N.Y. Insurance Law § 3217-i: Essential health benefits package and limit on cost-sharing

§ 3217-i. Essential health benefits package and limit on cost-sharing.

(a) (1) For purposes of this article, "essential health benefits" shall

mean the following categories of benefits:

(A) ambulatory patient services;

(B) emergency services;

(C) hospitalization;

(D) maternity and newborn care;

(E) mental health and substance use disorder services, including

behavioral health treatment;

(F) prescription drugs;

(G) rehabilitative and habilitative services and devices;

(H) laboratory services;

(I) preventive and wellness services and chronic disease management;

and

(J) pediatric services, including oral and vision care.

(2) An insurer shall not be required to provide coverage for pediatric

oral services as an essential health benefit if:

(A) for coverage offered through the exchange established by this

state, the exchange has determined sufficient coverage of the pediatric

oral benefit is available through stand-alone dental plans certified by

the exchange; or

(B) for coverage offered outside the exchange, the insurer obtains

reasonable written assurance that the individual or group has obtained a

stand-alone dental plan that has been approved by the superintendent as

meeting exchange certification standards.

(b) (1) Every individual and small group accident and health insurance

policy that provides hospital, surgical, or medical expense coverage and

is not a grandfathered health plan shall provide coverage that meets the

actuarial requirements of one of the following levels of coverage:

(A) Bronze Level. A plan in the bronze level shall provide a level of

coverage that is designed to provide benefits that are actuarially

equivalent to sixty percent of the full actuarial value of the benefits

provided under the plan;

(B) Silver Level. A plan in the silver level shall provide a level of

coverage that is designed to provide benefits that are actuarially

equivalent to seventy percent of the full actuarial value of the

benefits provided under the plan;

(C) Gold Level. A plan in the gold level shall provide a level of

coverage that is designed to provide benefits that are actuarially

equivalent to eighty percent of the full actuarial value of the benefits

provided under the plan; or

(D) Platinum Level. A plan in the platinum level shall provide a level

of coverage that is designed to provide benefits that are actuarially

equivalent to ninety percent of the full actuarial value of the benefits

provided under the plan.

(2) The superintendent may provide for a variation in the actuarial

values used in determining the level of coverage of a plan to account

for the differences in actuarial estimates.

(3) Every student accident and health insurance policy shall provide

coverage that meets at least sixty percent of the full actuarial value

of the benefits provided under the policy. The policy's schedule of

benefits shall include the level as described in paragraph one of this

subsection nearest to, but below the actual actuarial value.

(c) Every individual or group accident and health insurance policy

that provides hospital, surgical, or medical expense coverage and is not

a grandfathered health plan, and every student accident and health

insurance policy shall limit the insured's cost-sharing for in-network

services in a policy year to not more than the maximum out-of-pocket

amount determined by the superintendent for all policies subject to this

section. Such amount shall not exceed any annual out-of-pocket limit on

cost-sharing set by the United States secretary of health and human

services, if available.

(d) The superintendent may require the use of model language

describing the coverage requirements for any accident and health

insurance policy form that is subject to the superintendent's approval

pursuant to section three thousand two hundred one of this article.

(e) For purposes of this section:

(1) "actuarial value" means the percentage of the total expected

payments by the insurer for benefits provided to a standard population,

without regard to the population to whom the insurer actually provides

benefits;

(2) "cost-sharing" means annual deductibles, coinsurance, copayments,

or similar charges, for covered services;

(3) "essential health benefits package" means coverage that:

(A) provides for essential health benefits;

(B) limits cost-sharing for such coverage in accordance with

subsection (c) of this section; and

(C) provides one of the levels of coverage described in subsection (b)

of this section;

(4) "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);

(5) "small group" means a group of one hundred or fewer employees or

members exclusive of spouses and dependents; and

(6) "student accident and health insurance" shall have the meaning set

forth in subsection (a) of section three thousand two hundred forty of

this article.