of accident and health insurance shall be delivered or

issued for delivery to any person in this state unless:

(1) The entire money and other considerations therefor are expressed

therein.

(2) The time at which the insurance takes effect and terminates is

expressed therein.

(3) It purports to insure only one person, except that a policy may

insure, originally or by subsequent amendment, members of a family, as

defined herein, upon the application of an adult member of the family

who shall be deemed the policyholder.

(4) (A) Coverage of an unmarried dependent child who is incapable of

self-sustaining employment by reason of mental illness, developmental

disability, as defined in the mental hygiene law, or physical handicap

and who became so incapable prior to attainment of the age at which

dependent coverage would otherwise terminate and who is chiefly

dependent upon such policyholder for support and maintenance, shall not

terminate while the policy remains in force and the dependent remains in

such condition, if the policyholder has within thirty-one days of such

dependent's attainment of the limiting age submitted proof of such

dependent's incapacity as described herein.

(B) Coverage of a dependent spouse or named insured which would

terminate upon such spouse or named insured attaining the age prescribed

in subchapter XVIII of the federal Social Security Act, 42 U.S.C. §§

1395 et seq. ("medicare"), as the age of first eligibility for the

benefits provided by such law shall not so terminate, if such dependent

spouse is not then eligible for all of such benefits, for as long as the

policy remains in force and such dependent spouse remains ineligible to

receive any of such "medicare" benefits, provided proof of such

ineligibility is submitted to the insurer within thirty-one days of the

date notice of termination of coverage be sent by first class mail by

the insurer to the last known address of the policyholder.

(C) Any family coverage shall provide that coverage of newborn

infants, including newly born infants adopted by the insured or

subscriber if such insured or subscriber takes physical custody of the

infant upon such infant's release from the hospital and files a petition

pursuant to section one hundred fifteen-c of the domestic relations law

within thirty days of birth; and provided further that no notice of

revocation to the adoption has been filed pursuant to section one

hundred fifteen-b of the domestic relations law and consent to the

adoption has not been revoked, shall be effective from the moment of

birth for injury or sickness including the necessary care and treatment

of medically diagnosed congenital defects and birth abnormalities

including premature birth, except that in cases of adoption, coverage of

the initial hospital stay shall not be required where a birth parent has

insurance coverage available for the infant's care. In the case of

individual coverage the insurer must also permit the person to whom the

policy is issued to elect such coverage of newborn infants from the

moment of birth. If notification and/or payment of an additional premium

or contribution is required to make coverage effective for a newborn

infant, the coverage may provide that such notice and/or payment be made

within no less than thirty days of the day of birth to make coverage

effective from the moment of birth. This election shall not be required

in the case of student insurance.

(5) (A) Any family policy providing hospital or surgical expense

insurance (but not including such insurance against accidental injury

only) shall provide that, in the event such insurance on any person,

other than the policyholder, is terminated because the person is no

longer within the definition of the family as set forth in the policy

but before such person has attained the limiting age, if any, for

coverage of adults specified in the policy, such person shall be

entitled to have issued to that person by the insurer, without evidence

of insurability, upon application therefor and payment of the first

premium, within sixty days after such insurance shall have terminated,

an individual conversion policy that contains the essential health

benefits package described in paragraph three of subsection (f) of

section three thousand two hundred seventeen-i of this article. The

insurer shall offer one policy at each level of coverage as defined in

subsection (b) of section three thousand two hundred seventeen-i of this

article. The individual may choose any such policy offered by the

insurer. Provided, however, the superintendent may, after giving due

consideration to the public interest, approve a request made by an

insurer for the insurer to satisfy the requirements of this subparagraph

through the offering of policies that comply with this subparagraph by

another insurer, corporation or health maintenance organization within

the insurer's holding company system, as defined in article fifteen of

this chapter. The conversion privilege afforded herein shall also be

available upon the divorce or annulment of the marriage of the

policyholder to the former spouse of such policyholder.

(B) Written notice of entitlement to a conversion policy shall be

given by the insurer to the policyholder at least fifteen and not more

than sixty days prior to the termination of coverage due to the initial

limiting age of the covered dependent. Such notice shall include an

explanation of the rights of the dependent with respect to the dependent

being enrolled in an accredited institution of learning or his or her

incapacity for self-sustaining employment by reason of mental illness,

developmental disability as defined in the mental hygiene law or

physical handicap.

(C) Such individual conversion policy shall be subject to the

following terms and conditions:

(i) The premium shall be that applicable to the form and amount of

insurance therefor.

(ii) The benefits provided under such policy shall become effective

upon the date that such person was no longer eligible under the family

policy.

(iii) No insurer shall be required to issue a conversion policy if it

appears that the person applying for such policy shall have at that time

in force another insurance policy or hospital service or medical expense

indemnity contract providing similar benefits or is covered by or is

eligible for coverage by a group insurance policy or contract providing

similar benefits or shall be covered by similar benefits required by any

statute or provided by any welfare plan or program, which together with

the conversion policy would result in over insurance or duplication of

benefits according to standards on file with the superintendent relating

to individual policies.

(6) The style, arrangement and overall appearance of the policy give

no undue prominence to any portion of the text, and unless every printed

portion of the text of the policy and of any endorsements or attached

papers is plainly printed in light-faced type of a style in general use,

the size of which shall be uniform and not less than ten-point with a

lower-case unspaced alphabet length not less than one hundred

twenty-point (the "text" shall include all printed matter except the

name and address of the insurer, name or title of the policy, the brief

description, if any, and captions and subcaptions).

(7) The exceptions and reductions of indemnity are set forth in the

policy and, except those which are set forth in subsection (d) of this

section, are printed, at the insurer's option, either included with the

benefit provision to which they apply, or under an appropriate caption

such as "EXCEPTIONS", or "EXCEPTIONS AND REDUCTIONS", provided that if

an exception or reduction specifically applies only to a particular

benefit of the policy, a statement of such exception or reduction shall

be included with the benefit provision to which it applies.

(8) Each such form, including riders and endorsements, shall be

identified by a form number in the lower left-hand corner of the first

page thereof.

(9) It contains no provision purporting to make any portion of the

charter, rules, constitution, or by-laws of the insurer a part of the

policy unless such portion is set forth in full in the policy, except in

the case of the incorporation of, or reference to, a statement of rates

or classification of risks, or short-rate table filed with the

superintendent.

(10) There is prominently printed on the first page thereof or there

is attached thereto a notice to the effect that during a specified

period of time, which shall not be less than ten days nor more than

twenty days from the date the policy is delivered to the policyholder,

it may be surrendered to the insurer together with a written request for

cancellation of the policy and in such event the insurer will refund any

premium paid therefor including any policy fees or other charges,

provided, however, that this paragraph shall not apply to single premium

nonrenewable policies insuring against accidents only or accidental

bodily injuries only; provided, however, that a contract or certificate

sold by mail order and a contract or certificate providing medicare

supplemental insurance or long-term care insurance must contain a

provision permitting the contract or certificate holder a thirty day

period for such surrender.

(11) The age limit or date or period, if any, after which the coverage

provided by the policy will not be effective or the age limit, date or

period after which the policy may not be renewed is stated in a renewal

provision set forth on the first page of the policy or as a separate

provision bearing an appropriate caption on the first page of the policy

or in a brief description in not less than fourteen-point bold face type

set forth on the first page of the policy. Nothing herein contained

shall limit or restrict the right of the insurer to continue the policy

after the age or period so stated.

(12) Any policy, other than one issued in fulfillment of the

continuing care responsibilities of an operator of a continuing care

retirement community in accordance with article forty-six of the public

health law, made available because of residence in a particular

facility, housing development, or community shall contain the following

notice in twelve point type in bold face on the first page:

"NOTICE - THIS POLICY DOES NOT MEET THE REQUIREMENTS OF A CONTINUING

CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE WILL NOT QUALIFY

A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT COMMUNITY."

(13) Any persons covered by the policy who are also members of a

reserve component of the armed forces of the United States, including

the National Guard, shall be entitled, upon written request, to have

their coverage suspended during a period of active duty as described

herein. The policy shall provide that the insurer will refund any

unearned premiums for the period of such suspension. Persons covered by

the policy shall be entitled to resumption of coverage, upon written

application and payment of the required premium within sixty days after

the date of termination of the period of active duty, with no

limitations or conditions imposed as a result of such period of active

duty except as set forth in subparagraphs (A) and (B) herein. Coverage

shall be retroactive to the date of termination of the period of active

duty. Such right of resumption provided for herein shall be in addition

to other existing rights granted pursuant to state and federal laws and

regulations and shall not be deemed to qualify or limit such rights in

any way. No exclusion or waiting period may be imposed in connection

with coverage of a health or physical condition of a person entitled to

such right of resumption, or a health or physical condition of any other

person who is covered by the policy unless:

(A) the condition arose during the period of active duty and the

condition has been determined by the secretary of veterans affairs to be

a condition incurred in the line of duty; or

(B) a waiting period was imposed and had not been completed prior to

the period of suspension; in no event, however, shall the sum of the

waiting periods imposed prior to and subsequent to the period of

suspension exceed the length of the waiting period originally imposed.

(14) To be entitled to the right defined in paragraph thirteen of this

subsection a person must be a member of a component of the armed forces

of the United States, including the National Guard, who either:

(A) voluntarily or involuntarily enters upon active duty (other than

for the purpose of determining his or her physical fitness and other

than for training), or

(B) has his or her active duty voluntarily or involuntarily extended

during a period when the president is authorized to order units of the

ready reserve or members of a reserve component to active duty, provided

that such additional active duty is at the request and for the

convenience of the federal government, and

(C) serves no more than four years of active duty.

(15) Every policy delivered or issued for delivery in this state which

provides major medical or similar comprehensive-type coverage shall

provide space on any enrollment, renewal or initial online portal

process setup forms required of an insured or applicant for insurance,

except forms issued by the NY State of Health, the official Health Plan

Marketplace, other than those specifically referenced in subparagraph

(iv) of paragraph (a) of subdivision five of section forty-three hundred

ten and paragraph (v) of subdivision one of section two hundred six of

the public health law, required of an insured or applicant for insurance

so that the insured or applicant shall register or decline registration

in the donate life registry for organ, eye and tissue donations under

this section of the enrollment or renewal form and that the following is

stated on the form in clear and conspicuous type:

"You must fill out the following section: Would you like to be added

to the Donate Life Registry? Check box for 'yes' or 'skip this

question'."

(d) Each policy of accident and health insurance delivered or issued

for delivery to any person in this state shall contain the provisions

specified herein in the words in which the same appear in this

subsection, except that the insurer may, at its option, substitute for

one or more of such provisions corresponding provisions of different

wording approved by the superintendent which are not less favorable in

any respect to the insured or the beneficiary. Each provision contained

in the policy shall be preceded by the applicable caption herein or, at

the insurer's option, by such appropriate captions or subcaptions as the

superintendent may approve.

(1) Each policy shall, except with respect to designation by numbers

or letters as used below, contain the following provisions:

(A) ENTIRE CONTRACT; CHANGES: This policy, including the endorsements

and the attached papers, if any, constitutes the entire contract of

insurance. No change in this policy shall be valid until approved by an

executive officer of the insurer and unless such approval be endorsed

hereon or attached hereto. No agent or broker has authority to change

this policy or to waive any of its provisions.

(B) TIME LIMIT ON CERTAIN DEFENSES:

(i) After two years from the date of issue of this policy no

misstatements, except fraudulent misstatements, made by the applicant in

the application for such policy shall be used to void the policy or to

deny a claim for loss incurred or disability (as defined in the policy)

commencing after the expiration of such two year period.

(The foregoing policy provision shall not be so construed as to affect

any legal requirement for avoidance of a policy or denial of a claim

during such initial two year period, nor to limit the application of

subparagraphs (A) through (E), inclusive, of this paragraph in the event

of misstatement with respect to age or occupation or other insurance.)

(A policy which the insured has the right to continue in force subject

to its terms by the timely payment of premium until at least age fifty

or, in the case of a policy issued after age forty-four, for at least

five years from its date of issue, may contain in lieu of the foregoing

the following provision (from which the clause in parentheses may be

omitted at the insurer's option) under the caption "INCONTESTABLE":

After this policy has been in force for a period of two years during

the lifetime of the insured (excluding any period during which the

insured is disabled), it shall become incontestable as to the statements

contained in the application.)

(ii) No claim for loss incurred or disability (as defined in the

policy) commencing after two years from the date of issue of this policy

shall be reduced or denied on the ground that a disease or physical

condition not excluded from coverage by name or specific description

effective on the date of loss had existed prior to the effective date of

coverage of this policy.

(C) GRACE PERIOD: A grace period of ........................ (insert a

number not less than "7" for weekly premium policies, "10" for monthly

premium policies and "31" for all other policies) days will be granted

for the payment of each premium falling due after the first premium,

during which grace period the policy shall continue in force.

(A policy in which the insurer reserves the right to refuse renewal

shall have, at the beginning of the above provision, the following

clause:

"Unless not less than thirty days prior to the renewal date the

insurer has delivered to the insured or has sent by first class mail to

his last address as shown by the records of the insurer written notice

of its intention not to renew this policy beyond the period for which

the premium has been accepted,"

Furthermore, such a policy, except an accident only policy, shall also

provide in substance, in a provision thereof, or in an endorsement

thereon or in a rider attached thereto, that the insurer may refuse

renewal of the policy only as of the renewal date occurring on, or

nearest its first anniversary, or as of an anniversary of such renewal

date, or at the option of the insurer as of the renewal date occurring

on or nearest the anniversary of its date of last reinstatement.)

(D) REINSTATEMENT: If any renewal premium be not paid within the time

granted the insured for payment, a subsequent acceptance of the premium

by the insurer or by any agent or broker duly authorized by the insurer

to accept such premium, without requiring in connection therewith an

application for reinstatement, shall reinstate the policy; provided,

however, that if the insurer or such agent or broker requires an

application for reinstatement and issues a conditional receipt for the

premium tendered, the policy will be reinstated upon approval of such

application by the insurer or, lacking such approval, upon the

forty-fifth day following the date of such conditional receipt unless

the insurer has previously notified the insured in writing of its

disapproval of such application. The reinstated policy shall cover only

loss resulting from such accidental injury as may be sustained after the

date of reinstatement and loss due to such sickness as may begin more

than ten days after such date. In all other respects the insured and

insurer shall have the same rights thereunder as they had under the

policy immediately before the due date of the defaulted premium, subject

to any provisions endorsed hereon or attached hereto in connection with

the reinstatement. Any premium accepted in connection with a

reinstatement shall be applied to a period for which premium has not

been previously paid, but not to any period more than sixty days prior

to the date of reinstatement.

(The last sentence of the above provision may be omitted from any

policy which the insured has the right to continue in force subject to

its terms by the timely payment of premiums until at least age fifty or,

in the case of a policy issued after age forty-four, for at least five

years from its date of issue.)

(E) NOTICE OF CLAIM: Written notice of claim must be given to the

insurer within twenty days after the occurrence or commencement of any

loss covered by the policy, or as soon thereafter as is reasonably

possible. Notice given by or on behalf of the insured or the beneficiary

to the insurer at -------------- (insert the location of such office as

the insurer may designate for the purpose), or to any authorized agent

of the insurer or to any authorized broker, with information sufficient

to identify the insured, shall be deemed notice to the insurer. (In a

policy providing a loss-of-time benefit which may be payable for at

least two years, an insurer may at its option insert the following

between the first and second sentences of the above provision: Subject

to the qualifications set forth below, if the insured suffers loss of

time on account of disability for which indemnity may be payable for at

least two years, he shall, at least once in every six months after

having given notice of claim, give to the insurer notice of continuance

of said disability, except in the event of legal incapacity. The period

of six months following any filing of proof by the insured or any

payment by the insurer on account of such claim or any denial of

liability in whole or in part by the insurer shall be excluded in

applying this provision. Delay in the giving of such notice shall not

impair the insured's right to any indemnity which would otherwise have

accrued during the period of six months preceding the date on which such

notice is actually given.)

(F) CLAIM FORMS: The insurer, upon receipt of a notice of claim, will

furnish to the claimant such forms as are usually furnished by it for

filing proofs of loss. If such forms are not furnished within fifteen

days after the giving of such notice the claimant shall be deemed to

have complied with the requirements of this policy as to proof of loss

upon submitting, within the time fixed in the policy for filing proofs

of loss, written proof covering the occurrence, the character and extent

of the loss for which claim is made.

(G) PROOFS OF LOSS: Written proof of loss must be furnished to the

insurer at its said office in case of claim for loss for which this

policy provides any periodic payment contingent upon continuing loss

within ninety days after the termination of the period for which the

insurer is liable and in case of claim for any other loss within one

hundred twenty days after the date of such loss. Failure to furnish such

proof within the time required shall not invalidate nor reduce any claim

if it was not reasonably possible to give proof within such time,

provided such proof is furnished as soon as reasonably possible and in

no event, except in the absence of legal capacity, later than one year

from the time proof is otherwise required.

(H) TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy

for any loss other than loss for which this policy provides any periodic

payment will be paid immediately upon receipt of due written proof of

such loss. Subject to due written proof of loss, all accrued indemnities

for loss for which this policy provides periodic payment will be

paid ------------ (insert period for payment which must not be less

frequently than monthly) and any balance remaining unpaid upon the

termination of liability will be paid immediately upon receipt of due

written proof.

(I) PAYMENT OF CLAIMS: Any indemnity for loss of life will be payable

in accordance with the beneficiary designation and the provisions

respecting such payment which may be prescribed herein and effective at

the time of payment. If no such designation or provision is then

effective, such indemnity shall be payable to the estate of the insured.

Any other accrued indemnities unpaid at the insured's death may, at the

option of the insurer, be paid either to such beneficiary or to such

estate. All other indemnities will be payable to the insured. (The

following provisions, or either of them, may be included with the

foregoing provision at the option of the insurer: If any indemnity of

this policy shall be payable to the estate of the insured, or to an

insured or beneficiary who is a minor or otherwise not competent to give

a valid release, the insurer may pay such indemnity, up to an amount not

exceeding $-------------- (insert an amount which shall not exceed one

thousand dollars), to any relative by blood or connection by marriage of

the insured or beneficiary who is deemed by the insurer to be equitably

entitled thereto. Any payment made by the insurer in good faith pursuant

to this provision shall fully discharge the insurer to the extent of

such payment.

Subject to any written direction of the insured in the application or

otherwise all or a portion of any indemnities provided by this policy on

account of hospital, nursing, medical, or surgical services may, at the

insurer's option and unless the insured requests otherwise in writing

not later than the time of filing proofs of such loss, be paid directly

to the hospital or person rendering such services; but it is not

required that the service be rendered by a particular hospital or

person.)

(J) PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense

shall have the right and opportunity to examine the person of the

insured when and as often as it may reasonably require during the

pendency of a claim hereunder and to make an autopsy in case of death

where it is not forbidden by law.

(K) LEGAL ACTIONS: No action at law or in equity shall be brought to

recover on this policy prior to the expiration of sixty days after

written proof of loss has been furnished in accordance with the

requirements of this policy. No such action shall be brought after the

expiration of three years after the time written proof of loss is

required to be furnished.

(L) CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable

designation of beneficiary, the right to change of beneficiary is

reserved to the insured and the consent of the beneficiary or

beneficiaries shall not be requisite to surrender or assignment of this

policy or to any change of beneficiary or beneficiaries, or to any other

changes in this policy.

(The first clause of this provision, relating to the irrevocable

designation of beneficiary, may be omitted at the insurer's option.)

(M) "CONVERSION PRIVILEGE" (under this caption) a provision which

shall set forth in substance the conversion privileges and related

provisions required of certain policies by paragraph five of subsection

(c) of this section.

(2) Other provisions. No such policy delivered or issued for delivery

to any person in this state shall contain provisions respecting the

matters set forth below unless such provisions are in the words (not

including the designation by number or letter) in which the same appear

in this paragraph except that the insurer may, at its option, use in

lieu of any such provision a corresponding provision of different

wording approved by the superintendent which is not less favorable in

any respect to the insured or the beneficiary. Any such provision

contained in the policy shall be preceded individually by the

appropriate caption appearing herein or, at the option of the insurer,

by such appropriate individual or group captions or subcaptions as the

superintendent may approve.

(A) CHANGE OF OCCUPATION: If the insured be injured or contract

sickness after having changed his occupation to one classified by the

insurer as more hazardous than that stated in this policy or while doing

for compensation anything pertaining to an occupation so classified, the

insurer will pay only such portion of the indemnities provided in this

policy as the premium paid would have purchased at the rates and within

the limits fixed by the insurer for such more hazardous occupation. If

the insured changes his occupation to one classified by the insurer as

less hazardous than that stated in this policy, the insurer, upon

receipt of proof of such change of occupation, will reduce the premium

rate accordingly, and will return the excess pro-rata unearned premium

from the date of change of occupation or from the policy anniversary

date immediately preceding receipt of such proof, whichever is the more

recent. In applying this provision, the classification of occupational

risk and the premium rates shall be such as have been last filed by the

insurer prior to the occurrence of the loss for which the insurer is

liable or prior to date of proof of change in occupation with the state

official having supervision of insurance in the state where the insured

resided at the time this policy was issued; but if such filing was not

required, then the classification of occupational risk and the premium

rates shall be those last made effective by the insurer in such state

prior to the occurrence of the loss or prior to the date of proof of

change in occupation.

(B) MISSTATEMENT OF AGE: If the insured's age has been misstated, all

amounts payable under this policy shall be such as the premium paid

would have purchased at the correct age.

(C) OTHER INSURANCE IN THIS INSURER: If an accident or sickness or

accident and health policy or policies previously issued by the insurer

to the insured be in force concurrently herewith,

making the aggregate indemnity for ------------(insert type of

coverage or coverages) in excess of $-------------(insert maximum limit

of indemnity or indemnities) the excess insurance shall be void and all

premiums paid for such excess shall be returned to the insured or to his

estate,

or, in lieu thereof:

Insurance effective at any one time on the insured under a like policy

or policies in this insurer is limited to the one such policy elected by

the insured, his beneficiary or his estate, as the case may be, and the

insurer will return all premiums paid for all other such policies.

(D) INSURANCE WITH OTHER INSURERS: If there be other valid coverage,

not with this insurer, providing benefits for the same loss on a

provision of service basis or on an expense incurred basis and of which

this insurer has not been given written notice prior to the occurrence

or commencement of loss, the only liability under any expense incurred

coverage of this policy shall be for such proportion of the loss as the

amount which would otherwise have been payable hereunder plus the total

of the like amounts under all such other valid coverages for the same

loss of which this insurer had notice bears to the total like amounts

under all valid coverages for such loss, and for the return of such

portion of the premiums paid as shall exceed the pro-rata portion for

the amount so determined. For the purpose of applying this provision

when other coverage is on a provision of service basis, the "like

amount" of such other coverage shall be taken as the amount which the

services rendered would have cost in the absence of such coverage.

(If the foregoing policy provision is included in a policy which also

contains the next following policy provision there shall be added to the

caption of the foregoing provision the phrase "--- EXPENSE INCURRED

BENEFITS". The insurer may, at its option, include in this provision a

definition of "other valid coverage", approved as to form by the

superintendent, which definition shall be limited in subject matter to

coverage provided by organizations subject to regulation by insurance

law or by insurance authorities of this or any other state of the United

States or any province of Canada, and by hospital or medical service

organizations, and to any other coverage the inclusion of which may be

approved by the superintendent. In the absence of such definition such

term shall not include group insurance, automobile medical payments

insurance, or coverage provided by hospital or medical service

organizations or by union welfare plans or employer or employee benefit

organizations. For the purpose of applying the foregoing provision with

respect to any insured, any amount of benefit provided for such insured

pursuant to any compulsory benefit statute (including any workers'

compensation or employer's liability statute) whether provided by a

governmental agency or otherwise shall in all cases be deemed to be

"other valid coverage" of which the insurer has had notice. In applying

the foregoing policy provision no third party liability coverage shall

be included as "other valid coverage".)

(E) INSURANCE WITH OTHER INSURERS: If there be other valid coverage,

not with this insurer, providing benefits for the same loss on other

than an expense incurred basis and of which this insurer has not been

given written notice prior to the occurrence or commencement of loss,

the only liability for such benefits under this policy shall be for such

proportion of the indemnities otherwise provided hereunder for such loss

as the like indemnities of which the insurer had notice (including the

indemnities under this policy) bear to the total amount of all like

indemnities for such loss, and for the return of such portion of the

premium paid as shall exceed the pro-rata portion for the indemnities

thus determined.

(If the foregoing policy provision is included in a policy which also

contains the next preceding policy provision there shall be added to the

caption of the foregoing provision the phrase "--- OTHER BENEFITS". The

insurer may, at its option, include in this provision a definition of

"other valid coverage", approved as to form by the superintendent, which

definition shall be limited in subject matter to coverage provided by

organizations subject to regulation by insurance law or by insurance

authorities of this or any other state of the United States or any

province of Canada, and to any other coverage the inclusion of which may

be approved by the superintendent. In the absence of such definition

such term shall not include group insurance, or benefits provided by

union welfare plans or by employer or employee benefit organizations.

For the purpose of applying the foregoing policy provision with respect

to any insured, any amount of benefit provided for such insured pursuant

to any compulsory benefit statute (including any workers' compensation

or employer's liability statute) whether provided by a governmental

agency or otherwise shall in all cases be deemed to be "other valid

coverage" of which the insurer has had notice. In applying the foregoing

policy provision no third party liability coverage shall be included as

"other valid coverage".)

(F) RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of

loss of time benefits promised for the same loss under all valid loss of

time coverage upon the insured, whether payable on a weekly or monthly

basis, shall exceed the monthly earnings of the insured at the time

disability commenced or his average monthly earnings for the period of

two years immediately preceding a disability for which claim is made,

whichever is the greater, the insurer will be liable for only such

proportionate amount of such benefits under this policy as the amount of

such monthly earnings or such average monthly earnings of the insured

bears to the total amount of monthly benefits for the same loss under

all such coverage upon the insured at the time such disability commences

and for the return of such part of the premiums paid during such two

years as shall exceed the pro-rata amount of the premiums for the

benefits actually paid hereunder; but this shall not operate to reduce

the total monthly amount of benefits payable under all such coverage

upon the insured below the sum of two hundred dollars or the sum of the

monthly benefits specified in such coverages, whichever is the lesser,

nor shall it operate to reduce benefits other than those payable for

loss of time.

(The foregoing policy provision may be inserted only in a policy which

the insured has the right to continue in force subject to its terms by

the timely payment of premiums until at least age fifty or, in the case

of a policy issued after age forty-four, for at least five years from

its date of issue. The insurer may, at its option, include in this

provision a definition of "valid loss of time coverage", approved as to

form by the superintendent, which definition shall be limited in subject

matter to coverage provided by governmental agencies or by organizations

subject to regulation by the insurance law or by insurance authorities

of this or any other state of the United States or any province of

Canada, or to any other coverage the inclusion of which may be approved

by the superintendent or any combination of such coverages. In the

absence of such definition such term shall not include any coverage

provided for such insured pursuant to any compulsory benefit statute

(including any workers' compensation or employer's liability statute),

or benefits provided by union welfare plans or by employer or employee

benefit organizations.)

(G) UNPAID PREMIUM: Upon the payment of a claim under this policy, any

premium then due and unpaid or covered by any note or written order may

be deducted therefrom.

(H) CANCELLATION: Within the first ninety days after the date of

issue, the insurer may cancel this policy by written notice delivered to

the insured, or sent by first class mail to his last address as shown by

the records of the insurer, stating when, not less than ten days

thereafter, such cancellation shall be effective. In the event of

cancellation, the insurer will return promptly the pro-rata unearned

portion of any premium paid. Cancellation shall be without prejudice to

any claim originating prior to the effective date of cancellation.

(Nothing in this subsection shall be construed to prohibit an insurer

from granting to the insured the right to cancel a policy at any time

and to receive in such event a refund of the unearned portion of any

premium paid, computed by the use of the short-rate table last filed

with the state official having supervision of insurance in the state

where the insured resided when the policy was issued).

(I) CONFORMITY WITH STATE STATUTES: Any provision of this policy

which, on its effective date, is in conflict with the statutes of the

state in which the insured resides on such date is hereby amended to

conform to the minimum requirements of such statutes.

(J) ILLEGAL OCCUPATION: The insurer shall not be liable for any loss

to which a contributing cause was the insured's commission of or attempt

to commit a felony or to which a contributing cause was the insured's

being engaged in an illegal occupation.

(K) INTOXICANTS AND NARCOTICS: The insurer shall not be liable for any

loss sustained or contracted in consequence of the insured's being

intoxicated or under the influence of any narcotic unless administered

on the advice of a physician.

(3) If any provision of this subsection is in whole or in part

inapplicable to or inconsistent with the coverage provided by a

particular form of policy the insurer, with the approval of the

superintendent, shall omit from such policy any inapplicable provision

or part of a provision, and shall modify any inconsistent provision or

part of the provision in such manner as to make the provision as

contained in the policy consistent with the coverage provided by the

policy.

(4) The provisions which are the subject of paragraphs one and two of

this subsection, or any corresponding provisions which are used in lieu

thereof in accordance with such paragraphs, shall be printed in the

consecutive order of the provisions in such paragraphs or, at the option

of the insurer, any such provision may appear as a unit in any part of

the policy, with other provisions to which it may be logically related,

provided the resulting policy shall not be in whole or in part

unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a

person to whom the policy is offered, delivered or issued.

(5) The word "insured", as used in this section, shall not be

construed as preventing a person other than the insured with a proper

insurable interest from making application for and owning a policy

covering the insured or from being entitled under such a policy to any

indemnities, benefits and rights provided therein.

(6) The superintendent may make such reasonable rules and regulations

concerning the procedure for the filing or submission of policies

subject to this section as are necessary, proper or advisable to the

administration of this section. This provision shall not abridge any

other authority granted the superintendent by law.

(e) The acknowledgment by any insurer of the receipt of notice given

under any policy covered by this section, or the furnishing of forms for

filing proofs of loss, or the acceptance of such proofs, or the

investigation of any claim thereunder, shall not operate as a waiver of

any of the rights of the insurer in defense of any claim arising under

such policy.

(f) If any such policy contains a provision establishing, as an age

limit or otherwise, a date after which the coverage provided by the

policy will not be effective, and if such date falls within a period for

which premium is accepted by the insurer or if the insurer accepts a

premium after such date, the coverage provided by the policy will

continue in force subject to any right of cancellation until the end of

the period for which premium has been accepted. In the event the age of

the insured has been misstated and if, according to the correct age of

the insured, the coverage provided by the policy would not have become

effective, or would have ceased prior to the acceptance of such premium

or premiums, then the liability of the insurer shall be limited to the

refund, upon request, of all premiums paid for the period not covered by

the policy.

(g)(1) No insurer shall refuse to renew a policy of hospital, surgical

or medical expense insurance, an individual converted policy, or any

other policy in which one-third or more of the total premium is

allocable to hospital, surgical or medical expense benefits, or any

combination thereof (but not including insurance against accidental

injury only), except for one or more of the following reasons:

(A) nonpayment of premiums,

(B) fraud in applying for the policy or in applying for any benefits

under the policy or intentional misrepresentation of material fact under

the terms of the coverage,

(C) discontinuance of a class of policies in accordance with paragraph

two of this subsection, except that no insurer or organization certified

pursuant to article forty-four of the public health law shall refuse to

renew the policies of insureds holding contracts which provide major

medical or similar comprehensive type coverage in effect prior to June

first, two thousand one who are ineligible to purchase policies offered

pursuant to section four thousand three hundred twenty-one or four

thousand three hundred twenty-two of this chapter due to the provisions

of section 42 USC 1395ss in effect on January first, two thousand one,

and who are eligible for Medicare benefits by reason of disability.

(i) Coverage shall be reinstated only for such insureds terminated on

or after January first, two thousand one and such coverage shall be

reinstated on a prospective basis only, irrespective of any pre-existing

conditions.

(ii) In the event any such insured becomes eligible to purchase

policies offered pursuant to section four thousand three hundred

twenty-one or four thousand three hundred twenty-two of this chapter,

then such insured may be discontinued upon not less than five months

prior written notice. In the event any such insured becomes eligible for

Medicare by reason of age, then such insured may be terminated by not

less than thirty days notice with prior written notice.

(iii) Within sixty days of this item taking effect, the insurer or

organization shall notify the insured of the prospective reinstatement

of coverage under this section. Within thirty days of receipt of such

notice, an insured shall notify the insurer or organization of his or

her election for prospective coverage,

(D) discontinuance of all hospital, surgical and medical expense

coverage in the individual market in this state in accordance with

paragraph three of this subsection,

(E) in the case of an insurer that offers coverage in the individual

market through a network plan, termination of an individual who no

longer resides, lives or works in the service area (or in an area for

which the insurer is authorized to do business) but only if such

coverage is terminated under this subparagraph uniformly without regard

to any health status-related factor of covered individuals, and

(F) for such other reasons as are acceptable to the superintendent and

authorized by the Health Insurance Portability and Accountability Act of

1996, Public Law 104-191, and any later amendments or successor

provisions, or by any federal regulations or rules that implement the

provisions of the Act.

In no event shall any insurer refuse to renew any such policy because

of the physical or mental condition or the health of any person covered

thereunder. Furthermore, no insurer shall require as a condition for the

renewal of any such policy any rider, endorsement or other attachment

which shall limit the nature or extent of the benefits provided

thereunder. The superintendent may require every insurer to file with

him such documents, statistics or other information regarding the

refusal to renew permitted by this subsection as he may deem necessary

for the proper administration of this subsection.

(2) In any case in which an insurer decides to discontinue offering a

class of hospital, surgical or medical expense policies in the

individual health insurance market, coverage of the class of policies

may be discontinued by the insurer only if:

(A) the insurer gives at least ninety days prior written notice of

such discontinuance to the superintendent;

(B) the insurer provides written notice of such discontinuance to each

covered individual at least ninety days prior to the date of

discontinuance of such coverage;

(C) the insurer offers to each covered individual the option to

purchase all other individual hospital, surgical and medical expense

coverage currently being offered by the insurer in the individual health

insurance market; and

(D) in exercising the option to discontinue coverage of a class of

policies and in offering the option of coverage under subparagraph (C)

of this paragraph, the insurer acts uniformly without regard to claims

experience or to any health status-related factor of insured individuals

or individuals who may become eligible for such coverage.

(E) The superintendent may, after giving due consideration to the

public interest, approve a request made by an insurer for the insurer to

satisfy the requirements of subparagraph (C) of this paragraph through

the offering of policies at each level of coverage as defined in

subsection (b) of section three thousand two hundred seventeen-i of this

article that contains the essential health benefits package described in

paragraph three of subsection (e) of section three thousand two hundred

seventeen-i of this article by another insurer, corporation or health

maintenance organization within the insurer's same holding company

system, as defined in article fifteen of this chapter.

(3) In any case in which an insurer elects to discontinue offering all

hospital, surgical and medical expense coverage in the individual market

in this state, health insurance coverage may be discontinued by the

insurer only if:

(A) the insurer gives at least one hundred eighty days prior written

notice of such discontinuance to the superintendent;

(B) the insurer provides written notice of such discontinuance to each

covered individual at least one hundred eighty days prior to the date of

termination of such coverage;

(C) all hospital, surgical and medical expense coverage issued or

delivered for issuance in this state in the individual market is

discontinued and coverage under such health insurance coverage in such

market is not renewed; and

(D) in addition to the notice referred to in subparagraph (A) of this

paragraph, the insurer must provide the superintendent with a written

plan to minimize potential disruption in the marketplace occasioned by

its withdrawal from the individual market.

(4) In the case of a discontinuance under paragraph three of this

subsection, the insurer may not provide for the issuance of any policy

of hospital, surgical or medical expense insurance in the individual

market in this state during the five year period beginning on the date

of the discontinuance of the last health insurance coverage not so

renewed.

(5) At the time of coverage renewal, an insurer may modify the health

insurance coverage for a policy form offered to individuals in the

individual market so long as such modification is consistent with this

chapter and effective on a uniform basis among all individuals with that

policy form.

(6) For purposes of this subsection the term "network plan" shall mean

a health insurance policy under which the financing and delivery of

health care (including items and services paid for as such care) are

provided, in whole or in part, through a defined set of providers under

contract with the insurer or another entity which has contracted with

the insurer.

(h) This section shall not apply to or affect:

(1) Any contract of non-cancellable disability insurance which is

governed by or excepted from section three thousand two hundred fifteen

of this article.

(2) Any policy or contract of reinsurance.

(3) Any policy of group or blanket insurance which is governed by

section three thousand two hundred twenty-one of this article except

that the provisions of subsection (b) hereof and paragraphs one through

ten of subsection (i) hereof and the provisions of subsection (j) hereof

shall be applicable to a policy of group insurance authorized under

subparagraph (J) of paragraph one of subsection (c) of section four

thousand two hundred thirty-five of this chapter.

(4) Any policy providing disability benefits pursuant to article nine

of the workers' compensation law.

(5) Any policy of a co-operative life and accident insurance company

except as was provided in section two hundred thirty-seven of the former

insurance law.

(6) Life insurance, endowment or annuity contracts, or contracts

supplemental thereto which contain only such provisions relating to

accident and health insurance as provide additional benefits in case of

death or dismemberment or loss of sight by accident, or as operate to

safeguard such contracts against lapse, or to give a special surrender

value or special benefit or an annuity in the event that the insured or

annuitant shall become totally and permanently disabled, as defined by

the contract or supplemental contract.

(i) Every person insured under a policy of accident and health

insurance delivered or issued for delivery in this state shall be

entitled to the reimbursements and coverages specified below.

(1) If a policy provides for reimbursement for any optometric service

which is within the lawful scope of practice of a licensed optometrist,

the insured shall be entitled to reimbursement for such service whether

it is performed by a physician or licensed optometrist. Unless such

policy shall otherwise provide there shall be no reimbursement for

ophthalmic materials, lenses, spectacles, eyeglasses, or appurtenances

thereto.

(2) If a policy provides for reimbursement for any podiatrical service

within the lawful scope of practice of a licensed podiatrist, the

insured shall be entitled to reimbursement for such service whether it

is performed by a physician or licensed podiatrist.

(3) If a policy provides for reimbursement for any dental service

within the lawful scope of practice of a licensed dentist, the insured

shall be entitled to reimbursement for such service whether it is

performed by a physician or a licensed dentist.

(4) If a policy provides for reimbursement for psychiatric or

psychological services or for diagnosis and treatment of mental health

conditions however defined in the policy, the insured shall be entitled

to reimbursement for such services, diagnosis or treatment whether

performed by a physician, psychiatrist, a certified and registered

psychologist, or a nurse practitioner when the services rendered are

within the lawful scope of their practice.

(5) Every policy providing for reimbursement for laboratory tests or

reimbursement for diagnostic X-ray services shall provide for

reimbursement at the same percentage of reimbursement whether such tests

or services are provided to the insured as an admitted patient in a

health care facility or as an out-patient.

(6) Every policy which provides coverage for in-patient hospital care

shall provide coverage for home care to residents in this state. Such

home care coverage shall be included at the inception of all new

policies and, with respect to all other policies, at any anniversary

date of the policy subject to evidence of insurability.

(A) Home care means the care and treatment of a covered person who is

under the care of a physician but only if hospitalization or confinement

in a nursing facility as defined in subchapter XVIII of the federal

Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been

required if home care was not provided, and the plan covering the home

health service is established and approved in writing by such physician.

Home care shall be provided by an agency possessing a valid certificate

of approval or license issued pursuant to article thirty-six of the

public health law and shall consist of one or more of the following:

(i) Part-time or intermittent home nursing care by or under the

supervision of a registered professional nurse (R.N.).

(ii) Part-time or intermittent home health aide services which consist

primarily of caring for the patient.

(iii) Physical, occupational or speech therapy if provided by the home

health service or agency.

(iv) Medical supplies, drugs and medications prescribed by a

physician, and laboratory services by or on behalf of a certified home

health agency or licensed home care services agency to the extent such

items would have been covered under the contract if the covered person

had been hospitalized or confined in a skilled nursing facility as

defined in title subchapter XVIII of the federal Social Security Act, 42

U.S.C. §§ 1395 et seq.

(B) Coverage may be subject to an annual deductible of not more than

fifty dollars for each person covered under the policy and may be

subject to a coinsurance provision which provides for coverage of not

less than seventy-five percent of the reasonable charges for such

services. For the purpose of determining the benefits for home care

available to a covered person, each visit by a member of a home care

team shall be considered as one home care visit; the contract may

contain a limitation on the number of home care visits, but not less

than forty such visits in any calendar year or in any continuous period

of twelve months for each person covered under the contract; four hours

of home health aide service shall be considered as one home care visit.

(7) Every policy which provides coverage for in-patient hospital care

shall also provide coverage for pre-admission tests performed in

hospital out-patient facilities prior to scheduled surgery provided:

(A) the tests are ordered by a physician as a planned preliminary to

admission of the patient as an in-patient for surgery in the same

hospital;

(B) tests are necessary for and consistent with the diagnosis and

treatment of the condition for which surgery is to be performed;

(C) reservations for a hospital bed and for an operating room shall

have been made prior to the performance of the tests;

(D) the surgery actually takes place within seven days of such

presurgical tests; and

(E) the patient is physically present at the hospital for the tests.

(8) Every policy which provides coverage for in-patient surgical care

shall include coverage for a second surgical opinion by a qualified

physician on the need for surgery.

(9)(A) Every policy that provides coverage for inpatient hospital care

shall also include coverage for services to treat an emergency condition

in hospital facilities:

(i) without the need for any prior authorization determination;

(ii) regardless of whether the health care provider furnishing such

services is a participating provider with respect to such services;

(iii) if the emergency services are provided by a non-participating

provider, without imposing any administrative requirement or limitation

on coverage that is more restrictive than the requirements or

limitations that apply to emergency services received from participating

providers; and

(iv) if the emergency services are provided by a non-participating

provider, the cost-sharing requirement (expressed as a copayment or

coinsurance) shall be the same requirement that would apply if such

services were provided by a participating provider.

(B) Any requirements of section 2719A(b) of the Public Health Service

Act, 42 U.S.C. § 300gg19a(b) and regulations thereunder that exceed the

requirements of this paragraph with respect to coverage of emergency

services shall be applicable to every policy subject to this paragraph.

(C) For purposes of this paragraph, an "emergency condition" means a

medical or behavioral condition that manifests itself by acute symptoms

of sufficient severity, including severe pain, such that a prudent

layperson, possessing an average knowledge of medicine and health, could

reasonably expect the absence of immediate medical attention to result

in (i) placing the health of the person afflicted with such condition in

serious jeopardy, or in the case of a behavioral condition placing the

health of such person or others in serious jeopardy; (ii) serious

impairment to such person's bodily functions; (iii) serious dysfunction

of any bodily organ or part of such person; (iv) serious disfigurement

of such person; or (v) a condition described in clause (i), (ii) or

(iii) of section 1867(e)(1)(A) of the Social Security Act.

(D) For purposes of this paragraph, "emergency services" means, with

respect to an emergency condition: (i) a medical screening examination

as required under section 1867 of the Social Security Act, 42 U.S.C. §

1395dd, which is within the capability of the emergency department of a

hospital, including ancillary services routinely available to the

emergency department to evaluate such emergency medical condition; and

(ii) within the capabilities of the staff and facilities available at

the hospital, such further medical examination and treatment as are

required under section 1867 of the Social Security Act, 42 U.S.C. §

1395dd, to stabilize the patient.

(E) For purposes of this paragraph, "to stabilize" means, with respect

to an emergency condition, to provide such medical treatment of the

condition as may be necessary to assure, within reasonable medical

probability, that no material deterioration of the condition is likely

to result from or occur during the transfer of the insured from a

facility or to deliver a newborn child (including the placenta).

(10) (A) (i) Every policy which provides hospital, surgical or medical

coverage shall provide coverage for maternity care, including hospital,

surgical or medical care to the same extent that hospital, surgical or

medical coverage is provided for illness or disease under the policy.

Such maternity care coverage, other than coverage for perinatal

complications, shall include inpatient hospital coverage for mother and

for newborn for at least forty-eight hours after childbirth for any

delivery other than a caesarean section, and for at least ninety-six

hours after a caesarean section. Such coverage for maternity care shall

include the services of a midwife licensed pursuant to article one

hundred forty of the education law, practicing consistent with section

sixty-nine hundred fifty-one of the education law and affiliated or

practicing in conjunction with a facility licensed pursuant to article

twenty-eight of the public health law, but no insurer shall be required

to pay for duplicative routine services actually provided by both a

licensed midwife and a physician.

(ii) Maternity care coverage shall also include, at minimum, parent

education, assistance and training in breast or bottle feeding, and the

performance of any necessary maternal and newborn clinical assessments.

(iii) The mother shall have the option to be discharged earlier than

the time periods established in item (i) of this subparagraph. In such

case, the inpatient hospital coverage must include at least one home

care visit, which shall be in addition to, rather than in lieu of, any

home health care coverage available under the policy. The policy must

cover the home care visit which may be requested at any time within

forty-eight hours of the time of delivery (ninety-six hours in the case

of caesarean section) and shall be delivered within twenty-four hours,

(I) after discharge, or (II) of the time of the mother's request,

whichever is later. Such home care coverage shall be pursuant to the

policy and subject to the provisions of this subparagraph, and not

subject to deductibles, coinsurance or copayments.

(B) Coverage provided under this paragraph for care and treatment

during pregnancy shall include provision for not less than two payments,

at reasonable intervals and for services rendered, for prenatal care and

a separate payment for the delivery and postnatal care provided.

* (C) Coverage provided under this paragraph for care and treatment

during pregnancy shall include medically necessary transvaginal

ultrasounds when recommended by nationally recognized clinical practice

guidelines. For the purposes of this subparagraph, "nationally

recognized clinical practice guidelines" means evidence-based clinical

practice guidelines informed by a systematic review of evidence and an

assessment of the benefits, and risks of alternative care options

intended to optimize patient care developed by independent organizations

or medical professional societies utilizing a transparent methodology

and reporting structure and with a conflict of interest policy.

* NB Effective January 1, 2027

(10-a) Every policy that provides medical, major medical, or similar

comprehensive-type coverage shall provide coverage for prenatal vitamins

when prescribed by a health care practitioner licensed, certified, or

authorized under title eight of the education law, and acting within

their lawful scope of practice.

(11) (A) Every policy that provides coverage for hospital, surgical or

medical care shall provide the following coverage for mammography

screening for occult breast cancer:

(i) upon the recommendation of a physician, a mammogram, which may be

provided by breast tomosynthesis, at any age for covered persons having

a prior history of breast cancer or who have a first degree relative

with a prior history of breast cancer;

(ii) a single baseline mammogram, which may be provided by breast

tomosynthesis, for covered persons aged thirty-five through thirty-nine,

inclusive;

(iii) an annual mammogram, which may be provided by breast

tomosynthesis, for covered persons aged forty and older; and

(iv) upon the recommendation of a physician, screening and diagnostic

imaging, including diagnostic mammograms, breast ultrasounds, or

magnetic resonance imaging, recommended by nationally recognized

clinical practice guidelines for the detection of breast cancer. For the

purposes of this item, "nationally recognized clinical practice

guidelines" means evidence-based clinical practice guidelines informed

by a systematic review of evidence and an assessment of the benefits,

and risks of alternative care options intended to optimize patient care

developed by independent organizations or medical professional societies

utilizing a transparent methodology and reporting structure and with a

conflict of interest policy.

* (B) Such coverage required pursuant to subparagraph (A) or (C) of

this paragraph shall not be subject to annual deductibles or

coinsurance. If under federal law, application of this requirement would

result in health savings account ineligibility under 26 USC 223, this

requirement shall apply for health savings account-qualified high

deductible health plans with respect to the deductible of such a plan

after the enrollee has satisfied the minimum deductible under 26 USC

223, except for with respect to items or services that are preventive

care pursuant to 26 USC 223(c)(2)(C), in which case the requirements of

this paragraph shall apply regardless of whether the minimum deductible

under 26 USC 223 has been satisfied.

* NB Effective until January 1, 2027

* (B) Such coverage required pursuant to subparagraph (A) or (C) of

this paragraph shall not be subject to annual deductibles or

coinsurance. If under federal law, application of this requirement would

result in health savings account ineligibility under 26 USC 223, this

requirement shall apply for health savings account-qualified high

deductible health plans with respect to the deductible of such a plan

after the enrollee has satisfied the plan deductible, except for with

respect to items or services that are preventive care pursuant to 26 USC

223(c)(2)(C), in which case the requirements of this paragraph shall

apply regardless of whether the plan deductible has been satisfied.

* NB Effective January 1, 2027

(C) For purposes of subparagraphs (A) and (B) of this paragraph,

mammography screening means an X-ray examination of the breast using

dedicated equipment, including X-ray tube, filter, compression device,

screens, films and cassettes, with an average glandular radiation dose

less than 0.5 rem per view per breast; provided, however, that

mammography screening shall also include breast tomosynthesis.

(D) In addition to subparagraph (A), (B) or (C) of this paragraph,

every policy that provides coverage for hospital, surgical or medical

care, except for a grandfathered health plan under subparagraph (E) of

this paragraph, shall provide coverage for the following mammography

screening services, and such coverage shall not be subject to annual

deductibles or coinsurance:

(i) evidence-based items or services for mammography that have in

effect a rating of 'A' or 'B' in the current recommendations of the

United States preventive services task force; and

(ii) with respect to women, such additional preventive care and

screenings for mammography not described in item (i) of this

subparagraph and as provided for in comprehensive guidelines supported

by the health resources and services administration.

(E) For purposes of this paragraph, "grandfathered health plan" means

coverage provided by an insurer in which an individual was enrolled on

March twenty-third, two thousand ten for as long as the coverage

maintains grandfathered status in accordance with section 1251(e) of the

Affordable Care Act, 42 U.S.C. § 18011(e).

(11-a) (A) Every policy delivered or issued for delivery in this state

which provides medical coverage that includes coverage for physician

services in a physician's office and every policy which provides major

medical or similar comprehensive-type coverage shall provide, upon the

prescription of a health care provider legally authorized to prescribe

under title eight of the education law, the following coverage for

diagnostic screening for prostatic cancer:

(i) standard diagnostic testing including, but not limited to, a

digital rectal examination and a prostate-specific antigen test at any

age for men having a prior history of prostate cancer; and

(ii) an annual standard diagnostic examination including, but not

limited to, a digital rectal examination and a prostate-specific antigen

test for men age fifty and over who are asymptomatic and for men age

forty and over with a family history of prostate cancer or other

prostate cancer risk factors.

(B) Such coverage shall not be subject to annual deductibles or

coinsurance.

(11-c) (A) Every policy which provides medical, major medical, or

similar comprehensive-type coverage shall provide coverage for biomarker

precision medical testing for the purposes of diagnosis, treatment, or

appropriate management of, or ongoing monitoring to guide treatment

decisions for, an insured's disease or condition when one or more of the

following recognizes the efficacy and appropriateness of biomarker

precision medical testing for diagnosis, treatment, appropriate

management, or guiding treatment decisions for an insured's disease or

condition:

(i) labeled indications for a test approved or cleared by the federal

food and drug administration or indicated tests for a food and drug

administration approved drug;

(ii) centers for medicare and medicaid services national coverage

determinations or medicare administrative contractor local coverage

determinations;

(iii) nationally recognized clinical practice guidelines; or

(iv) peer-reviewed literature and peer-reviewed scientific studies

published in or accepted for publication by medical journals that meet

nationally recognized requirements for scientific manuscripts and that

submit most of their published articles for review by experts who are

not part of the editorial staff.

(B) Such coverage shall be provided in a manner that shall limit

disruptions in care including the need for multiple biopsies or

biospecimen samples.

(C) As used in this paragraph, the following terms shall have the

following meanings:

(i) "Biomarker" means a characteristic that is measured as an

indicator of normal biological processes, pathogenic processes, or

responses to an exposure or intervention, including therapeutic

interventions.

(ii) "Biomarker precision medical testing" means the analysis of a

patient's tissue, blood, or other biospecimen for the presence of a

biomarker. Biomarker testing includes but is not limited to

single-analyte tests and multi-plex panel tests performed at a

participating in-network laboratory facility that is either CLIA

certified or CLIA waived by the federal food and drug administration.

(iii) "Nationally recognized clinical practice guidelines" means

evidence-based clinical practice guidelines informed by a systematic

review of evidence and an assessment of the benefits, and risks of

alternative care options intended to optimize patient care developed by

independent organizations or medical professional societies utilizing a

transparent methodology and reporting structure and with a conflict of

interest policy.

(12) (A) Every policy which provides coverage for prescribed drugs

approved by the food and drug administration of the United States

government for the treatment of certain types of cancer shall not

exclude coverage of any such drug on the basis that such drug has been

prescribed for the treatment of a type of cancer for which the drug has

not been approved by the food and drug administration. Provided,

however, that such drug must be recognized for treatment of the specific

type of cancer for which the drug has been prescribed in one of the

following established reference compendia:

(i) the American Hospital Formulary Service-Drug Information

(AHFS-DI);

(ii) National Comprehensive Cancer Networks Drugs and Biologics

Compendium;

(iii) Thomson Micromedex DrugDex;

(iv) Elsevier Gold Standard's Clinical Pharmacology; or other

authoritative compendia as identified by the Federal Secretary of Health

and Human Services or the Centers for Medicare & Medicaid Services

(CMS); or recommended by review article or editorial comment in a major

peer reviewed professional journal.

(B) Notwithstanding the provisions of this paragraph, coverage shall

not be required for any experimental or investigational drugs or any

drug which the food and drug administration has determined to be

contraindicated for treatment of the specific type of cancer for which

the drug has been prescribed. The provisions of this paragraph shall

apply to cancer drugs only and nothing herein shall be construed to

create, impair, alter, limit, modify, enlarge, abrogate or prohibit

reimbursement for drugs used in the treatment of any other disease or

condition.

(12-a) (A) Every policy delivered or issued for delivery in this state

that provides medical, major medical, or similar comprehensive-type

coverage and provides coverage for prescription drugs and also provides

coverage for cancer chemotherapy treatment shall provide coverage for

prescribed, orally administered anticancer medications used to kill or

slow the growth of cancerous cells. Such coverage may be subject to

co-pays, coinsurance or deductibles, provided that the co-pays,

coinsurance or deductibles are at least as favorable to an insured as

the co-pays, coinsurance or deductibles that apply to coverage for

intravenous or injected anticancer medications.

(B) An insurer providing coverage under this paragraph and any

participating entity through which the insurer offers health services

shall not:

(i) vary the terms of the policy for the purpose or with the effect of

avoiding compliance with this paragraph;

(ii) provide incentives (monetary or otherwise) to encourage a covered

person to accept less than the minimum protections available under this

paragraph;

(iii) penalize in any way or reduce or limit the compensation of a

health care practitioner for recommending or providing care to a covered

person in accordance with this paragraph;

(iv) provide incentives (monetary or otherwise) to a health care

practitioner relating to the services provided pursuant to this

paragraph intended to induce or have the effect of inducing such

practitioner to provide care to a covered person in a manner

inconsistent with this paragraph; or

(v) achieve compliance with this paragraph by imposing an increase in

cost sharing for an intravenous or injected anticancer medication.

(13) (A) Every policy which provides coverage for hospital care shall

not exclude coverage for hospital care for diagnosis and treatment of

correctable medical conditions otherwise covered by the policy solely

because the medical condition results in infertility.

(B) Every policy which provides coverage for surgical and medical care

shall not exclude coverage for surgical and medical care for diagnosis

and treatment of correctable medical conditions otherwise covered by the

policy solely because the medical condition results in infertility.

(C) Every policy that provides medical, major medical or similar

comprehensive-type coverage shall provide coverage for standard

fertility preservation services when a medical treatment may directly or

indirectly cause iatrogenic infertility to an insured. Coverage may be

subject to annual deductibles and coinsurance, including copayments, as

may be deemed appropriate by the superintendent and as are consistent

with those established for other benefits within a given policy.

(i) For purposes of this subparagraph, "iatrogenic infertility" means

an impairment of fertility by surgery, radiation, chemotherapy or other

medical treatment affecting reproductive organs or processes.

(ii) No insurer providing coverage under this paragraph shall

discriminate based on an insured's expected length of life, present or

predicted disability, degree of medical dependency, perceived quality of

life, or other health conditions, nor based on personal characteristics,

including age, sex, sexual orientation, marital status or gender

identity.

(13-a) Every policy that provides coverage for prescription fertility

drugs and requires or permits prescription drugs to be purchased through

a network participating mail order or other non-retail pharmacy shall

provide the same coverage for prescription fertility drugs when such

drugs are purchased from a network participating non-mail order retail

pharmacy provided that the network participating non-mail order retail

pharmacy agrees in advance through a contractual network agreement, to

the same reimbursement amount, as well as the same applicable terms and

conditions, that the insurer has established for a network participating

mail order or other non-retail pharmacy. In such case, the policy shall

not impose any fee, co-payment, co-insurance, deductible or other

condition on any insured who elects to purchase prescription fertility

drugs through a network participating non-mail order retail pharmacy

that it does not impose on any insured who purchases prescription

fertility drugs through a network participating mail order or other

non-retail pharmacy.

(14) If a policy provides for reimbursement for the services of

licensed health professionals who can bill for services, the insured

shall be entitled to reimbursement for such service provided pursuant to

a clinical practice plan established pursuant to subdivision fourteen of

section two hundred six of the public health law.

(15) (A) Every policy that provides hospital, surgical or medical care

coverage or provides reimbursement for laboratory tests or reimbursement

for diagnostic X-ray services shall provide coverage for an annual

cervical cytology screening for cervical cancer and its precursor states

for women aged eighteen and older.

(B) For purposes of subparagraphs (A) and (C) of this paragraph,

cervical cytology screening shall include an annual pelvic examination,

collection and preparation of a Pap smear, and laboratory and diagnostic

services provided in connection with examining and evaluating the Pap

smear.

(C) Such coverage required pursuant to subparagraph (A) or (B) of this

paragraph may be subject to annual deductibles and coinsurance as may be

deemed appropriate by the superintendent and as are consistent with

those established for other benefits within a given policy.

(D) In addition to subparagraph (A), (B) or (C) of this paragraph,

every policy that provides hospital, surgical or medical care coverage,

except for a grandfathered health plan under subparagraph (E) of this

paragraph, shall provide coverage for the following cervical cytology

screening services, and such coverage shall not be subject to annual

deductibles or coinsurance:

(i) evidence-based items or services for cervical cytology that have

in effect a rating of 'A' or 'B' in the current recommendations of the

United States preventive services task force; and

(ii) with respect to women, such additional preventive care and

screenings for cervical cytology not described in item (i) of this

subparagraph and as provided for in comprehensive guidelines supported

by the health resources and services administration.

(E) For purposes of this paragraph, "grandfathered health plan" means

coverage provided by an insurer in which an individual was enrolled on

March twenty-third, two thousand ten for as long as the coverage

maintains grandfathered status in accordance with section 1251(e) of the

Affordable Care Act, 42 U.S.C. § 18011(e).

(15-a) (A) Every policy which provides medical coverage that includes

coverage for physician services in a physician's office and every policy

which provides major medical or similar comprehensive-type coverage

shall include coverage for the following equipment and supplies for the

treatment of diabetes, if recommended or prescribed by a physician or

other licensed health care provider legally authorized to prescribe

under title eight of the education law: blood glucose monitors and blood

glucose monitors for the visually impaired, data management systems,

test strips for glucose monitors and visual reading and urine testing

strips, insulin, injection aids, cartridges for the visually impaired,

syringes, insulin pumps and appurtenances thereto, insulin infusion

devices, and oral agents for controlling blood sugar. In addition, the

commissioner of the department of health shall provide and periodically

update by rule or regulation a list of additional diabetes equipment and

related supplies such as are medically necessary for the treatment of

diabetes, for which there shall also be coverage. Such policies shall

also include coverage for diabetes self-management education to ensure

that persons with diabetes are educated as to the proper self-management

and treatment of their diabetic condition, including information on

proper diets. Such coverage for self-management education and education

relating to diet shall be limited to visits medically necessary upon the

diagnosis of diabetes, where a physician diagnoses a significant change

in the patient's symptoms or conditions which necessitate changes in a

patient's self-management, or where reeducation or refresher education

is necessary. Such education may be provided by the physician or other

licensed health care provider legally authorized to prescribe under

title eight of the education law, or their staff, as part of an office

visit for diabetes diagnosis or treatment, or by a certified diabetes

nurse educator, certified nutritionist, certified dietitian or

registered dietitian upon the referral of a physician or other licensed

health care provider legally authorized to prescribe under title eight

of the education law. Education provided by the certified diabetes nurse

educator, certified nutritionist, certified dietitian or registered

dietitian may be limited to group settings wherever practicable.

Coverage for self-management education and education relating to diet

shall also include home visits when medically necessary.

(B) Such coverage may be subject to annual deductibles and coinsurance

as may be deemed appropriate by the superintendent and as are consistent

with those established for other benefits within a given policy;

provided, however, that covered prescription insulin drugs shall not be

subject to a deductible, copayment, coinsurance or any other cost

sharing requirement.

(16) If a policy provides for reimbursement for speech-language

pathology or audiology service which is within the lawful scope of

practice of a duly licensed speech-language pathologist or audiologist,

an insured shall be entitled to reimbursement for such service whether

the said service is performed by a physician or duly licensed

speech-language pathologist or audiologist, provided however, that

nothing contained herein shall be construed to impair any terms of such

policy which may require said service to be performed pursuant to a

medical order, or a similar or related service of a physician, in which

case coverage need not be provided for any tests, evaluations or

diagnoses if such tests, evaluations or diagnoses have already been

provided by or through a physician within twelve months of the referral

or order from the physician. However, nothing herein shall be construed

as preventing an insurer from covering more than one test or evaluation

provided by a speech-language pathologist or audiologist within a

twelve-month period where such test or evaluation is ordered by a

physician as medically necessary. Nor shall anything herein be construed

as prohibiting the limitation of such services, where covered, to

specified settings other than offices, such as hospitals or to services

provided by such professionals as part of a home care agency's services.

(17) (A) Every policy that provides medical, major-medical or similar

comprehensive-type coverage shall provide coverage for the provision of

preventive and primary care services.

(B) For the purposes of subparagraphs (A), (C) and (D) of this

paragraph, preventive and primary care services means the following

services rendered to a covered child of an insured from the date of

birth through the attainment of nineteen years;

(i) an initial hospital check-up and well-child visits scheduled in

accordance with the prevailing clinical standards of a national

association of pediatric physicians designated by the commissioner of

health (except for any standard that would limit the specialty or forum

of licensure of the practitioner providing the service other than the

limits under state law). Coverage for such services rendered shall be

provided only to the extent that such services are provided by or under

the supervision of a physician, or other professional licensed under

article one hundred thirty-nine of the education law whose scope of

practice pursuant to such law includes the authority to provide the

specified services. Coverage shall be provided for such services

rendered in a hospital, as defined in section twenty-eight hundred one

of the public health law, or in an office of a physician or other

professional licensed under article one hundred thirty-nine of the

education law whose scope of practice pursuant to such law includes the

authority to provide the specified services;

(ii) at each visit, services in accordance with the prevailing

clinical standards of such designated association, including a medical

history, a complete physical examination, developmental assessment,

anticipatory guidance, appropriate immunizations and laboratory tests

which tests are ordered at the time of the visit and performed in the

practitioner's office, as authorized by law, or in a clinical

laboratory; and

(iii) necessary immunizations, as determined by the superintendent in

consultation with the commissioner of health, consisting of at least

adequate dosages of vaccine against diphtheria, pertussis, tetanus,

polio, measles, rubella, mumps, haemophilus influenzae type b and

hepatitis b, which meet the standards approved by the United States

public health service for such biological products.

(C) Such coverage required pursuant to subparagraph (A) or (B) of this

paragraph shall not be subject to annual deductibles or coinsurance.

(D) Such coverage required pursuant to subparagraph (A) or (B) of this

paragraph shall not restrict or eliminate existing coverage provided by

the policy.

(E) In addition to subparagraph (A), (B), (C) or (D) of this

paragraph, every policy that provides hospital, surgical or medical care

coverage, except for a grandfathered health plan under subparagraph (F)

of this paragraph, shall provide coverage for the following preventive

care and screenings for insureds, and such coverage shall not be subject

to annual deductibles or coinsurance:

(i) evidence-based items or services for preventive care and

screenings that have in effect a rating of 'A' or 'B' in the current

recommendations of the United States preventive services task force;

(ii) immunizations that have in effect a recommendation from the

advisory committee on immunization practices of the centers for disease

control and prevention with respect to the individual involved, or that

are recommended by the commissioner of health to the superintendent

utilizing generally accepted medical standards and taking into

consideration recommendations of the American Academy of Pediatrics, the

American Academy of Family Physicians, the American College of

Obstetricians and Gynecologists, the American College of Physicians

and/or other similar nationally or internationally recognized scientific

organizations;

(iii) with respect to children, including infants and adolescents,

evidence-informed preventive care and screenings provided for in

comprehensive guidelines supported by the health resources and services

administration; and

(iv) with respect to women, such additional preventive care and

screenings not described in item (i) of this subparagraph and as

provided for in comprehensive guidelines supported by the health

resources and services administration.

(v) all FDA-approved contraceptive drugs, devices, and other products,

including all over-the-counter contraceptive drugs, devices, and

products as prescribed or as otherwise authorized under state or federal

law; voluntary sterilization procedures pursuant to 42 U.S.C. 18022 and

identified in the comprehensive guidelines supported by the health

resources and services administration and thereby incorporated in the

essential health benefits benchmark plan; patient education and

counseling on contraception; and follow-up services related to the

drugs, devices, products, and procedures covered under this clause,

including, but not limited to, management of side effects, counseling

for continued adherence, and device insertion and removal. Except as

otherwise authorized under this clause, a contract shall not impose any

restrictions or delays on the coverage required under this clause.

However, where the FDA has approved one or more therapeutic and

pharmaceutical equivalent, as defined by the FDA, versions of a

contraceptive drug, device, or product, a contract is not required to

include all such therapeutic and pharmaceutical equivalent versions in

its formulary, so long as at least one is included and covered without

cost-sharing and in accordance with this clause. If the covered

therapeutic and pharmaceutical equivalent versions of a drug, device, or

product are not available or are deemed medically inadvisable a contract

shall provide coverage for an alternate therapeutic and pharmaceutical

equivalent version of the contraceptive drug, device, or product without

cost-sharing. (a) This coverage shall include emergency contraception

without cost sharing when provided pursuant to a prescription, or order

under section sixty-eight hundred thirty-one of the education law or

when lawfully provided over-the-counter. (b) If the attending health

care provider, in his or her reasonable professional judgment,

determines that the use of a non-covered therapeutic or pharmaceutical

equivalent of a drug, device, or product is warranted, the health care

provider's determination shall be final. The superintendent shall

promulgate regulations establishing a process, including timeframes, for

an insured, an insured's designee or an insured's health care provider

to request coverage of a non-covered contraceptive drug, device, or

product. Such regulations shall include a requirement that insurers use

an exception form that shall meet criteria established by the

superintendent. (c) This coverage must allow for the dispensing of up to

twelve months worth of a contraceptive at one time. (d) For the purposes

of this clause, "over-the-counter contraceptive products" shall mean

those products provided for in comprehensive guidelines supported by the

health resources and services administration as of January twenty-first,

two thousand nineteen.

(F) For purposes of this paragraph, "grandfathered health plan" means

coverage provided by an insurer in which an individual was enrolled on

March twenty-third, two thousand ten for as long as the coverage

maintains grandfathered status in accordance with section 1251(e) of the

Affordable Care Act, 42 U.S.C. § 18011(e).

(18) (A) Every policy which provides coverage for inpatient hospital

care shall provide such coverage for such period as is determined by the

attending physician in consultation with the patient to be medically

appropriate for such covered person undergoing a lymph node dissection

or a lumpectomy for the treatment of breast cancer or a mastectomy

covered by the policy. Such coverage may be subject to annual

deductibles and coinsurance as may be deemed appropriate by the

superintendent and as are consistent with those established for other

benefits within a given policy. Written notice of the availability of

such coverage shall be delivered to the policyholder prior to inception

of such policy and annually thereafter.

(B) An insurer providing coverage under this paragraph and any

participating entity through which the insurer offers health services

shall not:

(i) deny to a covered person eligibility, or continued eligibility, to

enroll or to renew coverage under the terms of the policy or vary the

terms of the policy for the purpose or with the effect of avoiding

compliance with this paragraph;

(ii) provide incentives (monetary or otherwise) to encourage a covered

person to accept less than the minimum protections available under this

paragraph;

(iii) penalize in any way or reduce or limit the compensation of a

health care practitioner for recommending or providing care to a covered

person in accordance with this paragraph;

(iv) provide incentives (monetary or otherwise) to a health care

practitioner relating to the services provided pursuant to this

paragraph intended to induce or have the effect of inducing such

practitioner to provide care to a covered person in a manner

inconsistent with this paragraph; or

(v) restrict coverage for any portion of a period within a hospital

length of stay required under this paragraph in a manner which is

inconsistent with the coverage provided for any preceding portion of

such stay.

(C) The prohibitions in subparagraph (B) of this paragraph shall be in

addition to the provisions of sections three thousand two hundred

thirty-one and three thousand two hundred thirty-two of this article and

nothing in this subparagraph shall be construed to suspend, supersede,

amend or otherwise modify such sections.

(19) (A) Every policy which provides medical, major medical, or

similar comprehensive-type coverage must provide coverage for a second

medical opinion by an appropriate specialist, including but not limited

to a specialist affiliated with a specialty care center for the

treatment of cancer, in the event of a positive or negative diagnosis of

cancer or a recurrence of cancer or a recommendation of a course of

treatment for cancer, subject to the following:

(i) In the case of a policy that requires, or provides financial

incentives for, the insured to receive covered services from health care

providers participating in a provider network maintained by or under

contract with the insurer, the policy shall include coverage for a

second medical opinion from a non-participating specialist, including

but not limited to a specialist affiliated with a specialty care center

for the treatment of cancer, when the attending physician provides a

written referral to a non-participating specialist, at no additional

cost to the insured beyond what such insured would have paid for

services from a participating appropriate specialist. Provided however

that nothing herein shall impair an insured's rights (if any) under the

policy to obtain the second medical opinion from a non-participating

specialist without a written referral, subject to the payment of

additional coinsurance (if any) required by the policy for services

provided by non-participating providers. The insurer shall compensate

the non-participating specialist at the usual, customary and reasonable

rate, or at a rate listed on a fee schedule filed and approved by the

superintendent which provides a comparable level of reimbursement.

(ii) In the case of a policy that does not provide financial

incentives for, and does not require, the insured to receive covered

services from health care providers participating in a provider network

maintained by or under contract with the insurer, the policy shall

include coverage for a second medical opinion from a specialist at no

additional cost to the insured beyond what the insured would have paid

for comparable services covered under the policy.

(iii) Such coverage may be subject to annual deductibles and

coinsurance as may be deemed appropriate by the superintendent and as

are consistent with those established for other benefits within a given

policy, and, where applicable, consistent with the provisions of clauses

(i) and (ii) of this subparagraph.

Nothing in this paragraph shall eliminate or diminish an insurer's

obligation to comply with the provisions of section four thousand eight

hundred four of this chapter where applicable. Written notice of the

availability of such coverage shall be delivered to the policyholder

prior to the inception of such policy and annually thereafter.

(B) An insurer providing coverage under this paragraph and any

participating entity through which the insurer offers health services

shall not:

(i) deny to a covered person eligibility, or continued eligibility, to

enroll or to renew coverage under the terms of the policy or vary the

terms of the policy for the purpose or with the effect of avoiding

compliance with this paragraph;

(ii) provide incentives (monetary or otherwise) to encourage a covered

person to accept less than the minimum protections available under this

paragraph;

(iii) penalize in any way or reduce or limit the compensation of a

health care practitioner for recommending or providing care to a covered

person in accordance with this paragraph; or

(iv) provide incentives (monetary or otherwise) to a health care

practitioner relating to the services provided pursuant to this

paragraph intended to induce or have the effect of inducing such

practitioner to provide care to a covered person in a manner

inconsistent with this paragraph.

(C) The prohibitions in subparagraph (B) of this paragraph shall be in

addition to the provisions of sections three thousand two hundred

thirty-one and three thousand two hundred thirty-two of this article and

nothing in this subparagraph shall be construed to suspend, supersede,

amend or otherwise modify such sections.

(20) (A) Every policy which provides medical, major medical, or

similar comprehensive-type coverage shall provide the following coverage

for breast or chest wall reconstruction surgery after a mastectomy or

partial mastectomy:

(i) all stages of reconstruction of the breast or chest wall on which

the mastectomy or partial mastectomy has been performed; and

(ii) surgery and reconstruction of the other breast or chest wall to

produce a symmetrical appearance;

in the manner determined by the attending physician and the patient to

be appropriate. Chest wall reconstruction surgery shall include

aesthetic flat closure as such term is defined by the National Cancer

Institute. Such coverage may be subject to annual deductibles and

coinsurance provisions as may be deemed appropriate by the

superintendent and as are consistent with those established for other

benefits within a given policy. Written notice of the availability of

such coverage shall be delivered to the policyholder prior to inception

of such policy and annually thereafter.

(A-1) Every policy providing coverage as required by subparagraph (A)

of this paragraph shall also provide coverage for the tattooing of the

nipple-areolar complex pursuant to or as part of such reconstruction if

such tattooing is performed by a licensed physician or other health care

practitioner licensed, certified, or authorized pursuant to title eight

of the education law and acting within their scope of practice.

(B) An insurer providing coverage under this paragraph and any

participating entity through which the insurer offers health services

shall not:

(i) deny to a covered person eligibility, or continued eligibility, to

enroll or to renew coverage under the terms of the policy or vary the

terms of the policy for the purpose or with the effect of avoiding

compliance with this paragraph;

(ii) provide incentives (monetary or otherwise) to encourage a covered

person to accept less than the minimum protections available under this

paragraph;

(iii) penalize in any way or reduce or limit the compensation of a

health care practitioner for recommending or providing care to a covered

person in accordance with this paragraph;

(iv) provide incentives (monetary or otherwise) to a health care

practitioner relating to the services provided pursuant to this

paragraph intended to induce or have the effect of inducing such

practitioner to provide care to a covered person in a manner

inconsistent with this paragraph; or

(v) restrict coverage for any portion of a period within a hospital

length of stay required under this paragraph in a manner which is

inconsistent with the coverage provided for any preceding portion of

such stay.

(C) The prohibitions in this paragraph shall be in addition to the

provisions of sections three thousand two hundred thirty-one and three

thousand two hundred thirty-two of this article and nothing in this

paragraph shall be construed to suspend, supersede, amend or otherwise

modify such sections.

* (21) Every policy that provides coverage for prescription drugs

shall include coverage for the cost of enteral formulas for home use,

whether administered orally or via tube feeding, for which a physician

or other licensed health care provider legally authorized to prescribe

under title eight of the education law has issued a written order. Such

written order shall state that the enteral formula is clearly medically

necessary and has been proven effective as a disease-specific treatment

regimen. Specific diseases and disorders for which enteral formulas have

been proven effective shall include, but are not limited to, inherited

diseases of amino acid or organic acid metabolism; Crohn's Disease;

gastroesophageal reflux; disorders of gastrointestinal motility such as

chronic intestinal pseudo-obstruction; and multiple, severe food

allergies including, but not limited to immunoglobulin E and

nonimmunoglobulin E-mediated allergies to multiple food proteins; severe

food protein induced enterocolitis syndrome; eosinophilic disorders; and

impaired absorption of nutrients caused by disorders affecting the

absorptive surface, function, length, and motility of the

gastrointestinal tract. Enteral formulas that are medically necessary

and taken under written order from a physician for the treatment of

specific diseases shall be distinguished from nutritional supplements

taken electively. Coverage for certain inherited diseases of amino acid

and organic acid metabolism as well as severe protein allergic

conditions shall include modified solid food products that are low

protein, contain modified protein, or are amino acid based that are

medically necessary.

* NB There are 2 par (21)'s

* (21)(A) Every policy which is a "managed care product" as defined in

subparagraph (D) of this paragraph that provides coverage for physician

services in a physician's office, and every policy which is a "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.

(C) Every policy which includes coverage for physician services in a

physician's office, and every policy which provides major medical or

similar comprehensive-type coverage, other than a "managed care product"

as defined in subparagraph (D) of this paragraph, shall provide 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.

(D) For purposes of this paragraph, a "managed care product" shall

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 a referral be rendered by a

health care provider participating in the insurer's managed care

provider network. In addition, 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.

(E) The coverage required by this paragraph shall not be abridged by

any regulation promulgated by the superintendent.

* NB There are 2 par (21)'s

(22) No policy shall exclude coverage of a health care service, as

defined in paragraph two of subsection (e) of section four thousand nine

hundred of this chapter, rendered or proposed to be rendered to an

insured on the basis that such service is experimental or

investigational, is rendered as part of a clinical trial as defined in

subsection (b-2) of section forty-nine hundred of this chapter, or a

prescribed pharmaceutical product referenced in subparagraph (B) of

paragraph two of subsection (e) of section forty-nine hundred of this

chapter provided that coverage of the patient costs of such service has

been recommended for the insured by an external appeal agent upon an

appeal conducted pursuant to subparagraph (B) of paragraph four of

subsection (b) of section four thousand nine hundred fourteen of this

chapter. The determination of the external appeal agent shall be binding

on the parties. For purposes of this paragraph, patient costs shall have

the same meaning as such term has for purposes of subparagraph (B) of

paragraph four of subsection (b) of section four thousand nine hundred

fourteen of this chapter; provided, however, that coverage for the

services required under this paragraph shall be provided subject to the

terms and conditions generally applicable to other benefits provided

under the policy.

(23) If a policy provides for reimbursement for physical and

occupational therapy service which is within the lawful scope of

practice of a duly licensed physical or occupational therapist, an

insured shall be entitled to reimbursement for such service whether the

said service is performed by a physician or through a duly licensed

physical or occupational therapist, provided however, that nothing

contained herein shall be construed to impair any terms of such policy

including appropriate utilization review and the requirement that said

service be performed pursuant to a medical order, or a similar or

related service of a physician.

(24)(A) Every policy which provides major medical or similar

comprehensive-type coverage shall include coverage for prehospital

emergency medical services for the treatment of an emergency condition

when such services are provided by an ambulance service issued a

certificate to operate pursuant to section three thousand five of the

public health law.

(B) Payment by an insurer pursuant to this section shall be payment in

full for the services provided. An ambulance service reimbursed pursuant

to this section shall not charge or seek any reimbursement from, or have

any recourse against an insured for the services provided pursuant to

this paragraph, except for the collection of copayments, coinsurance or

deductibles for which the insured is responsible for under the terms of

the policy.

(C) An insurer shall provide reimbursement for those services

prescribed by this section at rates negotiated between the insurer and

the provider of such services. In the absence of agreed upon rates, an

insurer shall pay for such services at the usual and customary charge,

which shall not be excessive or unreasonable. The insurer shall send

such payments directly to the provider of such ambulance services, if

the ambulance service has on file an executed assignment of benefits

form with the claim.

(D) The provisions of this paragraph shall have no application to

transfers of patients between hospitals or health care facilities by an

ambulance service as described in subparagraph (A) of this paragraph

unless such services are covered under the policy.

(E) As used in this paragraph:

(i) "Prehospital emergency medical services" means the prompt

evaluation and treatment of an emergency medical condition, and/or

non-air-borne transportation of the patient to a hospital, provided

however, where the patient utilizes non-air-borne emergency

transportation pursuant to this paragraph, reimbursement shall be based

on whether a prudent layperson, possessing an average knowledge of

medicine and health, could reasonably expect the absence of such

transportation to result in (I) placing the health of the person

afflicted with such condition in serious jeopardy, or in the case of a

behavioral condition placing the health of such person or others in

serious jeopardy; (II) serious impairment to such person's bodily

functions; (III) serious dysfunction of any bodily organ or part of such

person; (IV) serious disfigurement of such person; or (V) a condition

described in clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the

Social Security Act.

(ii) "Emergency condition" means a medical or behavioral condition

that manifests itself by acute symptoms of sufficient severity,

including severe pain, such that a prudent layperson, possessing an

average knowledge of medicine and health, could reasonably expect the

absence of immediate medical attention to result in (I) placing the

health of the person afflicted with such condition in serious jeopardy,

or in the case of a behavioral condition placing the health of such

person or others in serious jeopardy; (II) serious impairment to such

person's bodily functions; (III) serious dysfunction of any bodily organ

or part of such person; (IV) serious disfigurement of such person; or

(V) a condition described in clause (i), (ii), or (iii) of section

1867(e)(1)(A) of the Social Security Act.

(25) (A) Every policy which provides coverage for hospital or surgical

coverage shall not exclude coverage for screening, diagnosis and

treatment of medical conditions otherwise covered by the policy solely

because the treatment is provided to diagnose or treat autism spectrum

disorder.

(B) Every policy that provides physician services, medical, major

medical or similar comprehensive-type coverage shall provide coverage

for the screening, diagnosis and treatment of autism spectrum disorder

in accordance with this paragraph and shall not exclude coverage for the

screening, diagnosis or treatment of medical conditions otherwise

covered by the policy because the individual is diagnosed with autism

spectrum disorder. Such coverage may be subject to annual deductibles,

copayments and coinsurance as may be deemed appropriate by the

superintendent and shall be consistent with those imposed on other

benefits under the policy. This paragraph shall not be construed as

limiting the benefits that are otherwise available to an individual

under the policy, provided however that such policy shall not contain

any limitations on visits that are solely applied to the treatment of

autism spectrum disorder. No insurer shall terminate coverage or refuse

to deliver, execute, issue, amend, adjust, or renew coverage to an

individual solely because the individual is diagnosed with autism

spectrum disorder or has received treatment for autism spectrum

disorder. Coverage shall be subject to utilization review and external

appeals of health care services pursuant to article forty-nine of this

chapter as well as case management and other managed care provisions.

(C) For purposes of this paragraph:

(i) "autism spectrum disorder" means any pervasive developmental

disorder as defined in the most recent edition of the diagnostic and

statistical manual of mental disorders.

(ii) "applied behavior analysis" means the design, implementation, and

evaluation of environmental modifications, using behavioral stimuli and

consequences, to produce socially significant improvement in human

behavior, including the use of direct observation, measurement, and

functional analysis of the relationship between environment and

behavior.

(iii) "behavioral health treatment" means counseling and treatment

programs, when provided by a licensed provider, and applied behavior

analysis, when provided by a person licensed, certified or otherwise

authorized to provide applied behavior analysis, that are necessary to

develop, maintain, or restore, to the maximum extent practicable, the

functioning of an individual.

(iv) "diagnosis of autism spectrum disorder" means assessments,

evaluations, or tests to diagnose whether an individual has autism

spectrum disorder.

(v) "pharmacy care" means medications prescribed by a licensed health

care provider legally authorized to prescribe under title eight of the

education law.

(vi) "psychiatric care" means direct or consultative services provided

by a psychiatrist licensed in the state in which the psychiatrist

practices.

(vii) "psychological care" means direct or consultative services

provided by a psychologist licensed in the state in which the

psychologist practices.

(viii) "therapeutic care" means services provided by licensed or

certified speech therapists, occupational therapists, social workers, or

physical therapists.

(ix) "treatment of autism spectrum disorder" shall include the

following care and assistive communication devices prescribed or ordered

for an individual diagnosed with autism spectrum disorder by a licensed

physician or a licensed psychologist:

(1) behavioral health treatment;

(2) psychiatric care;

(3) psychological care;

(4) medical care provided by a licensed health care provider;

(5) therapeutic care, including therapeutic care which is deemed

habilitative or nonrestorative, in the event that the policy provides

coverage for therapeutic care; and

(6) pharmacy care in the event that the policy provides coverage for

prescription drugs.

(D) Coverage may be denied on the basis that such treatment is being

provided to the covered person pursuant to an individualized education

plan under article eighty-nine of the education law. The provision of

services pursuant to an individualized family service plan under section

twenty-five hundred forty-five of the public health law, an

individualized education plan under article eighty-nine of the education

law, or an individualized service plan pursuant to regulations of the

office for persons with developmental disabilities shall not affect

coverage under the policy for services provided on a supplemental basis

outside of an educational setting if such services are prescribed by a

licensed physician or licensed psychologist.

(E) Nothing in this paragraph shall be construed to affect any

obligation to provide services to an individual under an individualized

family service plan under section twenty-five hundred forty-five of the

public health law, an individualized education plan under article

eighty-nine of the education law, or an individualized service plan

pursuant to regulations of the office for persons with developmental

disabilities.

(G) Nothing in this paragraph shall be construed to prevent a policy

from providing services through a network of participating providers who

shall meet certain requirements for participation, including provider

credentialing.

(H) Coverage under this paragraph shall not apply financial

requirements or treatment limitations to autism spectrum disorder

benefits that are more restrictive than the predominant financial

requirements and treatment limitations applied to substantially all

medical and surgical benefits covered by the policy.

(I) The criteria for medical necessity determinations under the policy

with respect to autism spectrum disorder benefits shall be made

available by the insurer to any insured, prospective insured, or

in-network provider upon request.

(J) For purposes of this paragraph:

(i) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(ii) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement; and

(iii) "treatment limitation" means limits on the frequency of

treatment, number of visits, days of coverage, or other similar limits

on the scope or duration of treatment and includes nonquantitative

treatment limitations such as: medical management standards limiting or

excluding benefits based on medical necessity, or based on whether the

treatment is experimental or investigational; formulary design for

prescription drugs; network tier design; standards for provider

admission to participate in a network, including reimbursement rates;

methods for determining usual, customary, and reasonable charges;

fail-first or step therapy protocols; exclusions based on failure to

complete a course of treatment; and restrictions based on geographic

location, facility type, provider specialty, and other criteria that

limit the scope or duration of benefits for services provided under the

policy.

(K) An insurer shall provide coverage under this paragraph, at a

minimum, consistent with the federal Paul Wellstone and Pete Domenici

Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §

1185a).

(26)(A) No managed care health insurance policy that provides coverage

for hospital, medical or surgical care shall provide that services of a

participating hospital will be covered as out-of-network services solely

on the basis that the health care provider admitting or rendering

services to the insured is not a participating provider.

(B) No managed care health insurance policy that provides coverage for

hospital, medical or surgical care shall provide that services of a

participating health care provider will be covered as out-of-network

services solely on the basis that the services are rendered in a

non-participating hospital.

(C) For purposes of this paragraph, a "health care provider" is a

health care professional licensed, registered or certified pursuant to

title eight of the education law or a health care professional

comparably licensed, registered or certified by another state.

(D) For purposes of this paragraph, a "managed care health insurance

policy" is a policy that requires that services be provided by a

provider participating in the insurer's network in order for the insured

to receive the maximum level of reimbursement under the policy.

(27) No policy delivered or issued for delivery in this state which

provides coverage for prescription drugs and for which cost-sharing,

deductibles or co-insurance obligations are determined by category of

prescription drugs shall impose cost-sharing, deductibles or

co-insurance obligations for any prescription drug that exceeds the

dollar amount of cost-sharing, deductibles or co-insurance obligations

for non-preferred brand drugs or its equivalent (or brand drugs if there

is no non-preferred brand drug category).

(28) Notwithstanding title eleven of article five of the social

services law or any other law to the contrary, every policy which

provides coverage for prescription drugs shall, with regard to eye drop

medication requiring a prescription that has been approved by the

insurer for coverage, allow for the limited refilling of the

prescription prior to the last day of the approved dosage period without

regard to any coverage restrictions on early refill of renewals.

Provided, however, that any refill dispensed prior to the expiration of

the prescribed and approved coverage period pursuant to this paragraph,

shall, to the extent practicable, be limited in quantity so as not to

exceed the remaining dosage initially approved for coverage. Provided,

further, that such limited refilling shall not limit or restrict

coverage with regard to any previously or subsequently approved

prescription for eye drop medication and shall be subject to the terms

and conditions of the policy otherwise applicable to this coverage.

Provided, further, that a pharmacist may contact the prescribing

physician or health care provider to verify the prescription.

(29) Every individual policy which provides medical, major medical or

similar comprehensive-type coverage that includes coverage for a

physical or well care visit once in every three hundred sixty-five days

shall be interpreted to mean that such physical or well care visit can

be had once every calendar year, regardless of whether or not a period

of three hundred sixty-five days has passed since the previous physical

or well care visit.

* (30)(A) Every policy that provides hospital, major medical or

similar comprehensive coverage shall provide inpatient coverage for the

diagnosis and treatment of substance use disorder, including

detoxification and rehabilitation services. Such inpatient coverage

shall include unlimited medically necessary treatment for substance use

disorder treatment services provided in residential settings. Further,

such inpatient coverage shall not apply financial requirements or

treatment limitations, including utilization review requirements, to

inpatient substance use disorder benefits that are more restrictive than

the predominant financial requirements and treatment limitations applied

to substantially all medical and surgical benefits covered by the

policy.

(B) Coverage provided under this paragraph may be limited to

facilities in New York state that are licensed, certified or otherwise

authorized by the office of alcoholism and substance abuse services and,

in other states, to those which are accredited by the joint commission

as alcoholism, substance abuse, or chemical dependence treatment

programs and are similarly licensed, certified or otherwise authorized

in the state in which the facility is located.

(C) Coverage provided under this paragraph may be subject to annual

deductibles and co-insurance as deemed appropriate by the superintendent

and that are consistent with those imposed on other benefits within a

given policy.

(D) This subparagraph shall apply to facilities in this state that are

licensed, certified or otherwise authorized by the office of alcoholism

and substance abuse services that are participating in the insurer's

provider network. Coverage provided under this paragraph shall not be

subject to preauthorization. Coverage provided under this paragraph

shall also not be subject to concurrent utilization review during the

first twenty-eight days of the inpatient admission provided that the

facility notifies the insurer of both the admission and the initial

treatment plan within two business days of the admission. The facility

shall perform daily clinical review of the patient, including periodic

consultation with the insurer at or just prior to the fourteenth day of

treatment to ensure that the facility is using the evidence-based and

peer reviewed clinical review tool utilized by the insurer which is

designated by the office of alcoholism and substance abuse services and

appropriate to the age of the patient, to ensure that the inpatient

treatment is medically necessary for the patient. Prior to discharge,

the facility shall provide the patient and the insurer with a written

discharge plan which shall describe arrangements for additional services

needed following discharge from the inpatient facility as determined

using the evidence-based and peer-reviewed clinical review tool utilized

by the insurer which is designated by the office of alcoholism and

substance abuse services. Prior to discharge, the facility shall

indicate to the insurer whether services included in the discharge plan

are secured or determined to be reasonably available. Any utilization

review of treatment provided under this subparagraph may include a

review of all services provided during such inpatient treatment,

including all services provided during the first twenty-eight days of

such inpatient treatment. Provided, however, the insurer shall only deny

coverage for any portion of the initial twenty-eight day inpatient

treatment on the basis that such treatment was not medically necessary

if such inpatient treatment was contrary to the evidence-based and peer

reviewed clinical review tool utilized by the insurer which is

designated by the office of alcoholism and substance abuse services. An

insured shall not have any financial obligation to the facility for any

treatment under this subparagraph other than any copayment, coinsurance,

or deductible otherwise required under the policy.

(E) An insurer shall make available to any insured, prospective

insured, or in-network provider, upon request, the criteria for medical

necessity determinations under the policy with respect to inpatient

substance use disorder benefits.

(F) For purposes of this paragraph:

(i) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(ii) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement;

(iii) "treatment limitation" means limits on the frequency of

treatment, number of visits, days of coverage, or other similar limits

on the scope or duration of treatment and includes nonquantitative

treatment limitations such as: medical management standards limiting or

excluding benefits based on medical necessity, or based on whether the

treatment is experimental or investigational; formulary design for

prescription drugs; network tier design; standards for provider

admission to participate in a network, including reimbursement rates;

methods for determining usual, customary, and reasonable charges;

fail-first or step therapy protocols; exclusions based on failure to

complete a course of treatment; and restrictions based on geographic

location, facility type, provider specialty, and other criteria that

limit the scope or duration of benefits for services provided under the

policy; and

(iv) "substance use disorder" shall have the meaning set forth in the

most recent edition of the diagnostic and statistical manual of mental

disorders or the most recent edition of another generally recognized

independent standard of current medical practice, such as the

international classification of diseases.

(G) An insurer shall provide coverage under this paragraph, at a

minimum, consistent with the federal Paul Wellstone and Pete Domenici

Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §

1185a).

* NB Effective until January 1, 2027

* (30)(A) Every policy that provides hospital, major medical or

similar comprehensive coverage shall provide inpatient coverage for the

diagnosis and treatment of substance-related and addictive disorder,

including detoxification and rehabilitation services. Such inpatient

coverage shall include unlimited medically necessary treatment for

substance-related and addictive disorder treatment services provided in

residential settings. Further, such inpatient coverage shall not apply

financial requirements or treatment limitations, including utilization

review requirements, to inpatient substance-related and addictive

disorder benefits that are more restrictive than the predominant

financial requirements and treatment limitations applied to

substantially all medical and surgical benefits covered by the policy.

(B) Coverage provided under this paragraph may be limited to

facilities in New York state that are licensed, certified or otherwise

authorized by the office of addiction services and supports and, in

other states, to those which are accredited by the joint commission as

alcoholism, addiction, substance abuse, or chemical dependence treatment

programs and are similarly licensed, certified or otherwise authorized

in the state in which the facility is located.

(C) Coverage provided under this paragraph may be subject to annual

deductibles and co-insurance as deemed appropriate by the superintendent

and that are consistent with those imposed on other benefits within a

given policy.

(D) This subparagraph shall apply to facilities in this state that are

licensed, certified or otherwise authorized by the office of addiction

services and supports that are participating in the insurer's provider

network. Coverage provided under this paragraph shall not be subject to

preauthorization. Coverage provided under this paragraph shall also not

be subject to concurrent utilization review during the first

twenty-eight days of the inpatient admission provided that the facility

notifies the insurer of both the admission and the initial treatment

plan within two business days of the admission. The facility shall

perform daily clinical review of the patient, including periodic

consultation with the insurer at or just prior to the fourteenth day of

treatment to ensure that the facility is using the evidence-based and

peer reviewed clinical review tool utilized by the insurer which is

designated by the office of addiction services and supports and

appropriate to the age of the patient, to ensure that the inpatient

treatment is medically necessary for the patient. Prior to discharge,

the facility shall provide the patient and the insurer with a written

discharge plan which shall describe arrangements for additional services

needed following discharge from the inpatient facility as determined

using the evidence-based and peer-reviewed clinical review tool utilized

by the insurer which is designated by the office of addiction services

and supports. Prior to discharge, the facility shall indicate to the

insurer whether services included in the discharge plan are secured or

determined to be reasonably available. Any utilization review of

treatment provided under this subparagraph may include a review of all

services provided during such inpatient treatment, including all

services provided during the first twenty-eight days of such inpatient

treatment. Provided, however, the insurer shall only deny coverage for

any portion of the initial twenty-eight day inpatient treatment on the

basis that such treatment was not medically necessary if such inpatient

treatment was contrary to the evidence-based and peer reviewed clinical

review tool utilized by the insurer which is designated by the office of

addiction services and supports. An insured shall not have any financial

obligation to the facility for any treatment under this subparagraph

other than any copayment, coinsurance, or deductible otherwise required

under the policy.

(E) An insurer shall make available to any insured, prospective

insured, or in-network provider, upon request, the criteria for medical

necessity determinations under the policy with respect to inpatient

substance-related and addictive disorder benefits.

(F) For purposes of this paragraph:

(i) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(ii) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement;

(iii) "treatment limitation" means limits on the frequency of

treatment, number of visits, days of coverage, or other similar limits

on the scope or duration of treatment and includes nonquantitative

treatment limitations such as: medical management standards limiting or

excluding benefits based on medical necessity, or based on whether the

treatment is experimental or investigational; formulary design for

prescription drugs; network tier design; standards for provider

admission to participate in a network, including reimbursement rates;

methods for determining usual, customary, and reasonable charges;

fail-first or step therapy protocols; exclusions based on failure to

complete a course of treatment; and restrictions based on geographic

location, facility type, provider specialty, and other criteria that

limit the scope or duration of benefits for services provided under the

policy; and

(iv) " substance-related and addictive disorder" shall have the

meaning set forth in the most recent edition of the diagnostic and

statistical manual of mental disorders or the most recent edition of

another generally recognized independent standard of current medical

practice, such as the international classification of diseases.

(G) An insurer shall provide coverage under this paragraph, at a

minimum, consistent with the federal Paul Wellstone and Pete Domenici

Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §

1185a).

* NB Effective January 1, 2027

* NB There are 2 par (30)'s

* (30) Every policy that provides medical coverage that includes

coverage for physician services in a physician's office and every policy

that provides major medical or similar comprehensive-type coverage shall

include coverage for equipment and supplies used for the treatment of

ostomies, if prescribed by a physician or other licensed health care

provider legally authorized to prescribe under title eight of the

education law. Such coverage shall be subject to annual deductibles and

coinsurance as deemed appropriate by the superintendent. The coverage

required by this paragraph shall be identical to, and shall not enhance

or increase the coverage required as part of essential health benefits

as defined in subsection (a) of section three thousand two hundred

seventeen-i of this article.

* NB There are 2 par (30)'s

* (31) (A) Every policy that provides medical, major medical or

similar comprehensive-type coverage shall provide outpatient coverage

for the diagnosis and treatment of substance use disorder, including

detoxification and rehabilitation services. Such coverage shall not

apply financial requirements or treatment limitations to outpatient

substance use disorder benefits that are more restrictive than the

predominant financial requirements and treatment limitations applied to

substantially all medical and surgical benefits covered by the policy.

(B) Coverage under this paragraph may be limited to facilities in this

state that are licensed, certified or otherwise authorized by the office

of addiction services and supports to provide outpatient substance use

disorder services and crisis stabilization centers licensed pursuant to

section 36.01 of the mental hygiene law, and, in other states, to those

which are accredited by the joint commission as alcoholism or chemical

dependence substance abuse treatment programs and are similarly

licensed, certified, or otherwise authorized in the state in which the

facility is located.

(C) Coverage provided under this paragraph may be subject to annual

deductibles and co-insurance as deemed appropriate by the superintendent

and that are consistent with those imposed on other benefits within a

given policy.

(D) A policy providing coverage for substance use disorder services

pursuant to this paragraph shall provide up to twenty outpatient visits

per policy or calendar year to an individual who identifies him or

herself as a family member of a person suffering from substance use

disorder and who seeks treatment as a family member who is otherwise

covered by the applicable policy pursuant to this paragraph. The

coverage required by this paragraph shall include treatment as a family

member pursuant to such family member's own policy provided such family

member:

(i) does not exceed the allowable number of family visits provided by

the applicable policy pursuant to this paragraph; and

(ii) is otherwise entitled to coverage pursuant to this paragraph and

such family member's applicable policy.

(E) This subparagraph shall apply to facilities in this state that are

licensed, certified or otherwise authorized by the office of alcoholism

and substance abuse services for the provision of outpatient, intensive

outpatient, outpatient rehabilitation and opioid treatment that are

participating in the insurer's provider network. Coverage provided under

this paragraph shall not be subject to preauthorization. Coverage

provided under this paragraph shall not be subject to concurrent review

for the first four weeks of continuous treatment, not to exceed

twenty-eight visits, provided the facility notifies the insurer of both

the start of treatment and the initial treatment plan within two

business days. The facility shall perform clinical assessment of the

patient at each visit, including periodic consultation with the insurer

at or just prior to the fourteenth day of treatment to ensure that the

facility is using the evidence-based and peer reviewed clinical review

tool utilized by the insurer which is designated by the office of

alcoholism and substance abuse services and appropriate to the age of

the patient, to ensure that the outpatient treatment is medically

necessary for the patient. Any utilization review of the treatment

provided under this subparagraph may include a review of all services

provided during such outpatient treatment, including all services

provided during the first four weeks of continuous treatment, not to

exceed twenty-eight visits, of such outpatient treatment. Provided,

however, the insurer shall only deny coverage for any portion of the

initial four weeks of continuous treatment, not to exceed twenty-eight

visits, for outpatient treatment on the basis that such treatment was

not medically necessary if such outpatient treatment was contrary to the

evidence-based and peer reviewed clinical review tool utilized by the

insurer which is designated by the office of alcoholism and substance

abuse services. An insured shall not have any financial obligation to

the facility for any treatment under this subparagraph other than any

copayment, coinsurance, or deductible otherwise required under the

policy.

(F) The criteria for medical necessity determinations under the policy

with respect to outpatient substance use disorder benefits shall be made

available by the insurer to any insured, prospective insured, or

in-network provider upon request.

(G) For purposes of this paragraph:

(i) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(ii) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement;

(iii) "treatment limitation" means limits on the frequency of

treatment, number of visits, days of coverage, or other similar limits

on the scope or duration of treatment and includes nonquantitative

treatment limitations such as: medical management standards limiting or

excluding benefits based on medical necessity, or based on whether the

treatment is experimental or investigational; formulary design for

prescription drugs; network tier design; standards for provider

admission to participate in a network, including reimbursement rates;

methods for determining usual, customary, and reasonable charges;

fail-first or step therapy protocols; exclusions based on failure to

complete a course of treatment; and restrictions based on geographic

location, facility type, provider specialty, and other criteria that

limit the scope or duration of benefits for services provided under the

policy; and

(iv) "substance use disorder" shall have the meaning set forth in the

most recent edition of the diagnostic and statistical manual of mental

disorders or the most recent edition of another generally recognized

independent standard of current medical practice such as the

international classification of diseases.

(H) An insurer shall provide coverage under this paragraph, at a

minimum, consistent with the federal Paul Wellstone and Pete Domenici

Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §

1185a).

(I) This subparagraph shall apply to crisis stabilization centers in

this state that are licensed pursuant to section 36.01 of the mental

hygiene law and participate in the insurer's provider network. Benefits

for care in a crisis stabilization center shall not be subject to

preauthorization. All treatment provided under this subparagraph may be

reviewed retrospectively. Where care is denied retrospectively, an

insured shall not have any financial obligation to the facility for any

treatment under this subparagraph other than any copayment, coinsurance,

or deductible otherwise required under the policy.

(J) (i) This clause shall apply to facilities in this state that are

licensed, certified, or otherwise authorized by the office of addiction

services and supports for the provision of outpatient, intensive

outpatient, outpatient rehabilitation and opioid treatment that are

participating in the insurer's provider network. Reimbursement for

covered outpatient treatment provided by such facilities shall be at

rates negotiated between the insurer and the participating facility,

provided that such rates are not less than the rates that would be paid

for such treatment pursuant to the medical assistance program under

title eleven of article five of the social services law. For the

purposes of this clause, the rates that would be paid for such treatment

pursuant to the medical assistance program under title eleven of article

five of the social services law shall be the rates with an effective

date of April first of the preceding year, which shall be established

prior to October first of the preceding calendar year.

(ii) The office of addiction services and supports shall publish

information adequate to calculate the rates that would be paid for such

treatment pursuant to the medical assistance program under title eleven

of article five of the social services law. Such information shall be

provided in a form and manner to be determined by the commissioner of

addiction services and supports. Nothing in this clause shall be

construed to relieve an insurer of the obligation to reimburse at no

less than the applicable minimum rate set forth in clause (i) of this

subparagraph. Prior to the submission of premium rate filings and

applications, the superintendent shall provide insurers with guidance on

factors to consider in calculating the impact of rate changes for the

purposes of submitting premium rate filings and applications to the

superintendent for the subsequent policy year. To the extent that the

rates with an effective date of April first differ from the estimated

rates incorporated in premium rate filings and applications, insurers

may account for such differences in future premium rate filings and

applications submitted to the superintendent for approval.

* NB Effective until January 1, 2027

* (31) (A) Every policy that provides medical, major medical or

similar comprehensive-type coverage shall provide outpatient coverage

for the diagnosis and treatment of substance-related and addictive

disorder, including detoxification and rehabilitation services. Such

coverage shall not apply financial requirements or treatment limitations

to outpatient substance-related and addictive disorder benefits that are

more restrictive than the predominant financial requirements and

treatment limitations applied to substantially all medical and surgical

benefits covered by the policy.

(B) Coverage under this paragraph may be limited to facilities in this

state that are licensed, certified or otherwise authorized by the office

of addiction services and supports to provide outpatient

substance-related and addictive disorder services and crisis

stabilization centers licensed pursuant to section 36.01 of the mental

hygiene law, and, in other states, to those which are accredited by the

joint commission as alcoholism, addiction or chemical dependence

substance abuse treatment programs and are similarly licensed,

certified, or otherwise authorized in the state in which the facility is

located.

(C) Coverage provided under this paragraph may be subject to annual

deductibles and co-insurance as deemed appropriate by the superintendent

and that are consistent with those imposed on other benefits within a

given policy.

(D) A policy providing coverage for substance-related and addictive

disorder services pursuant to this paragraph shall provide up to twenty

outpatient visits per policy or calendar year to an individual who

identifies themselves as a family member of a person suffering from

substance-related and addictive disorder and who seeks treatment as a

family member who is otherwise covered by the applicable policy pursuant

to this paragraph. The coverage required by this paragraph shall include

treatment as a family member pursuant to such family member's own policy

provided such family member:

(i) does not exceed the allowable number of family visits provided by

the applicable policy pursuant to this paragraph; and

(ii) is otherwise entitled to coverage pursuant to this paragraph and

such family member's applicable policy.

(E) This subparagraph shall apply to facilities in this state that are

licensed, certified or otherwise authorized by the office of addiction

services and supports for the provision of outpatient, intensive

outpatient, outpatient rehabilitation and opioid treatment that are

participating in the insurer's provider network. Coverage provided under

this paragraph shall not be subject to preauthorization. Coverage

provided under this paragraph shall not be subject to concurrent review

for the first four weeks of continuous treatment, not to exceed

twenty-eight visits, provided the facility notifies the insurer of both

the start of treatment and the initial treatment plan within two

business days. The facility shall perform clinical assessment of the

patient at each visit, including periodic consultation with the insurer

at or just prior to the fourteenth day of treatment to ensure that the

facility is using the evidence-based and peer reviewed clinical review

tool utilized by the insurer which is designated by the office of

addiction services and supports and appropriate to the age of the

patient, to ensure that the outpatient treatment is medically necessary

for the patient. Any utilization review of the treatment provided under

this subparagraph may include a review of all services provided during

such outpatient treatment, including all services provided during the

first four weeks of continuous treatment, not to exceed twenty-eight

visits, of such outpatient treatment. Provided, however, the insurer

shall only deny coverage for any portion of the initial four weeks of

continuous treatment, not to exceed twenty-eight visits, for outpatient

treatment on the basis that such treatment was not medically necessary

if such outpatient treatment was contrary to the evidence-based and peer

reviewed clinical review tool utilized by the insurer which is

designated by the office of addiction services and supports. An insured

shall not have any financial obligation to the facility for any

treatment under this subparagraph other than any copayment, coinsurance,

or deductible otherwise required under the policy.

(F) The criteria for medical necessity determinations under the policy

with respect to outpatient substance-related and addictive disorder

benefits shall be made available by the insurer to any insured,

prospective insured, or in-network provider upon request.

(G) For purposes of this paragraph:

(i) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(ii) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement;

(iii) "treatment limitation" means limits on the frequency of

treatment, number of visits, days of coverage, or other similar limits

on the scope or duration of treatment and includes nonquantitative

treatment limitations such as: medical management standards limiting or

excluding benefits based on medical necessity, or based on whether the

treatment is experimental or investigational; formulary design for

prescription drugs; network tier design; standards for provider

admission to participate in a network, including reimbursement rates;

methods for determining usual, customary, and reasonable charges;

fail-first or step therapy protocols; exclusions based on failure to

complete a course of treatment; and restrictions based on geographic

location, facility type, provider specialty, and other criteria that

limit the scope or duration of benefits for services provided under the

policy; and

(iv) "substance-related and addictive disorder" shall have the meaning

set forth in the most recent edition of the diagnostic and statistical

manual of mental disorders or the most recent edition of another

generally recognized independent standard of current medical practice

such as the international classification of diseases.

(H) An insurer shall provide coverage under this paragraph, at a

minimum, consistent with the federal Paul Wellstone and Pete Domenici

Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §

1185a).

(I) This subparagraph shall apply to crisis stabilization centers in

this state that are licensed pursuant to section 36.01 of the mental

hygiene law and participate in the insurer's provider network. Benefits

for care in a crisis stabilization center shall not be subject to

preauthorization. All treatment provided under this subparagraph may be

reviewed retrospectively. Where care is denied retrospectively, an

insured shall not have any financial obligation to the facility for any

treatment under this subparagraph other than any copayment, coinsurance,

or deductible otherwise required under the policy.

(J) (i) This clause shall apply to facilities in this state that are

licensed, certified, or otherwise authorized by the office of addiction

services and supports for the provision of outpatient, intensive

outpatient, outpatient rehabilitation and opioid treatment that are

participating in the insurer's provider network. Reimbursement for

covered outpatient treatment provided by such facilities shall be at

rates negotiated between the insurer and the participating facility,

provided that such rates are not less than the rates that would be paid

for such treatment pursuant to the medical assistance program under

title eleven of article five of the social services law. For the

purposes of this clause, the rates that would be paid for such treatment

pursuant to the medical assistance program under title eleven of article

five of the social services law shall be the rates with an effective

date of April first of the preceding year, which shall be established

prior to October first of the preceding calendar year.

(ii) The office of addiction services and supports shall publish

information adequate to calculate the rates that would be paid for such

treatment pursuant to the medical assistance program under title eleven

of article five of the social services law. Such information shall be

provided in a form and manner to be determined by the commissioner of

addiction services and supports. Nothing in this clause shall be

construed to relieve an insurer of the obligation to reimburse at no

less than the applicable minimum rate set forth in clause (i) of this

subparagraph. Prior to the submission of premium rate filings and

applications, the superintendent shall provide insurers with guidance on

factors to consider in calculating the impact of rate changes for the

purposes of submitting premium rate filings and applications to the

superintendent for the subsequent policy year. To the extent that the

rates with an effective date of April first differ from the estimated

rates incorporated in premium rate filings and applications, insurers

may account for such differences in future premium rate filings and

applications submitted to the superintendent for approval.

* NB Effective January 1, 2027

* (31-a) (A) No policy that provides medical, major medical or similar

comprehensive-type coverage and provides coverage for prescription drugs

for medication for the treatment of a substance use disorder shall

require prior authorization for an initial or renewal prescription for

the detoxification or maintenance treatment of a substance use disorder,

including all buprenorphine products, methadone, long acting injectable

naltrexone, or medication for opioid overdose reversal prescribed or

dispensed to an insured covered under the policy, including federal food

and drug administration-approved over-the-counter opioid overdose

reversal medication as prescribed, dispensed or as otherwise authorized

under state or federal law, except where otherwise prohibited by law.

(B) Coverage provided under this paragraph may be subject to

copayments, coinsurance, and annual deductibles that are consistent with

those imposed on other benefits within the policy.

* NB Effective until January 1, 2027

* (31-a) (A) No policy that provides medical, major medical or similar

comprehensive-type coverage and provides coverage for prescription drugs

for medication for the treatment of a substance-related and addictive

disorder shall require prior authorization for an initial or renewal

prescription for the detoxification or maintenance treatment of a

substance-related and addictive disorder, including all buprenorphine

products, methadone, long acting injectable naltrexone, or medication

for opioid overdose reversal prescribed or dispensed to an insured

covered under the policy, including federal food and drug

administration-approved over-the-counter opioid overdose reversal

medication as prescribed, dispensed or as otherwise authorized under

state or federal law, except where otherwise prohibited by law.

(B) Coverage provided under this paragraph may be subject to

copayments, coinsurance, and annual deductibles that are consistent with

those imposed on other benefits within the policy.

* NB Effective January 1, 2027

(31-b) Every policy that provides coverage for treatment at an opioid

treatment program shall not impose a co-payment fee during the course of

treatment on any insured for such treatment. For the purposes of this

section "opioid treatment program" means a program or practitioner

engaged in opioid treatment of individuals with an opioid agonist

treatment medication.

(32) No policy delivered or issued for delivery in this state that

provides reimbursement for non-physician surgical first assistant

services when the services are provided by a non-physician surgical

first assistant shall exclude such coverage on the basis that the

non-physician surgical first assistant services were performed by a

registered nurse first assistant provided that: (A) the registered nurse

first assistant is certified in operating room nursing; (B) the services

are within the scope of practice of a non-physician surgical first

assistant; and (C) the terms and conditions of the policy otherwise

provide for the coverage of the services. Nothing in this paragraph

shall be construed to prevent the medical management or utilization

review of the services or prevent a policy from requiring that services

are to be provided through a network of participating providers who meet

certain requirements for participation, including provider

credentialing.

* (33) Every policy delivered or issued for delivery in this state

that provides coverage for prescription drugs subject to a copayment

shall charge a copayment for a limited initial prescription of an opioid

drug, which is prescribed in accordance with paragraph (b) of

subdivision five of section thirty-three hundred one of the public

health law, that is either (i) proportional between the copayment for a

thirty-day supply and the amount of drugs the patient was prescribed; or

(ii) equivalent to the copayment for a full thirty-day supply of the

opioid drug, provided that no additional copayments may be charged for

any additional prescriptions for the remainder of the thirty-day supply.

* NB There are 2 par (33)'s

* (33) Whenever in this section an insurer is required to provide

benefits with no coinsurance or deductible, the requirement only applies

with respect to participating providers in the insurer's network, or

with respect to non-participating providers, if the insurer does not

have a participating provider in the in-network benefits portion of its

network with the appropriate training and experience to meet the

particular health care needs of the insured pursuant to subsection (d)

of section three thousand two hundred seventeen-d of this article.

* NB There are 2 par (33)'s

(34) Health care forensic examinations performed pursuant to section

twenty-eight hundred five-i of the public health law covered under the

policy shall not be subject to annual deductibles or coinsurance.

(35) (A) Every policy delivered or issued for delivery in this state

that provides coverage for inpatient hospital care or coverage for

physician services shall provide coverage for the diagnosis and

treatment of mental health conditions as follows:

* (i) where the policy provides coverage for inpatient hospital care,

such policy shall include benefits for inpatient care in a hospital as

defined by subdivision ten of section 1.03 of the mental hygiene law and

benefits for outpatient care provided in a facility issued an operating

certificate by the commissioner of mental health pursuant to the

provisions of article thirty-one of the mental hygiene law, or in a

facility operated by the office of mental health, or in a crisis

stabilization center licensed pursuant to section 36.01 of the mental

hygiene law, or, for care provided in other states, to similarly

licensed or certified hospitals or facilities; and

* NB Effective until after the superintendent of financial services

and the commissioner of health have promulgated regulations

*(i) where the policy provides coverage for inpatient hospital care,

such policy shall include benefits for: inpatient care in a hospital as

defined by subdivision ten of section 1.03 of the mental hygiene law;

sub-acute care in a residential facility licensed or operated by the

office of mental health; outpatient care provided by a facility issued

an operating certificate by the commissioner of mental health pursuant

to the provisions of article thirty-one of the mental hygiene law or by

a facility operated by the office of mental health; outpatient care

provided by a crisis stabilization center licensed pursuant to section

36.01 of the mental hygiene law; outpatient care provided by a mobile

crisis intervention services provider licensed, certified, or designated

by the office of mental health or the office of addiction services and

supports; outpatient and inpatient care for critical time intervention

services and outpatient care for assertive community treatment services

provided by facilities issued an operating certificate by the

commissioner of mental health pursuant to the provisions of article

thirty-one of the mental hygiene law, beginning no later than thirty

days following discharge from a hospital as defined by subdivision ten

of section 1.03 of the mental hygiene law or the emergency department of

a hospital licensed pursuant to article twenty-eight of the public

health law; or, for care provided in other states, to similarly licensed

or certified hospitals, facilities, or licensed, certified or designated

providers; and

* NB Effective after the superintendent of financial services and the

commissioner of health have promulgated regulations

(ii) where the policy provides coverage for physician services, such

policy shall include benefits for outpatient care provided by a

psychiatrist or psychologist licensed to practice in this state, a

licensed clinical social worker within the lawful scope of his or her

practice, who is licensed pursuant to article one hundred fifty-four of

the education law, a mental health counselor, marriage and family

therapist, or psychoanalyst licensed pursuant to article one hundred

sixty-three of the education law, a nurse practitioner licensed to

practice in this state, or a professional corporation or university

faculty practice corporation thereof. Nothing herein shall be construed

to modify or expand the scope of practice of a mental health counselor,

marriage and family therapist, or psychoanalyst licensed pursuant to

article one hundred sixty-three of the education law. Further, nothing

herein shall be construed to create a new mandated health benefit.

(B) Coverage required by this paragraph may be subject to annual

deductibles, copayments and coinsurance as may be deemed appropriate by

the superintendent and shall be consistent with those imposed on other

benefits under the policy.

(C) Coverage under this paragraph shall not apply financial

requirements or treatment limitations to mental health benefits that are

more restrictive than the predominant financial requirements and

treatment limitations applied to substantially all medical and surgical

benefits covered by the policy.

(D) The criteria for medical necessity determinations under the policy

with respect to mental health benefits shall be made available by the

insurer to any insured, prospective insured, or in-network provider upon

request.

(E) For purposes of this paragraph:

(i) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(ii) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement;

* (iii) "treatment limitation" means limits on the frequency of

treatment, number of visits, days of coverage, or other similar limits

on the scope or duration of treatment and includes nonquantitative

treatment limitations such as: medical management standards limiting or

excluding benefits based on medical necessity, or based on whether the

treatment is experimental or investigational; formulary design for

prescription drugs; network tier design; standards for provider

admission to participate in a network, including reimbursement rates;

methods for determining usual, customary, and reasonable charges;

fail-first or step therapy protocols; exclusions based on failure to

complete a course of treatment; and restrictions based on geographic

location, facility type, provider specialty, and other criteria that

limit the scope or duration of benefits for services provided under the

policy; and

* NB Effective until after the superintendent of financial services

and the commissioner of health have promulgated regulations

* (iii) "treatment limitation" means limits on the frequency of

treatment, number of visits, days of coverage, or other similar limits

on the scope or duration of treatment and includes nonquantitative

treatment limitations such as: medical management standards limiting or

excluding benefits based on medical necessity, or based on whether the

treatment is experimental or investigational; formulary design for

prescription drugs; network tier design; standards for provider

admission to participate in a network, including reimbursement rates;

methods for determining usual, customary, and reasonable charges;

fail-first or step therapy protocols; exclusions based on failure to

complete a course of treatment; and restrictions based on geographic

location, facility type, provider specialty, and other criteria that

limit the scope or duration of benefits for services provided under the

policy;

* NB Effective after the superintendent of financial services and the

commissioner of health have promulgated regulations

* (iv) "mental health condition" means any mental health disorder as

defined in the most recent edition of the diagnostic and statistical

manual of mental disorders or the most recent edition of another

generally recognized independent standard of current medical practice

such as the international classification of diseases.

* NB Effective until after the superintendent of financial services

and the commissioner of health have promulgated regulations

* (iv) "mental health condition" means any mental health disorder as

defined in the most recent edition of the diagnostic and statistical

manual of mental disorders or the most recent edition of another

generally recognized independent standard of current medical practice

such as the international classification of diseases;

* NB Effective after the superintendent of financial services and the

commissioner of health have promulgated regulations

* (v) "assertive community treatment services" means a comprehensive

and integrated combination of treatment, rehabilitation, case

management, and support services primarily provided in an insured's

residence or other community locations by a mobile multidisciplinary

mental health treatment team licensed pursuant to article thirty-one of

the mental hygiene law;

* NB Effective after the superintendent of financial services and the

commissioner of health have promulgated regulations

* (vi) "critical time intervention services" means services rendered

by a provider licensed under article thirty-one of the mental hygiene

law that provides evidence-based, therapeutic interventions that include

intensive outreach, engagement, and care coordination services that are

provided to an insured before the insured is discharged from inpatient

care in a hospital as defined by subdivision ten of section 1.03 of the

mental hygiene law or the emergency department of a hospital licensed

pursuant to article twenty-eight of the public health law and continue

after discharge until the insured is stabilized; and

* NB Effective after the superintendent of financial services and the

commissioner of health have promulgated regulations

* (vii) "residential facility" means crisis residence facilities and

community residences for eating disorder integrated treatment programs

licensed pursuant to article thirty-one of the mental hygiene law.

* NB Effective after the superintendent of financial services and the

commissioner of health have promulgated regulations

(F) An insurer shall provide coverage under this paragraph, at a

minimum, consistent with the federal Paul Wellstone and Pete Domenici

Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §

1185a).

(G) This subparagraph shall apply to hospitals and crisis residence

facilities in this state that are licensed or operated by the office of

mental health that are participating in the insurer's provider network.

Where the policy provides coverage for inpatient hospital care, benefits

for inpatient hospital care in a hospital as defined by subdivision ten

of section 1.03 of the mental hygiene law and benefits for sub-acute

care in a crisis residence facility licensed or operated by the office

of mental health shall not be subject to preauthorization. Coverage

provided under this subparagraph shall also not be subject to concurrent

utilization review for individuals who have not attained the age of

eighteen during the first fourteen days of the inpatient admission,

provided the facility notifies the insurer of both the admission and the

initial treatment plan within two business days of the admission,

performs daily clinical review of the insured, and participates in

periodic consultation with the insurer to ensure that the facility is

using the evidence-based and peer reviewed clinical review criteria

utilized by the insurer which is approved by the office of mental health

and appropriate to the age of the insured, to ensure that the inpatient

care is medically necessary for the insured. For individuals who have

attained age eighteen, coverage provided under this subparagraph shall

also not be subject to concurrent review during the first thirty days of

the inpatient or residential admission, provided the facility notifies

the insurer of both the admission and the initial treatment plan within

two business days of the admission, performs daily clinical review of

the insured, and participates in periodic consultation with the insurer

to ensure that the facility is using the evidence-based and peer

reviewed clinical review criteria utilized by the insurer which is

approved by the office of mental health and appropriate to the age of

the insured, to ensure that the inpatient or residential care is

medically necessary for the insured. However, concurrent review may be

performed during the first thirty days if an insured meets clinical

criteria designated by the office of mental health or where the insured

is admitted to a hospital or facility which has been designated by the

office of mental health for concurrent review, in consultation with the

commissioner of health and the superintendent. All treatment provided

under this subparagraph may be reviewed retrospectively. Where care is

denied retrospectively, an insured shall not have any financial

obligation to the facility for any treatment under this subparagraph

other than any copayment, coinsurance, or deductible otherwise required

under the policy.

(H) This subparagraph shall apply to crisis stabilization centers in

this state that are licensed pursuant to section 36.01 of the mental

hygiene law and participate in the insurer's provider network. Benefits

for care by a crisis stabilization center shall not be subject to

preauthorization. All treatment provided under this subparagraph may be

reviewed retrospectively. Where care is denied retrospectively, an

insured shall not have any financial obligation to the facility for any

treatment under this subparagraph other than any copayment, coinsurance,

or deductible otherwise required under the policy.

* (I) This subparagraph shall apply to mobile crisis intervention

services providers licensed, certified, or designated by the office of

mental health or the office of addiction services and supports. For

purposes of this subparagraph, "mobile crisis intervention services"

means mental health and substance use disorder services consisting of:

(1) telephonic crisis triage and response; (2) mobile crisis response to

provide intervention and facilitate access to other behavioral health

services; and (3) mobile and telephonic follow-up services after the

initial crisis response until the insured is stabilized, provided to an

insured who is experiencing, or is at imminent risk of experiencing, a

behavioral health crisis, which includes instances in which an insured

cannot manage their primarily psychiatric or substance use related

symptoms without de-escalation or intervention. Mobile crisis

intervention services do not include services provided to an insured

after the insured has been stabilized.

(i) Benefits for covered services provided by a mobile crisis

intervention services provider shall not be subject to preauthorization.

Except where otherwise required by law, nothing in this subparagraph

shall prevent services provided subsequent to the provision of mobile

crisis intervention services from being subject to preauthorization.

(ii) Benefits for covered services provided by a mobile crisis

intervention services provider shall be covered regardless of whether

the mobile crisis intervention services provider is a participating

provider.

(iii) If the covered services are provided by a non-participating

mobile crisis intervention services provider, an insurer shall not

impose any administrative requirement or limitation on coverage that is

more restrictive than the requirements or limitations that apply to

covered services received from a participating mobile crisis

intervention services provider.

(iv) If the covered services are provided by a non-participating

mobile crisis intervention services provider, the insured's copayment,

coinsurance, and deductible shall be the same as would apply if such

covered services were provided by a participating mobile crisis

intervention services provider.

(v) A mobile crisis intervention services provider reimbursed pursuant

to this section shall not charge or seek any reimbursement from, or have

any recourse against, an insured for the services provided pursuant to

this subparagraph, except for the collection of in-network copayments,

coinsurance, or deductibles for which the insured is responsible for

under the terms of the policy.

* NB Effective after the superintendent of financial services and the

commissioner of health have promulgated regulations

(J) This subparagraph shall apply to school-based mental health

clinics that are licensed pursuant to article thirty-one of the mental

hygiene law and provide outpatient care in pre-school, elementary, or

secondary schools. An insurer shall provide reimbursement for covered

outpatient care when provided by such school-based mental health clinics

at a pre-school, elementary, or secondary school, regardless of whether

the school-based mental health clinic furnishing such services is a

participating provider with respect to such services. Reimbursement for

such covered services shall be at the rate negotiated between the

insurer and school-based mental health clinic or, in the absence of a

negotiated rate, an amount no less than the rate that would be paid for

such services pursuant to the medical assistance program under title

eleven of article five of the social services law. Payment by an insurer

pursuant to this section shall be payment in full for the services

provided. The school-based mental health clinic reimbursed pursuant to

this section shall not charge or seek any reimbursement from, or have

any recourse against, an insured for the services provided pursuant to

this subparagraph, except for the collection of in-network copayments,

coinsurance, or deductibles for which the insured is responsible for

under the terms of the policy.

(K) (i) This clause shall apply to outpatient treatment provided in a

facility issued an operating certificate by the commissioner of mental

health pursuant to the provisions of article thirty-one of the mental

hygiene law, or in a facility operated by the office of mental health,

or in a crisis stabilization center licensed pursuant to section 36.01

of the mental hygiene law, that is participating in the insurer's

provider network. Reimbursement for covered outpatient treatment

provided by such a facility shall be at rates negotiated between the

insurer and the participating facility, provided that such rates are not

less than the rates that would be paid for such treatment pursuant to

the medical assistance program under title eleven of article five of the

social services law. For the purposes of this clause, the rates that

would be paid for such treatment pursuant to the medical assistance

program under title eleven of article five of the social services law

shall be the rates with an effective date of April first of the

preceding year, which shall be established prior to October first of the

preceding calendar year.

(ii) The office of mental health shall publish information adequate to

calculate the rates that would be paid for such treatment pursuant to

the medical assistance program under title eleven of article five of the

social services law. Such information shall be provided in a form and

manner to be determined by the commissioner of mental health. Nothing in

this clause shall be construed to relieve an insurer of the obligation

to reimburse at no less than the applicable minimum rate set forth in

clause (i) of this subparagraph. Prior to the submission of premium rate

filings and applications, the superintendent shall provide insurers with

guidance on factors to consider in calculating the impact of rate

changes for the purposes of submitting premium rate filings and

applications to the superintendent for the subsequent policy year. To

the extent that the rates with an effective date of April first differ

from the estimated rates incorporated in premium rate filings and

applications, insurers may account for such differences in future

premium rate filings and applications submitted to the superintendent

for approval.

* (36) (A) Every policy which provides hospital, surgical, or medical

coverage and which offers maternity coverage pursuant to paragraph ten

of this subsection shall also provide coverage for abortion services for

an enrollee.

(B) Coverage for abortion shall not be subject to annual deductibles

or coinsurance, including co-payments, unless the policy is a high

deductible health plan as defined in section 223(c)(2) of the internal

revenue code of 1986, in which case coverage for abortion may be subject

to the plan's annual deductible.

(C) Coverage for abortion shall include coverage of any drug

prescribed for the purpose of an abortion, including both generic and

brand name drugs, even if such drug has not been approved by the food

and drug administration for abortion, provided, however, that such drug

shall be a recognized medication for abortion in one of the following

established reference compendia:

(i) The WHO Model Lists of Essential Medicines;

(ii) The WHO Abortion Care Guidance; or

(iii) The National Academies of Science, Engineering, and Medicine

Consensus Study Report.

* NB There are 2 par (36)'s

* (36)(A) Every policy that includes coverage for dialysis treatment

that requires such services to be provided by an in-network provider and

that does not provide coverage for out-of-network dialysis treatment

shall not deny coverage of such services because the services are

provided by an out-of-network provider, provided that each of the

following conditions are met:

(i) The out-of-network provider is duly licensed to practice and

authorized to provide such treatment;

(ii) The out-of-network provider is located outside the service area

of the insurer;

(iii) The in-network healthcare provider treating the insured for the

condition issues a written order for dialysis treatment stating that in

his or her opinion such treatment is necessary;

(iv) The insured has notified, in writing, the insurer at least thirty

days in advance of the proposed date or dates of such out-of-network

dialysis treatment. The notice shall include the authorization required

by clause (iii) of this subparagraph. In the event the insured must

travel on sudden notice due to family or other emergency, shorter notice

may be permitted, provided that the insurer has reasonable opportunity

to review the travel and treatment plans of the insured;

(v) The insurer shall have the right to pre-approve the dialysis

treatment and schedule; and

(vi) Such coverage is limited to no greater than ten out-of-network

treatments in a calendar year.

(B) Where coverage for out-of-network dialysis treatment is provided

pursuant to subparagraph (A) of this paragraph, no insurer shall be

obligated to reimburse the out-of-network provider at an amount greater

than it would have paid for the same treatment within a network,

including all drugs and ancillary services tied to dialysis treatment,

and any amount charged by a provider in excess of the amount reimbursed

by the insurer shall be the responsibility of the insured receiving the

out-of-network services.

(C) Such coverage of out-of-network dialysis services required by

subparagraph (A) of this paragraph shall otherwise be subject to the

limitations, exclusions and terms of the policy, including, but not

limited to, utilization review, annual deductibles, copayments, and

coinsurance, consistent with those required for other similar benefits

under the policy.

* NB There are 2 par (36)'s

* (37) Any policy that provides coverage for prescription drugs shall

apply any third-party payments, financial assistance, discount, voucher

or other price reduction instrument for out-of-pocket expenses made on

behalf of an insured individual for the cost of a prescription drug to

the insured's deductible, copayment, coinsurance, out-of-pocket maximum,

or any other cost-sharing requirement when calculating such insured

individual's overall contribution to any out-of-pocket maximum or any

cost-sharing requirement. If under federal law, application of this

requirement would result in health savings account ineligibility under

26 USC 223, this requirement shall apply for health savings

account-qualified high deductible health plans with respect to the

deductible of such a plan after the enrollee has satisfied the minimum

deductible under 26 USC 223, except for with respect to items or

services that are preventive care pursuant to 26 USC 223(c)(2)(C), in

which case the requirements of this paragraph shall apply regardless of

whether the minimum deductible under 26 USC 223 has been satisfied. This

paragraph only applies to a prescription drug that is either (A) a

brand-name drug without an AB rated generic equivalent, as determined by

the United States Food and Drug Administration; or (B) a brand-name drug

with an AB rated generic equivalent, as determined by the United States

Food and Drug Administration, and the insured has access to the

brand-name drug through prior authorization by the insurer or through

the insurer's appeal process, including any step-therapy process; or (C)

a generic drug the insurer will cover, with or without prior

authorization or an appeal process.

* NB Effective until January 1, 2027

* (37) Any policy that provides coverage for prescription drugs shall

apply any third-party payments, financial assistance, discount, voucher

or other price reduction instrument for out-of-pocket expenses made on

behalf of an insured individual for the cost of a prescription drug to

the insured's deductible, copayment, coinsurance, out-of-pocket maximum,

or any other cost-sharing requirement when calculating such insured

individual's overall contribution to any out-of-pocket maximum or any

cost-sharing requirement. If under federal law, application of this

requirement would result in health savings account ineligibility under

26 USC 223, this requirement shall apply for health savings

account-qualified high deductible health plans with respect to the

deductible of such a plan after the enrollee has satisfied the plan

deductible, except for with respect to items or services that are

preventive care pursuant to 26 USC 223(c)(2)(C), in which case the

requirements of this paragraph shall apply regardless of whether the

plan deductible has been satisfied. This paragraph only applies to a

prescription drug that is either (A) a brand-name drug without an AB

rated generic equivalent, as determined by the United States Food and

Drug Administration; or (B) a brand-name drug with an AB rated generic

equivalent, as determined by the United States Food and Drug

Administration, and the insured has access to the brand-name drug

through prior authorization by the insurer or through the insurer's

appeal process, including any step-therapy process; or (C) a generic

drug the insurer will cover, with or without prior authorization or an

appeal process.

* NB Effective January 1, 2027

* NB There are 2 par (37)'s

* (37) (A) Definitions. For the purpose of this paragraph:

(i) "Same reimbursement amount" shall mean that any coverage described

under subparagraph (B) of this paragraph shall provide the same

benchmark index, including the same average wholesale price, maximum

allowable cost and national prescription drug codes to reimburse all

pharmacies participating in the insurance network regardless of whether

a pharmacy is a mail order pharmacy or a non-mail order pharmacy.

(ii) "Mail order pharmacy" means a pharmacy whose primary business is

to receive prescriptions by mail, telefax or through electronic

submissions and to dispense medication to patients through the use of

the United States mail or other common or contract carrier services and

provides any consultation with patients electronically rather than

face-to-face.

(B) Any policy that provides coverage for prescription drugs shall

permit each insured to fill any covered prescription that may be

obtained at a network participating mail order or other non-retail

pharmacy, at the insured's option, at a network participating non-mail

order retail pharmacy provided that the network participating non-mail

order retail pharmacy agrees to the same reimbursement amount that the

insurer has established for the network participating mail order or

other non-retail pharmacy. In such a case, the policy shall not impose a

co-payment fee or other condition on any insured who elects to purchase

prescription drugs from a network participating non-mail order retail

pharmacy which is not also imposed on insureds electing to purchase

drugs from a network participating mail order or other non-retail

pharmacy; provided, however, that the provisions of this subparagraph

shall not supersede the terms of a collective bargaining agreement or

apply to a policy that is a result of a collective bargaining agreement

between an employer and a recognized or certified employee organization.

* NB There are 2 par (37)'s

(38) Every policy that provides coverage for hospital, surgical or

medical care shall provide the following coverage for pasteurized donor

human milk (PDHM), which may include fortifiers as medically indicated,

for which a licensed medical practitioner has issued an order for an

infant who is medically or physically unable to receive maternal breast

milk or participate in breast feeding or whose mother is medically or

physically unable to produce maternal breast milk at all or in

sufficient quantities or participate in breast feeding despite optimal

lactation support. Such infant shall: (i) have a documented birth weight

of less than one thousand five hundred grams; or (ii) have a congenital

or acquired condition that places the infant at a high risk for

development of necrotizing enterocolitis.

* (39) No policy that provides coverage for antiretroviral

prescription drugs prescribed for the treatment or prevention of the

human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome

(AIDS) shall subject such drugs to prior authorization.

* NB There are 2 par (39)'s

* (39) (A) Every insurer issuing a policy of accident and health

insurance delivered or issued for delivery in this state which provides

major medical or similar comprehensive-type coverage and provides

coverage for prescription drugs shall include coverage for medically

necessary epinephrine devices for the emergency treatment of

life-threatening allergic reactions. Such coverage may be subject to

annual deductibles and coinsurance as may be deemed appropriate by the

superintendent; provided however, the total amount that an insured is

required to pay out-of-pocket for such devices shall be capped at an

amount not to exceed one hundred dollars annually regardless of the

insured's deductible, copayment, coinsurance or any other cost-sharing

requirement. If under federal law, application of the annual cap would

result in health savings account ineligibility under 26 USC 223, such

coverage may be subject to the plan's annual deductible, except for with

respect to items or services that are preventive care pursuant to 26 USC

223(c)(2)(C), in which case the requirements of this paragraph shall

apply regardless of whether the minimum deductible under 26 USC 223 has

been satisfied.

(B) For the purposes of this paragraph, "epinephrine device" shall

have the same meaning as provided in paragraph (b) of subdivision one of

section three thousand-c of the public health law.

* NB There are 2 par (39)'s

(40) (A) Every policy that provides coverage for physician services,

medical, major medical or similar comprehensive-type coverage shall,

upon the referral of a physician, provide coverage for comprehensive

neuropsychological examinations for dyslexia when performed by a health

care professional licensed, certified, or authorized pursuant to title

eight of the education law and acting within their scope of practice and

in accordance with this paragraph and shall not exclude coverage for the

screening, diagnosis or treatment of medical conditions otherwise

covered by the policy.

(B) Nothing in this paragraph shall be construed to prevent the

medical management or utilization review of the services or prevent a

policy from requiring that services be provided through a network of

participating providers.

* (41) (A) Every policy which provides medical, major medical or

similar comprehensive-type coverage and provides coverage for

prescription drugs shall include coverage for inhalers for the treatment

of asthma if prescribed by a physician or other licensed health care

provider legally authorized to prescribe under title eight of the

education law.

(B) Coverage shall be provided for one form of rescue and one form of

maintenance inhaler that shall not be subject to a deductible,

copayment, coinsurance or any other cost-sharing requirement.

(C) If the policy is a high deductible health plan as defined in

section 223(c)(2) of the Internal Revenue Code of 1986, such coverage

may be subject to the plan's annual deductible if application of this

requirement would result in ineligibility for a health savings account.

* NB Effective January 1, 2027

* NB There are 2 par (41)'s

* (41) (A) Every policy which provides medical, major medical, or

similar comprehensive-type coverage shall provide coverage for follow-up

screening or diagnostic services for lung cancer upon the recommendation

of a health care provider acting within the provider's scope of practice

pursuant to title eight of the education law, and as recommended by

nationally recognized clinical practice guidelines for the detection of

lung cancer.

(B) Notwithstanding any other provision of law, any policy that

provides coverage required by this paragraph shall not impose patient

cost sharing for follow-up screening or diagnostic services for lung

cancer.

(C) For the purposes of this paragraph, "nationally recognized

clinical practice guidelines" means evidence-based, peer reviewed

clinical practice guidelines informed by a systematic review of evidence

and an assessment of the benefits, and risks of alternative care options

intended to optimize patient care developed by independent organizations

or medical professional societies utilizing a transparent methodology

and reporting structure and with a conflict of interest policy.

(D) Nothing in this paragraph shall be construed to prevent medical

management or utilization review of the services, including

preauthorization, to ensure that such services are consistent with

nationally recognized clinical practice guidelines for the detection of

lung cancer.

(E) If the policy is a high deductible health plan as defined in

section 223(c)(2) of the Internal Revenue Code of 1986, such coverage

may be subject to the plan's annual deductible if application of this

requirement would result in ineligibility for a health savings account.

* NB Effective January 1, 2027

* NB There are 2 par (41)'s

(j) (1) Every insurer issuing a policy of accident and health

insurance for delivery in this state which provides coverage for

in-patient hospital care must make available and, if requested by the

policyholder, provide coverage for care in a nursing home. Such coverage

shall be made available at the inception of all new policies and, with

respect to all other policies at any anniversary date of the policy

subject to evidence of insurability.

(A) In this paragraph nursing home care means the continued care and

treatment of a covered person who is under the care of a physician but

only if (i) the care is provided in a nursing home as defined in section

twenty-eight hundred one of the public health law or a skilled nursing

facility as defined in subchapter XVIII of the federal Social Security

Act, 42 U.S.C. §§ 1395 et seq, (ii) the covered person has been in a

hospital for at least three days immediately preceding admission, and

(iii) further hospitalization would otherwise be necessary. The

aggregate of the number of covered days of care in a hospital and the

number of covered days of care in a nursing home, with two days of care

in a nursing home equivalent to one day of care in a hospital, may not

exceed the number of covered days of hospital care provided under the

contract in a benefit period. The level of benefits to be provided for

nursing home care must be reasonably related to the benefits provided

for hospital care.

(B) Ambulatory care means care in hospital out-patient facilities, as

a hospital is defined in section twenty-eight hundred one of the public

health law or subchapter XVIII of the federal Social Security Act, 42

U.S.C. §§ 1395 et seq, and physicians' offices. Ambulatory care in

hospital out-patient facilities means services for diagnostic X-rays,

laboratory and pathological examinations, physical therapy and radiation

therapy, and services and medications used for nonexperimental cancer

chemotherapy and cancer hormone therapy, provided that such services and

medications are (i) related to and necessary for the treatment or

diagnosis of the patient's illness or injury, (ii) ordered by a

physician and (iii) in the case of physical therapy, services are to be

furnished in connection with the same illness for which the patient had

been hospitalized or in connection with surgical care, but in no event

need benefits be provided for physical therapy which commences more than

six months after discharge from a hospital or the date surgical care was

rendered, and in no event need benefits for physical therapy be provided

after three hundred sixty-five days from the date of discharge from a

hospital or the date surgical care was rendered. Ambulatory care in

physicians' offices means services for diagnostic X-rays, radiation

therapy, laboratory and pathological examinations, and services and

medications used for nonexperimental cancer chemotherapy and cancer

hormone therapy, provided that such services and medications are related

to and necessary for the treatment or diagnosis of the patient's illness

or injury, and ordered by a physician. Such coverage shall be made

available at the inception of all new policies and, with respect to all

other policies, at any anniversary date of the policy subject to

evidence of insurability.

(2) Every insurer issuing a policy of accident and health insurance

for delivery in this state which provides coverage supplementing part A

and part B of subchapter XVIII of the federal Social Security Act, 42

U.S.C. §§ 1395 et seq, must make available and, if requested by the

insured, provide coverage of supplemental home care visits beyond those

provided by part A and part B, sufficient to produce an aggregate

coverage of three hundred sixty-five home case visits per policy year.

Such coverage shall be provided pursuant to regulations prescribed by

the superintendent.

(3) Consistent with federal law, every insurer issuing a policy of

accident and health insurance for delivery in this state which provides

coverage supplementing part A and part B of subchapter XVIII of the

federal Social Security Act, 42 USC §§ 1395 et seq., shall make

available and, if requested by the insured, provide coverage for at

least ninety days of care in a nursing home as defined in section

twenty-eight hundred one of the public health law, except where such

coverage would duplicate coverage that is available under the

aforementioned subchapter XVIII. Such coverage shall be made available

at the inception of all new policies and, with respect to all other

policies, at each anniversary date of the policy.

(A) Coverage shall be subject to a copayment of twenty-five dollars

per day.

(B) Brochures describing such coverage must be provided to all

applicants at the time of application for all new policies and

thereafter on each anniversary date of the policy, and with respect to

all other policies annually at each anniversary date of the policy. Such

brochures must be approved by the superintendent in consultation with

the commissioner of health.

(C) The commensurate rate for the coverage must be approved by the

superintendent.

(D) Such insurers shall report to the superintendent each year the

number of contract holders to whom such insurers have issued such

policies for nursing home coverage and the approximate number of persons

covered by such policies.

(k) Any person, partnership or corporation willfully violating any

provision of this section, regulation or order of the superintendent

made in accordance with this section, shall forfeit to the people of the

state a sum not to exceed one hundred dollars for each such violation.

The superintendent may also suspend or revoke the license of an insurer

or agent or broker for any such willful violation.

(l) An insurer shall not offer individual hospital, medical or

surgical expense insurance policies unless the policies meet the

requirements of subsection (b) of section four thousand three hundred

twenty-eight of this chapter. Such policies that are offered within the

health benefit exchange established by this state also shall meet any

requirements established by the health benefit exchange.

(m) An insurer shall not be required to offer the policyholder any

benefits that must be made available pursuant to this section if the

benefits must be covered as essential health benefits. For any policy

issued within the health benefit exchange established by this state, an

insurer shall not be required to offer the policyholder any benefits

that must be made available pursuant to this section. For purposes of

this subsection, "essential health benefits" shall have the meaning set

forth in subsection (a) of section three thousand two hundred

seventeen-i of this article.

* (n) With respect to high deductible health plans offered in

conjunction with a health savings account, if application of any cost

sharing requirements would result in health savings account

ineligibility under section two hundred twenty-three of the internal

revenue code, such coverage may be subject to the plan's annual

deductible.

* NB Effective January 1, 2027