N.Y. Insurance Law § 3221: Group or blanket accident and health insurance policies; standard provisions

§ 3221. Group or blanket accident and health insurance policies;

standard provisions. (a) No policy of group or blanket accident and

health insurance shall, except as provided in subsection (d) hereof, be

delivered or issued for delivery in this state unless it contains in

substance the following provisions or provisions which in the opinion of

the superintendent are more favorable to the holders of such

certificates or not less favorable to the holders of such certificates

and more favorable to policyholders, provided however, that the

provisions set forth in paragraphs six and thirteen of this subsection

shall not be applicable to any such policy which is issued to a

policyholder in accordance with subparagraph (E) of paragraph one of

subsection (c) of section four thousand two hundred thirty-five of this

chapter:

(1) (A) No statement made by the person insured shall avoid the

insurance or reduce benefits thereunder unless contained in a written

instrument signed by the person insured.

(B) All statements contained in any such written instrument shall be

deemed representations and not warranties.

(2) That no agent has authority to change the policy or waive any of

its provisions and that no change in the policy shall be valid unless

approved by an officer of the insurer and evidenced by endorsement on

the policy, or by amendment to the policy signed by the policyholder and

the insurer.

(3) That all new employees or new members in the classes eligible for

insurance must be added to such class for which they are eligible.

(4) That all premiums due under the policy shall be remitted by the

employer or employers of the persons insured or by some other designated

person acting on behalf of the association or group insured, to the

insurer on or before the due date thereof, with such period of grace as

may be specified therein.

(5) The conditions under which the insurer may decline to renew the

policy.

(6) That the insurer shall issue either to the employer or person in

whose name such policy is issued, for delivery to each member of the

insured group, a certificate setting forth in summary form a statement

of the essential features of the insurance coverage and in substance the

following provisions of this subsection.

(7) The ages, to which the insurance provided therein shall be

limited; and the ages, for which additional restrictions are placed on

benefits, and the additional restrictions placed on the benefits at such

ages.

(8) That 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. Failure to give notice within such time shall not invalidate

or reduce any claim if it shall be shown not to have been reasonably

possible to give such notice and that notice was given as soon as was

reasonably possible.

(9) That in the case of claim for loss of time for disability, written

proof of such loss must be furnished to the insurer within thirty days

after the commencement of the period for which the insurer is liable,

and that subsequent written proofs of the continuance of such disability

must be furnished to the insurer at such intervals as the insurer may

reasonably require, and that in the case of claim for any other loss,

written proof of such loss must be furnished to the insurer within one

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

proof within such time shall not invalidate or reduce any claim if it

shall be shown not to have been reasonably possible to furnish such

proof within such time, provided such proof was furnished as soon as

reasonably possible.

(10) That the insurer will furnish to the person making claim or to

the policyholder for delivery to such person such forms as are usually

furnished by it for filing proof of loss. If such forms are not

furnished before the expiration of fifteen days after the insurer

receives notice of any claim under the policy, the person making such

claim shall be deemed to have complied with the requirements of the

policy as to proof of loss upon submitting within the time fixed in the

policy for filing proof of loss, written proof covering the occurrence,

character and extent of the loss for which claim is made.

(11) That the insurer shall have the right and opportunity to examine

the person of the individual for whom claim is made when and so often as

it may reasonably require during the pendency of claim under the policy

and also the right and opportunity to make an autopsy in case of death

where it is not prohibited by law.

(12) That benefits payable under the policy other than benefits for

loss of time will be payable not more than sixty days after receipt of

proof, and that, subject to due proof of loss all accrued benefits

payable under the policy for loss of time will be paid not less

frequently than monthly during the continuance of the period for which

the insurer is liable, and that any balance remaining unpaid at the

termination of such period will be paid immediately upon receipt of such

proof.

(13) That indemnity for loss of life of the insured is payable in

accordance with subsection (e) of section four thousand two hundred

thirty-five of this chapter; and that all other indemnities of the

policy are payable to the insured, except as may be otherwise provided

in accordance with such subsection; and that if a beneficiary is

designated, the consent of the beneficiary shall not be requisite to

change of beneficiary, or to any other changes in the policy or

certificate, except as may be specifically provided by the policy.

(14) That no action at law or in equity shall be brought to recover on

the policy prior to the expiration of sixty days after proof of loss has

been filed in accordance with the requirements of the policy and that no

such action shall be brought after the expiration of two years following

the time such proof of loss is required by the policy.

(15) Any policy and certificate, 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 OR CERTIFICATE 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."

(16) 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).

(17) 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 so

that the insured or applicant for insurance shall register or decline

registration in the donate life registry for organ, eye and tissue

donations under this section of the enrollment, renewal or initial

online portal process setup forms 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'."

(b) No such policy shall be delivered or issued for delivery in this

state unless a schedule of the premium rates pertaining to such form

shall have been filed with the superintendent.

(c) Any portion of any such policy, which purports, by reason of the

circumstances under which a loss is incurred, to reduce any benefits

promised thereunder to an amount less than that provided for the same

loss occurring under ordinary circumstances, shall be printed, in such

policy and in each certificate issued thereunder, in bold face type and

with greater prominence than any other portion of the text of such

policy or certificate; and all other exceptions of the policy shall be

printed in the policy and in the certificate, with the same prominence

as the benefits to which they apply. If any such policy contains any

provision which affects the liability of the insurer, on the grounds

stated in subparagraph (J) or (K) of paragraph two of subsection (d) of

section three thousand two hundred sixteen of this article, then such

provision shall be contained in the policy and certificate in the form

set forth in such section.

(d) (1) The superintendent may approve any form of certificate to be

issued under a blanket accident and health insurance policy as defined

in section four thousand two hundred thirty-seven of this chapter, which

omits or modifies any of the provisions hereinbefore required, if the

superintendent deems such omission or modification suitable for the

character of such insurance and not unjust to the persons insured

thereunder. Certificates issued under a policy or contract of student

accident and health insurance as defined in section three thousand two

hundred forty of this article shall comply with such section.

(2) The superintendent may approve any form of group insurance policy

providing disability benefits to be issued pursuant to article nine of

the workers' compensation law which omits or modifies any of the

provisions hereinbefore required, if such omission or modification is

not inconsistent with the provisions of such article nine and he deems

such omission or modification suitable for the character of such

insurance and not unjust to the persons insured thereunder.

(3) The superintendent may also approve any form of group insurance

policy to be issued to a social services district pursuant to

subdivision two of section three hundred sixty-seven-a of the social

services law, which omits or modifies any of the provisions hereinbefore

required, if he deems such omission or modification suitable for the

character of such insurance.

(e) (1) A group policy providing hospital, medical or surgical expense

insurance for other than specific diseases or accident only, shall

provide that if the insurance on an employee or member insured under the

group policy ceases because of termination of (A) employment or of

membership in the class or classes eligible for coverage under the

policy or (B) the policy, for any reason whatsoever, unless the

policyholder has replaced the group policy with similar and continuous

coverage for the same group whether insured or self-insured, such

employee or member who has been insured under the group policy shall be

entitled to have issued to the insured by the insurer without evidence

of insurability upon application made to the insurer within sixty days

after such termination, and payment of the quarterly, or, at the option

of the employee or member, a less frequent premium applicable to the

form and amount of insurance, an individual policy of insurance. The

insurer may, at its option elect to provide the insurance coverage under

a group insurance policy, delivered in this state, in lieu of the

issuance of a converted individual policy of insurance. Such individual

policy, or group policy, as the case may be is hereafter referred to as

the converted policy. The benefits provided under the converted policy

shall be those required by subsection (f) and (g) of this section, in

the event of termination of the converted group policy of insurance,

each insured thereunder shall have a right of conversion to a converted

individual policy of insurance.

(2) The insurer shall not be required to issue a converted policy

covering any person if such person is covered for similar benefits by

another hospital or surgical or medical expense insurance policy or

hospital or medical service subscriber contract or medical practice or

other prepayment plan or by any other plan or program or such person is

eligible for similar benefits, whether or not covered therefor, under

any arrangement of coverage for individuals in a group, other than under

the converted policy, whether on an insured or uninsured basis or

similar benefits are provided for or available to such person pursuant

to any statute; and the benefits provided or available under any of such

sources which together with the benefits provided under the converted

policy would result in overinsurance or duplication of benefits

according to standards on file with the superintendent.

(3) The converted policy shall, at the option of the employee or

member, provide identical coverage for the dependents of such employee

or member who were covered under the group policy. Provided, however,

that if the employee or member chooses the option of dependent coverage

then dependents acquired after the permitted time to convert stated in

paragraph one of this subsection shall be added to the converted family

policy in accordance with the provisions of subsection (c) of section

thirty-two hundred sixteen of this article and any regulations

promulgated or guidelines issued by the superintendent. The effective

date of the individual's coverage under the converted policy shall be

the date of the termination of the individual's insurance under the

group policy as to those persons covered under the group policy.

(4) If delivery of an individual converted policy is to be made

outside this state, it may be on such form as the insurer may then be

offering for such conversion in the jurisdiction where such delivery is

to be made.

(5) The conversion provision shall also be available upon the death of

the employee or member, to the surviving spouse with respect to such of

the spouse and children as are then covered by the group policy, and

shall be available to a child solely with respect to himself upon his

attaining the limiting age of coverage under the group policy while

covered as a dependent thereunder. It shall also be available upon the

divorce or annulment of the marriage of the employee or member, to the

former spouse of such employee or member.

(6) (A) Each certificate holder shall be given written notice of such

conversion privilege and its duration within fifteen days before or

after the date of termination of group coverage, provided that if such

notice be given more than fifteen days but less than ninety days after

the date of termination of group coverage, the time allowed for the

exercise of such privilege of conversion shall be extended for

forty-five days after the giving of such notice. If such notice be not

given within ninety days after the date of termination of group

coverage, the time allowed for the exercise of such conversion privilege

shall expire at the end of such ninety days.

(B) Written notice by the policyholder given to the certificate holder

or mailed to the certificate holder's last known address, or written

notice by the insurer be sent by first class mail to the certificate

holder at the last address furnished to the insurer by the policyholder,

shall be deemed full compliance with the provisions of this subsection

for the giving of notice.

(C) A group contract issued by an insurer may contain a provision to

the effect that notice of such conversion privilege and its duration

shall be given by the policyholder to each certificate holder upon

termination of his group coverage.

(7) In addition to the right of conversion herein, the employee or

member insured under the policy shall at his option, as an alternative

to conversion, be entitled to have his coverage continued under the

group policy in accordance with the conditions and limitations contained

in subsection (m) of this section, and have issued at the end of the

period of continuation an individual conversion policy subject to the

terms of this subsection. The effective date for the conversion policy

shall be the day following the termination of insurance under the group

policy, or if there is a continuation of coverage, on the day following

the end of the period of continuation. Notwithstanding the foregoing,

the superintendent may require conversion or continuation of insurance

under conditions as set forth in a regulation for insureds under a

policy issued in accordance with subparagraph (E) of paragraph one of

subsection (c) of section four thousand two hundred thirty-five of this

chapter.

(8) For purposes of this subsection, the term "dependent" shall

include a child as described in subsection (f) of section four thousand

two hundred thirty-five of this chapter.

(f) If the group insurance policy insures the employee or member for

hospital, medical or surgical expense insurance, or if the group

insurance policy insures the employee or member for major medical or

similar comprehensive-type coverage, then the conversion privilege shall

entitle the employee or member to obtain coverage under a converted

policy providing, at the insured's option, coverage under any one of the

plans described in subsection (g) of this section on an expense incurred

basis.

(g) For conversion purposes, an insurer shall offer to the employee or

member a policy 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. 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

subsection and subsections (e) and (f) of this section through the

offering of policies that comply with this subsection by another

insurer, corporation or health maintenance organization within the

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

chapter.

(h) Every small group policy or association group policy delivered or

issued for delivery in this state that provides coverage for hospital,

medical or surgical expense insurance and is not a grandfathered health

plan shall provide coverage for the essential health benefits package.

For purposes of this subsection:

(1) "essential health benefits package" shall have the meaning set

forth in paragraph three of subsection (e) of section three thousand two

hundred seventeen-i of this article;

(2) "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);

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

members exclusive of spouses and dependents; and

(4) "association group" means a group defined in subparagraphs (B),

(D), (H), (K), (L) or (M) of paragraph one of subsection (c) of section

four thousand two hundred thirty-five of this chapter, provided that:

(A) the group includes one or more individual members; or

(B) the group includes one or more member employers or other member

groups that are small groups.

(i) 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 pursuant to subsection (h) of this section. 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.

(j) No policy of group or blanket accident and health insurance shall

be issued as excess coverage for volunteer firefighters over and above

the coverage provided for pursuant to the volunteer firefighters'

benefit law unless such excess policy provides for each of the types of

coverages set forth in subdivision one of section five of such law. Any

excess policy which does not contain such provisions shall be construed

as if such coverages were embodied therein.

(k) (1) (A) Every group policy delivered or issued for delivery in

this state which provides coverage for in-patient hospital care shall

provide coverage for home care to residents in this state, except that

this provision shall not apply to a policy which covers persons employed

in more than one state or the benefit structure of which was the subject

of collective bargaining affecting persons who are employed in more than

one state. Such home care coverage shall be included at the inception of

all new policies and, with respect to all other policies, added at any

anniversary date of the policy subject to evidence of insurability.

(B) Such 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.

(C) 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.

(D) 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 subchapter XVIII of the federal Social Security Act, 42

U.S.C. §§ 1395 et seq.

(E) 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.

(2) (A) Every insurer issuing a group policy delivered or issued for

delivery in this state which provides coverage for in-patient hospital

care shall include coverage for preadmission tests performed in hospital

facilities prior to scheduled surgery, except that this provision shall

not apply to a policy which covers persons employed in more than one

state or the benefit structure of which was the subject of collective

bargaining affecting persons who are employed in more than one state.

(B) Such policy shall provide benefits for tests ordered by a

physician which are performed in the out-patient facilities of a

hospital as a planned preliminary to admission of the patient as an

in-patient for surgery in the same hospital, provided that:

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

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

(ii) reservations for a hospital bed and for an operating room were

made prior to the performance of the tests;

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

presurgical tests; and

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

(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.

(3) Every group policy delivered or issued for delivery in this state

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, except that this provision shall not apply to a policy

which covers persons employed in more than one state or the benefit

structure of which was the subject of collective bargaining affecting

persons who are employed in more than one state.

(4) (A) Every group policy delivered or issued for delivery in this

state that provides coverage for inpatient hospital care shall include

coverage for services to treat an emergency condition provided in

hospital facilities, except that this provision shall not apply to a

policy which covers persons employed in more than one state or the

benefit structure of which was the subject of collective bargaining

affecting persons who are employed in more than one state unless the

policy otherwise provides coverage for services to treat an emergency

condition provided 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) In 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) In 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) In 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).

(5) (A) (i) Every group or blanket policy delivered or issued for

delivery in this state which provides hospital, surgical or medical

coverage shall include coverage for maternity care, including hospital,

surgical or medical care to the same extent that 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 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.

* (D) 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

(5-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.

(6) (A) Every group policy issued or delivered in this state 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; provided, however that:

(i) subject to the provisions of subparagraph (C) of this paragraph,

in no case shall such coverage exclude surgical or medical procedures

provided as part of such hospital care which would correct malformation,

disease or dysfunction resulting in infertility; and

(ii) provided, further however, that subject to the provisions of

subparagraph (C) of this paragraph, in no case shall such coverage

exclude diagnostic tests and procedures provided as part of such

hospital care that are necessary to determine infertility or that are

necessary in connection with any surgical or medical treatments or

prescription drug coverage provided pursuant to this paragraph,

including such diagnostic tests and procedures as hysterosalpingogram,

hysteroscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post

coital tests, testis biopsy, semen analysis, blood tests and ultrasound;

and

(iii) provided, further however, every such policy which provides

coverage for prescription drugs shall include, within such coverage,

coverage for prescription drugs approved by the federal Food and Drug

Administration for use in the diagnosis and treatment of infertility in

accordance with subparagraph (C) of this paragraph.

(B) Every group policy issued or delivered in this state 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; provided, however

that:

(i) subject to the provisions of subparagraph (C) of this paragraph,

in no case shall such coverage exclude surgical or medical procedures

which would correct malformation, disease or dysfunction resulting in

infertility; and

(ii) provided, further however, that subject to the provisions of

subparagraph (C) of this paragraph, in no case shall such coverage

exclude diagnostic tests and procedures that are necessary to determine

infertility or that are necessary in connection with any surgical or

medical treatments or prescription drug coverage provided pursuant to

this paragraph, including such diagnostic tests and procedures as

hysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy,

sono-hysterogram, post coital tests, testis biopsy, semen analysis,

blood tests and ultrasound; and

(iii) provided, further however, every such policy which provides

coverage for prescription drugs shall include, within such coverage,

coverage for prescription drugs approved by the federal Food and Drug

Administration for use in the diagnosis and treatment of infertility in

accordance with subparagraph (C) of this paragraph.

(C) Coverage of diagnostic and treatment procedures, including

prescription drugs, used in the diagnosis and treatment of infertility

as required by subparagraphs (A) and (B) of this paragraph shall be

provided in accordance with the provisions of this subparagraph.

(i) Diagnosis and treatment of infertility shall be prescribed as part

of a physician's overall plan of care and consistent with the guidelines

for coverage as referenced in this subparagraph.

(ii) Coverage may be subject to co-payments, coinsurance and

deductibles as may be deemed appropriate by the superintendent and as

are consistent with those established for other benefits within a given

policy.

(iii) Except as provided in items (vi) and (vii) of this subparagraph,

coverage shall not be required to include the diagnosis and treatment of

infertility in connection with: (I) in vitro fertilization, gamete

intrafallopian tube transfers or zygote intrafallopian tube transfers;

(II) the reversal of elective sterilizations; (III) sex change

procedures; (IV) cloning; or (V) medical or surgical services or

procedures that are deemed to be experimental in accordance with

clinical guidelines referenced in item (iv) of this subparagraph.

(iv) The superintendent, in consultation with the commissioner of

health, shall promulgate regulations which shall stipulate the

guidelines and standards which shall be used in carrying out the

provisions of this subparagraph, which shall include:

(I) The identification of experimental procedures and treatments not

covered for the diagnosis and treatment of infertility determined in

accordance with the standards and guidelines established and adopted by

the American College of Obstetricians and Gynecologists and the American

Society for Reproductive Medicine;

(II) The identification of the required training, experience and other

standards for health care providers for the provision of procedures and

treatments for the diagnosis and treatment of infertility determined in

accordance with the standards and guidelines established and adopted by

the American College of Obstetricians and Gynecologists and the American

Society for Reproductive Medicine; and

(III) The determination of appropriate medical candidates by the

treating physician in accordance with the standards and guidelines

established and adopted by the American College of Obstetricians and

Gynecologists and/or the American Society for Reproductive Medicine.

(v)(I) For the purposes of this paragraph, "infertility" means a

disease or condition characterized by the incapacity to impregnate

another person or to conceive, defined by the failure to establish a

clinical pregnancy after twelve months of regular, unprotected sexual

intercourse or therapeutic donor insemination, or after six months of

regular, unprotected sexual intercourse or therapeutic donor

insemination for a female thirty-five years of age or older. Earlier

evaluation and treatment may be warranted based on an individual's

medical history or physical findings.

(II) For purposes of this paragraph, "iatrogenic infertility" means an

impairment of fertility by surgery, radiation, chemotherapy or other

medical treatment affecting reproductive organs or processes.

(vi) Coverage shall also include 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.

(vii) Every large group policy delivered or issued for delivery in

this state that provides medical, major medical or similar

comprehensive-type coverage shall provide coverage for three cycles of

in-vitro fertilization used in the treatment of infertility. 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. For purposes of this item, a "cycle" is defined as either all

treatment that starts when: preparatory medications are administered for

ovarian stimulation for oocyte retrieval with the intent of undergoing

in-vitro fertilization using a fresh embryo transfer; or medications are

administered for endometrial preparation with the intent of undergoing

in-vitro fertilization using a frozen embryo transfer.

(viii) No insurer providing coverage under this paragraph shall

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

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.

(D) 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 covered person who elects to purchase prescription

fertility drugs through a network participating non-mail order retail

pharmacy that it does not impose on any covered person who purchases

prescription fertility drugs through a network participating mail order

or other non-retail pharmacy; provided, however, that the provisions of

this section shall not supersede the terms of a collective bargaining

agreement or apply to a policy that is the result of a collective

bargaining agreement between an employer and a recognized or certified

employee organization.

(7)(A) Every group or blanket accident and health insurance policy

issued 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 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.

(C) This paragraph shall not apply to a policy which covers persons

employed in more than one state or the benefit structure of which was

the subject of collective bargaining affecting persons employed in more

than one state unless such policy is issued under the New York state

health insurance plan established under article eleven of the civil

service law or issued to or through a local government.

(8) (A) Every group or blanket policy delivered or issued for delivery

in this state 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.

(9)(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 an 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 coverage 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.

(10) (A) Every group or blanket policy delivered or issued for

delivery in this state 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 group or blanket 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.

* (11) 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 (11)'s

* (11)(A) Every policy which is a "managed care product" as defined in

subparagraph (D) of this paragraph that includes 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 that 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 (11)'s

(12) No policy of group or blanket accident and health insurance

delivered or issued for delivery in this state shall exclude coverage of

a health care service, as defined in paragraph two of such subdivision

(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.

(13) Every group or blanket policy delivered or issued for delivery in

this state that provides major medical or similar comprehensive-type

coverage shall provide such coverage for bone mineral density

measurements or tests, and if such contract otherwise includes coverage

for prescription drugs, drugs and devices approved by the federal food

and drug administration or generic equivalents as approved substitutes.

In determining appropriate coverage provided by subparagraphs (A), (B)

and (C) of this paragraph, the insurer or health maintenance

organization shall adopt standards that include the criteria of the

federal Medicare program and the criteria of the national institutes of

health for the detection of osteoporosis, provided that such coverage

shall be further determined as follows:

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

mineral density measurements or tests, drugs and devices shall include

those covered under the federal Medicare program as well as those in

accordance with the criteria of the national institutes of health,

including, as consistent with such criteria, dual-energy x-ray

absorptiometry.

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

mineral density measurements or tests, drugs and devices shall be

covered for individuals meeting the criteria under the federal Medicare

program or the criteria of the national institutes of health; provided

that, to the extent consistent with such criteria, individuals

qualifying for coverage shall at a minimum, include individuals:

(i) previously diagnosed as having osteoporosis or having a family

history of osteoporosis; or

(ii) with symptoms or conditions indicative of the presence, or the

significant risk, of osteoporosis; or

(iii) on a prescribed drug regimen posing a significant risk of

osteoporosis; or

(iv) with lifestyle factors to such a degree as posing a significant

risk of osteoporosis; or

(v) with such age, gender and/or other physiological characteristics

which pose a significant risk for osteoporosis.

(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 group or blanket 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 items or services for bone mineral density and such coverage

shall not be subject to annual deductibles or coinsurance:

(i) evidence-based items or services for bone mineral density 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 bone mineral density 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).

(14) No group or blanket policy delivered or issued for delivery in

this state which provides medical, major medical or similar

comprehensive-type coverage shall exclude coverage for services covered

under such policy when provided by a comprehensive care center for

eating disorders pursuant to article thirty of the mental hygiene law;

provided, however, that reimbursement under such policy for services

provided through such comprehensive care centers shall, to the extent

possible and practicable, be structured in a manner to facilitate the

individualized, comprehensive and integrated plans of care which such

centers' network of practitioners and providers are required to provide.

(15)(A) No group or blanket 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 group or blanket 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.

(16)(A) Every group or blanket 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.

(17) 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 verity the prescription.

(18) Every group or blanket 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.

(19) Every group or blanket accident and health insurance policy

delivered or issued for delivery in this state 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.

(20) No group or blanket 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.

(21) Every group or blanket 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.

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

coverage and which offers maternity care coverage pursuant to paragraph

five 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) Notwithstanding any other provision, a group policy that provides

hospital, surgical, or medical expense coverage delivered or issued for

delivery in this state to a religious employer, as defined in item one

of subparagraph (E) of paragraph sixteen of subsection (l) of this

section, may exclude coverage for abortion only if the insurer:

(i) obtains an annual certification from the group policyholder that

the policyholder is a religious employer and that the religious employer

requests a policy without coverage for abortion;

(ii) issues a rider to each certificate holder at no premium to be

charged to the certificate holder or religious employer for the rider,

that provides coverage for abortion subject to the same rules as would

have been applied to the same category of treatment in the policy issued

to the religious employer. The rider shall clearly and conspicuously

specify that the religious employer does not administer abortion

benefits, but that the insurer is issuing a rider for coverage of

abortion, and shall provide the insurer's contact information for

questions; and

(iii) provides notice of the issuance of the policy and rider to the

superintendent in a form and manner acceptable to the superintendent.

(23) (A) Every group or blanket 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 provide 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.

(l) (1) Every insurer delivering a group policy or issuing a group

policy 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 policyholder, 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 care visits per

policy year. Such coverage shall be provided pursuant to regulations

prescribed by the superintendent. Written notice of the availability of

such coverage shall be delivered to the policyholder prior to inception

of such group policy and annually thereafter, except that this notice

shall not be required where a policy covers two hundred or more

employees or where the benefit structure was the subject of collective

bargaining affecting persons who are employed in more than one state.

(2) (A) Every insurer delivering a group policy or issuing a group

policy 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. Written

notice of the availability of such coverage shall be delivered to the

policyholder prior to inception of such group policy and annually

thereafter, except that this notice shall not be required where a policy

covers two hundred or more employees or where the benefit structure was

the subject of collective bargaining affecting persons who are employed

in more than one state.

(B) 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.

(C) In this paragraph, care in a nursing home 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 admittance to the nursing home or the skilled

nursing facility; and

(iii) further hospitalization would otherwise be necessary.

(D) In determining the total days of coverage for nursing home care

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, need

not exceed the number of covered days of hospital care provided under

the contract in a benefit period.

(E) The level of benefits to be provided for nursing home care must be

reasonably related to the benefits provided for hospital care.

(3) (A) Every insurer delivering a group policy or issuing a group

policy for delivery, in this state, which provides coverage for

in-patient hospital care must make available and if requested by the

policyholder provide coverage to residents in this state for ambulatory

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. Written notice of the availability of such coverage

shall be delivered to the policyholder prior to inception of such group

policy and annually thereafter, except that this notice shall not be

required where a policy covers two hundred or more employees or where

the benefit structure was the subject of collective bargaining affecting

persons who are employed in more than one state.

(B) In this paragraph:

(i) "Ambulatory care in hospital out-patient facilities" means

services for diagnostic X-rays, laboratory and pathological

examinations, physical and occupational therapy and radiation therapy,

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, are ordered by a physician and, 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 for

physical therapy be provided 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.

(ii) "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.

(C) Such coverage shall be made available at the inception of all new

policies and, with respect to policies issued before January first,

nineteen hundred eighty-three, at the first annual anniversary date

thereafter, without evidence of insurability and at any subsequent

annual anniversary date subject to evidence of insurability.

(4) (A) Every insurer delivering a group policy or issuing a group

policy for delivery, in this state, that provides reimbursement for

psychiatric or psychological services or for the diagnosis and treatment

of mental health conditions, however defined in such policy, by

physicians, psychiatrists or psychologists, shall provide the same

coverage to insureds for such services when performed by 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 and mental health counselors, marriage and family

therapists, and psychoanalysts licensed pursuant to article one hundred

sixty-three of the education law, within the lawful scope of his or her

practice. 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) The state board for social work shall maintain a list of all

licensed clinical social workers qualified for reimbursement under this

paragraph.

(C) Such coverage shall be made available at the inception of all new

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

annual anniversary date of the policy subject to evidence of

insurability.

(E) The state board for social work shall maintain a list of all

licensed clinical social workers qualified for reimbursement under

subparagraph (D) of this paragraph.

(5) (A) Every insurer delivering a group or school blanket policy or

issuing a group or school blanket policy for delivery, in this state,

which provides coverage for inpatient hospital care or coverage for

physician services shall provide coverage for the diagnosis and

treatment of mental health conditions and:

* (i) where the policy provides coverage for inpatient hospital care,

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,

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, it

shall include benefits for outpatient care provided by a psychiatrist or

psychologist licensed to practice in this state, or a mental health

counselor, marriage and family therapist, or psychoanalyst licensed

pursuant to article one hundred sixty-three of the education law, or 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 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, co-pays and coinsurance as may be deemed appropriate by the

superintendent and shall be consistent with those imposed on other

benefits under the policy. Provided that no copayment or coinsurance

imposed for outpatient mental health services provided in a facility

licensed, certified or otherwise authorized by the office of mental

health shall exceed the copayments or coinsurance imposed for a primary

care office visit 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.

(6) * (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.

* NB Effective until January 1, 2027

* (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.

* NB Effective January 1, 2027

* (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.

* NB Effective until January 1, 2027

* (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.

* NB Effective January 1, 2027

(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.

* NB Effective until January 1, 2027

* (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.

* NB Effective January 1, 2027

* (E) The criteria for medical necessity determinations under the

policy with respect to inpatient substance use disorder benefits shall

be made available by the insurer to any insured, prospective insured, or

in-network provider upon request.

* NB Effective until January 1, 2027

* (E) The criteria for medical necessity determinations under the

policy with respect to inpatient substance-related and addictive

disorder benefits shall be made available by the insurer to any insured,

prospective insured, or in-network provider upon request.

* NB Effective January 1, 2027

* (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.

* NB Effective until January 1, 2027

* (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.

* NB Effective January 1, 2027

(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).

* (7) (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 treatment programs and 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.

(C-1) A large group policy that provides coverage under this paragraph

shall not impose copayments or coinsurance for outpatient substance use

disorder services that exceeds the copayment or coinsurance imposed for

a primary care office visit. Provided that no greater than one such

copayment may be imposed for all services provided in a single day by a

facility licensed, certified or otherwise authorized by the office of

alcoholism and substance abuse services to provide outpatient substance

use disorder services.

(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

* (7) (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

treatment programs and 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.

(C-1) A large group policy that provides coverage under this paragraph

shall not impose copayments or coinsurance for outpatient

substance-related and addictive disorder services that exceeds the

copayment or coinsurance imposed for a primary care office visit.

Provided that no greater than one such copayment may be imposed for all

services provided in a single day by a facility licensed, certified or

otherwise authorized by the office of addiction services and supports to

provide outpatient substance-related and addictive disorder services.

(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 a

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

(7-a) * (A) No policy that provides medical, major medical or similar

comprehensive-type small group 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. Every policy that provides medical, major medical or

similar comprehensive-type large group coverage shall provide coverage

for prescription drugs for medication for the treatment of a substance

use disorder and shall not 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.

* NB Effective until January 1, 2027

* (A) No policy that provides medical, major medical or similar

comprehensive-type small group 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. Every policy that provides medical, major medical or

similar comprehensive-type large group coverage shall provide coverage

for prescription drugs for medication for the treatment of a

substance-related and addictive disorder and shall not 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.

* NB Effective January 1, 2027

(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.

(7-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.

(8) (A) Every insurer issuing a group policy for delivery in this

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

coverage shall provide coverage for the provision of preventive and

primary care services.

(B) In 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 of age:

(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 group policy that provides hospital, surgical or

medical care coverage, except for a grandfathered health plan under

subparagraph (G) 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, and 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.

(F) The requirements of this paragraph shall also be applicable to a

blanket policy of hospital, medical or surgical expense insurance

covering students pursuant to subparagraph (C) of paragraph three of

subsection (a) of section four thousand two hundred thirty-seven of this

chapter.

(G) 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).

(9) Every insurer issuing a group policy for delivery in this state

which policy provides coverage for any service within the lawful scope

of practice of a duly licensed registered professional nurse, must make

available, and if requested by the contract holder, provide

reimbursement for such service when such service is performed by a duly

licensed registered professional nurse provided, however, that

reimbursement shall not be made for nursing services provided to an

insured in a general hospital, nursing home or a facility providing

health related services, as such terms are defined in section

twenty-eight hundred one of the public health law, or in a facility, as

such term is defined in subdivision six of section 1.03 of the mental

hygiene law, or in a physician's office. Such coverage may be subject to

annual deductibles and co-insurance as may be deemed appropriate by the

superintendent and are consistent with those imposed on other benefits

within a given policy. Such coverage shall not replace, restrict or

eliminate existing coverage provided by the policy. Coverage for the

services of a duly licensed registered professional nurse need be

provided only if the nature of the patient's illness or condition

requires nursing care which can appropriately be provided by a person

with the education and professional skill of a registered professional

nurse and the nursing care is necessary in the treatment of the

patient's illness or condition. Written notice of the availability of

such coverage shall be delivered to the policyholder prior to inception

of such group policy and annually thereafter, except that this notice

shall not be required where a policy covers two hundred or more

employees or where the benefit structure was the subject of collective

bargaining affecting persons who are employed in more than one state.

(10) (A) Every insurer issuing a group policy for delivery in this

state which provides coverage for inpatient hospital care must make

available and if requested by the policyholder provide coverage for

hospice care. Written notice of the availability of such coverage shall

be delivered to the policyholder prior to inception of such group policy

and annually thereafter, except that this notice shall not be required

where a policy covers two hundred or more employees or where the benefit

structure was the subject of collective bargaining affecting persons who

are employed in more than one state.

(B) For the purposes of this paragraph, hospice care shall mean the

care and treatment of a covered person who has been certified by such

person's primary attending physician as having a life expectancy of six

months or less and which is provided by a hospice organization certified

pursuant to article forty of the public health law or under a similar

certification process required by the state in which the hospice

organization is located.

(C) Hospice care coverage shall be at least equal to: (i) a total of

two hundred ten days of coverage beginning with the first day on which

care is provided, for inpatient hospice care in a hospice or in a

hospital and home care and outpatient services provided by the hospice,

including drugs and medical supplies, and (ii) five visits for

bereavement counseling services, either before or after the insured's

death, provided to the family of the terminally ill insured.

(D) Such coverage shall be made available at the inception of all new

policies and, with respect to policies issued before the effective date

of this provision, at the first annual anniversary date thereafter,

without evidence of insurability and at any subsequent annual

anniversary date subject to evidence of insurability.

(E) Such coverage may be subject to annual deductibles and coinsurance

as may be deemed appropriate by the superintendent and are consistent

with those imposed on other benefits within a given policy period.

(11) (A) Every insurer delivering a group or blanket policy or issuing

a group or blanket policy for delivery in this state 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;

(iv) for large group policies that provide coverage for hospital,

surgical or medical care, an annual mammogram for covered persons aged

thirty-five through thirty-nine, inclusive, upon the recommendation of a

physician, subject to the insurer's determination that the mammogram is

medically necessary; and

(v) 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 group or blanket 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-b) (A) Every large group 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 large group policy

which provides major medical or similar comprehensive-type coverage

shall provide, upon the prescription of a health care provider acting

within the provider's scope of practice pursuant to title eight of the

education law, coverage for colorectal cancer preventive screenings in

accordance with the American Cancer Society Guidelines for colorectal

cancer screening of average risk individuals. The coverage required by

this paragraph shall also include coverage for all additional colorectal

cancer examinations and laboratory tests recommended in accordance with

the American Cancer Society Guidelines for colorectal cancer screening

of average risk individuals, including an initial colonoscopy or other

medical test or procedure for colorectal cancer screening and a

follow-up colonoscopy performed as a result of a positive result on a

non-colonoscopy preventive screening test. A large group policy shall

cover colorectal cancer screenings, examinations, and laboratory tests

described in this paragraph upon any policy issuance or renewal that

occurs six months after the date the guideline described in this

paragraph is issued.

(B) An insured shall not be subject to a deductible, coinsurance, or

any other cost-sharing requirements for services consistent with

subparagraph (A) of this paragraph received from participating

providers.

(11-c) (A) Every insurer delivering a group or blanket policy or

issuing a group or blanket policy for delivery in this state that

provides coverage for 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 insurer delivering a group or blanket policy or issuing

a group or blanket policy for delivery in this state 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.

(12-b) (A) Every large group policy delivered or issued for delivery

in this state that provides medical, major medical, or similar

comprehensive-type coverage and provides coverage cancer chemotherapy

treatment shall provide coverage for scalp cooling systems used in

connection with cancer chemotherapy treatment. Coverage provided under

this paragraph 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.

(B) For the purposes of this paragraph, "scalp cooling system" means

any device used to cool the human scalp to prevent or reduce hair loss

during cancer chemotherapy treatment, provided that such device is

designed and intended for repeated use and is primarily and customarily

used to serve a medical purpose.

(13) Consistent with federal law every insurer delivering a group

policy or issuing a group policy 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 policyholder, 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 the

policyholder at the inception of 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.

(14) (A) Every group or blanket policy delivered or issued for

delivery in this state that provides hospital, surgical or medical

coverage 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 group or blanket policy that provides hospital, surgical or

medical 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) Every group or blanket policy delivered or issued for delivery

in this state 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

affected 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.

(16) (A) Every group or blanket policy that provides medical, major

medical, or similar comprehensive type coverage that is issued, amended,

renewed, effective or delivered on or after January first, two thousand

twenty, shall provide coverage for all of the following services and

contraceptive methods:

(1) All FDA-approved contraceptive drugs, devices, and other products.

This includes all FDA-approved over-the-counter contraceptive drugs,

devices, and products as prescribed or as otherwise authorized under

state or federal law. The following applies to this coverage:

(a) 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 group or blanket policy 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 paragraph;

(b) if the covered therapeutic and pharmaceutical equivalent versions

of a drug, device, or product are not available or are deemed medically

inadvisable a group or blanket policy shall provide coverage for an

alternate therapeutic and pharmaceutical equivalent version of the

contraceptive drug, device, or product without cost-sharing. 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 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; and

(d) this coverage must allow for the dispensing of up to twelve months

worth of a contraceptive at one time;

(2) 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;

(3) Patient education and counseling on contraception; and

(4) Follow-up services related to the drugs, devices, products, and

procedures covered under this paragraph, including, but not limited to,

management of side effects, counseling for continued adherence, and

device insertion and removal.

(B) A group or blanket policy subject to this paragraph shall not

impose a deductible, coinsurance, copayment, or any other cost-sharing

requirement on the coverage provided pursuant to this paragraph.

(C) Except as otherwise authorized under this paragraph, a group or

blanket policy shall not impose any restrictions or delays on the

coverage required under this paragraph.

(D) Benefits for an enrollee under this paragraph shall be the same

for an enrollee's covered spouse or domestic partner and covered

nonspouse dependents.

(E) Notwithstanding any other provision of this subsection, a

religious employer may request a contract without coverage for federal

food and drug administration approved contraceptive methods that are

contrary to the religious employer's religious tenets. If so requested,

such contract shall be provided without coverage for contraceptive

methods. This paragraph shall not be construed to deny an enrollee

coverage of, and timely access to, contraceptive methods.

(1) For purposes of this subsection, a "religious employer" is an

entity for which each of the following is true:

(a) The inculcation of religious values is the purpose of the entity.

(b) The entity primarily employs persons who share the religious

tenets of the entity.

(c) The entity serves primarily persons who share the religious tenets

of the entity.

(d) The entity is a nonprofit organization as described in Section

6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.

(2) Every religious employer that invokes the exemption provided under

this paragraph shall provide written notice to prospective enrollees

prior to enrollment with the plan, listing the contraceptive health care

services the employer refuses to cover for religious reasons.

(F) (1) Where a group policyholder makes an election not to purchase

coverage for contraceptive drugs or devices in accordance with

subparagraph (E) of this paragraph each certificateholder covered under

the policy issued to that group policyholder shall have the right to

directly purchase the rider required by this paragraph from the insurer

which issued the group policy at the prevailing small group community

rate for such rider whether or not the employee is part of a small

group.

(2) Where a group policyholder makes an election not to purchase

coverage for contraceptive drugs or devices in accordance with

subparagraph (E) of this paragraph, the insurer that provides such

coverage shall provide written notice to certificateholders upon

enrollment with the insurer of their right to directly purchase a rider

for coverage for the cost of contraceptive drugs or devices. The notice

shall also advise the certificateholders of the additional premium for

such coverage.

(G) Nothing in this paragraph shall be construed as authorizing a

group or blanket policy which provides coverage for prescription drugs

to exclude coverage for prescription drugs prescribed for reasons other

than contraceptive purposes.

(H) For the purposes of this paragraph, "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.

(17) (A) Every group or blanket accident and health insurance policy

delivered or issued for delivery in this state which provides coverage

for hospital or surgical care coverage shall not exclude coverage for

screening, diagnosis and treatment of medical conditions otherwise

covered by the policy because the treatment is provided to diagnose or

treat autism spectrum disorder.

(B) Every group or blanket 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 group or blanket policy. This

paragraph shall not be construed as limiting the benefits that are

otherwise available to an individual under the group or blanket 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 group or

blanket 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).

(18) (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 insurer delivering a group or blanket policy or issuing a

group or blanket policy for delivery in this state 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 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 section shall not supersede the terms of a collective bargaining

agreement or apply to a policy that is the result of a collective

bargaining agreement between an employer and a recognized or certified

employee organization.

(19) 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.

* (20) 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.

* NB There are 2 par (20)'s

* (20) Every insurer delivering a group or blanket policy or issuing a

group or blanket policy for delivery in this state 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.

* NB There are 2 par (20)'s

* (21) Every large group policy which provides medical, major medical,

or comprehensive-type coverage shall include coverage for the cost of

pre-exposure prophylaxis (PrEP) for the prevention of HIV and

post-exposure prophylaxis to prevent HIV infection. Such coverage may be

subject to annual deductibles, coinsurance, and copayments as may be

deemed appropriate by the superintendent and as are consistent with

those established for other benefits within a given policy, unless the

pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis has in

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

United States preventive services task force.

* NB There are 2 par (21)'s

* (21) Every group or blanket policy delivered or issued for delivery

in this state that provides coverage for a prescription drug 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 prescription drugs 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

* (21) Every group or blanket policy delivered or issued for delivery

in this state that provides coverage for a prescription drug 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 prescription drugs 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 (21)'s

(22) Every group or blanket policy delivered or issued for delivery in

this state that provides coverage for antiretroviral prescription drugs

for the treatment or prevention of the human immunodeficiency virus

(HIV) or acquired immunodeficiency syndrome (AIDS) shall not subject

such drug to a prior authorization requirement.

* (23) (A) Every group or blanket accident and health insurance policy

issued or issued for delivery in this state 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 (23)'s

* (23) (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 (23)'s

(m) A group policy providing hospital, surgical or medical expense

insurance for other than accident only shall provide that if all or any

portion of the insurance on an employee or member insured under the

policy ceases because of termination of employment or membership in the

class or classes eligible for coverage under the policy, such employee

or member shall be entitled without evidence of insurability upon

application to continue his hospital, surgical or medical expense

insurance for himself or herself and his or her eligible dependents,

subject to all of the group policy's terms and conditions applicable to

those forms of benefits and to the following conditions:

(1) Continuation shall cease on the date which the employee, member or

dependant first becomes, after the date of election: (A) entitled to

coverage under title XVIII of the United States Social Security Act

(Medicare) as amended or superseded; or (B) covered as an employee,

member or dependent by any other insured or uninsured arrangement which

provides hospital, surgical or medical coverage for individuals in a

group which does not contain any exclusion or limitation with respect to

any pre-existing condition of such employee, member or dependent, except

the group insurance policy conversion option of this section shall not

be considered as such an arrangement under which an employee, member or

dependent could become covered.

(2) (A) An employee or member who wishes continuation of coverage must

request such continuation in writing within the sixty day period

following the later of: (i) the date of such termination; or (ii) the

date the employee is sent notice by first class mail of the right of

continuation by the group policyholder.

(B) An employee or member who wishes continuation of coverage under

subparagraph (D) of paragraph four of this subsection must give notice

to the employer or group policyholder within sixty days of the

determination under title II or title XVI of the United States Social

Security Act that such employee or member was disabled at the time of

termination of employment or membership or at any time during the first

sixty days of continuation of coverage.

(3) An employee or member electing continuation must pay to the group

policyholder or his employer, but not more frequently than on a monthly

basis in advance, the amount of the required premium payment, but not

more than one hundred two percent of the group rate for the benefits

being continued under the group policy on the due date of each payment.

The employee's or member's written election of continuation, together

with the first premium payment required to establish premium payment on

a monthly basis in advance, must be given to the policyholder or

employer within sixty days of the date the employee's or member's

benefits would otherwise terminate.

(4) Subject to paragraph one of this subsection, continuation of

benefits under the group policy for any person shall terminate at the

first to occur of the following:

(A) The date thirty-six months after the date the employee's or

member's benefits under the policy would otherwise have terminated

because of termination of employment or membership; or

(B) The end of the period for which premium payments were made, if the

employee or member fails to make timely payment of a required premium

payment; or

(C) In the case of an eligible dependent of an employee or member, the

date thirty-six months after the date such person's benefits under the

policy would otherwise have terminated by reason of:

(i) the death of the employee or member;

(ii) the divorce or legal separation of the employee or member from

his or her spouse;

(iii) the employee or member becoming entitled to benefits under title

XVIII of the United States Social Security Act (Medicare); or

(iv) a dependent child ceasing to be a dependent child under the

generally applicable requirements of the policy; or

(D) The date on which the group policy is terminated or, in the case

of an employee, the date his employer terminates participation under the

group policy. However, if this clause applies and the coverage ceasing

by reason of such termination is replaced by similar coverage under

another group policy, the following shall apply:

(i) The employee or member shall have the right to become covered

under that other group policy, for the balance of the period that he

would have remained covered under the prior group policy in accordance

with this subparagraph had a termination described in this subparagraph

not occurred, and

(ii) The minimum level of benefits to be provided by the other group

policy shall be the applicable level of benefits of the prior group

policy reduced by any benefits payable under that prior group policy,

and

(iii) The prior group policy shall continue to provide benefits to the

extent of its accrued liabilities and extension of benefits as if the

replacement had not occurred.

(5) A notification of the continuation privilege and the time period

in which to request continuation shall be included in each certificate

of coverage.

(6) This subsection shall not be applicable where a continuation

benefit is available to the employee or member pursuant to Chapter 18 of

the Employee Retirement Income Security Act, 29 U.S.C. § 1161 et seq or

Chapter 6A of the Public Health Service Act, 42 U.S.C. § 300 bb - 1 et

seq. However, a group policy shall offer an insured who has exhausted

continuation coverage pursuant to Chapter 18 of the Employee Retirement

Income Security Act, 29 U.S.C. § 1161 et seq. or Chapter 6A of the

Public Health Service Act, 42 U.S.C. § 300 bb - 1 et seq. the

opportunity to continue coverage for up to thirty-six months from the

date the employee's or member's continuation coverage began, if the

employee or member is entitled to less than thirty-six months of

continuation benefits under federal law.

(7)(A) Special enrollment period. An individual who does not have an

election of continuation coverage as described in this subsection in

effect on the effective date of the American Recovery and Reinvestment

act of 2009, but who would be an assistance eligible individual under

Title III of such act if such election were in effect, may elect

continuation coverage pursuant to this subsection. Such election shall

be made no later than sixty days after the date the administrator of the

group health plan (or other entity involved) provides the notice

required by section 3001(a)(7) of the American Recovery and Reinvestment

act of 2009. The administrator of the group health plan (or other entity

involved) shall provide such individuals with additional notice of the

right to elect coverage pursuant to this paragraph within sixty days of

the date of enactment of the American Recovery and Reinvestment act of

2009.

(B) Continuation coverage elected pursuant to subparagraph (A) of this

paragraph shall commence with the first period of coverage beginning on

or after the date of the enactment of the American Recovery and

Reinvestment act of 2009 and shall not extend beyond the period of

continuation coverage that would have been required if the coverage had

instead been elected pursuant to paragraph two of this subsection.

(C) With respect to an individual who elects continuation coverage

pursuant to subparagraph (A) of this paragraph, the period beginning on

the date of the qualifying event and ending on the date of the first

period of coverage on or after the enactment of the American Recovery

and Reinvestment act of 2009 shall be disregarded for purposes of

determining the sixty-three day period referred to in section three

thousand two hundred thirty-two of this article.

(8) For purposes of this subsection, the term "dependent" shall

include a child as described in subsection (f) of section four thousand

two hundred thirty-five of this chapter.

(n) In addition to all the rights of conversion and continuation

otherwise provided for herein, employees or members insured under 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 to

have supplementary conversion and continuation rights in certain

circumstances as follows:

(1) If the employee or member insured enters upon active duty as

defined in subsection (o) of this section, and the employer or group

policyholder does not voluntarily maintain coverage for such employee or

member insured, the employee or member insured shall be entitled to have

his or her coverage continued under the group policy in accordance with

the conditions and limitations contained in paragraph seven of this

subsection and have issued at the end of the period of continuation an

individual conversion policy subject to the terms of this subsection.

The effective date for the conversion policy shall be the day following

the termination of insurance under the group policy, or if there is a

continuation of coverage on the day following the end of the period of

continuation.

(2) If the employer or group policyholder does not voluntarily

maintain coverage for the employee or member insured during the period

of active duty, and such employee or member insured does not elect the

supplementary conversion and continuation rights provided for herein,

coverage for such employee or member insured shall be suspended during

the period of active duty.

(3) If the employee or member insured elects the supplementary

continuation right provided for herein or coverage under the group plan

is suspended, and such employee or member insured dies during the period

of active duty, the conversion right provided by this section shall be

available to the surviving spouse and children, and shall be available

to a child solely with respect to himself or herself upon his or her

attaining the limiting age of coverage under the group policy while

covered as a dependent thereunder. It shall also be available upon the

divorce or annulment of the marriage of the employee or member insured,

to the former spouse of such employee or member insured, if such divorce

or annulment occurs during the period of active duty.

(4) If the employee or member insured elects the supplementary

conversion and continuation right provided for herein or coverage under

the group plan is suspended, and such employee or member insured is

either reemployed or restored to participation in the group upon return

to civilian status, he or she shall be entitled to resume participation

in insurance offered by the group pursuant to this section, 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. The right

of resumption provided for herein shall extend to coverage for the

spouse and dependents of the employee or member insured and 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.

(5) If the employee or member insured elects the supplementary

conversion and continuation coverage provided for herein:

(A) when such employee or member insured is either reemployed or

restored to participation in the group, coverage under the supplementary

rights provided for herein shall terminate on the date that coverage is

effective due to resumption of participation in the group.

(B) when such employee or member insured is not reemployed or restored

to participation in the group upon return to civilian status, he or she

shall be entitled to the conversion and continuation rights provided by

subsections (e) and (m) of this section.

(i) To elect an individual conversion policy pursuant to subsection

(e) of this section, the employee or member insured must apply to the

insurer within thirty-one days of the termination of active duty or

discharge from hospitalization incident to such active duty, which

hospitalization continues for a period of not more than one year. Upon

commencement of coverage under the conversion right provided pursuant to

subsection (e) of this section, coverage under the supplementary

continuation right provided for herein shall terminate.

(ii) To elect continuation of coverage pursuant to subsections (e) and

(m) of this section, the employee or member insured must request such

continuation of the employer within thirty-one days of the termination

of active duty or discharge from hospitalization incident to such active

duty, which hospitalization continues for a period of not more than one

year. Upon commencement of coverage under the continuation right

provided pursuant to subsection (e) of this section, coverage under the

supplementary continuation right provided for herein shall terminate.

The employee or member insured shall be entitled to have issued at the

end of the period of continuation an individual conversion policy.

(6) If coverage under the group plan is suspended during the period of

active duty:

(A) when the employee or member insured returns to participation in

the group plan, coverage under the group plan shall be retroactive to

the date of termination of the period of active duty.

(B) when such employee or member insured is not reemployed or restored

to participation in the group upon return to civilian status, he or she

shall be entitled to the conversion and continuation rights provided by

subsections (e) and (m) of this section.

(i) To elect an individual conversion policy pursuant to subsection

(e) of this section, the employee or member insured must apply to the

insurer within thirty-one days of the termination of active duty or

discharge from hospitalization incident to such active duty, which

hospitalization continues for a period of not more than one year.

(ii) To elect continuation of coverage pursuant to subsections (e) and

(m) of this section, the employee or member insured must request such

continuation of the employer within thirty-one days of the termination

of active duty or discharge from hospitalization incident to such active

duty, which hospitalization continues for a period of not more than one

year. The employee or member insured shall be entitled to have issued at

the end of the period of continuation an individual conversion policy.

(7) A group policy providing hospital, surgical or medical expense

insurance for other than accident only shall provide that if all or any

portion of the insurance on an employee or member insured under the

policy ceases because the employee or member insured is ordered to

active duty as defined in subsection (o) of this section, such employee

or member insured shall be entitled, without evidence of insurability,

upon application to continue his or her hospital, surgical or medical

expense insurance for himself or herself and his or her eligible

dependents, under the supplementary conversion and continuation rights

provided for herein, subject to all of the group policy's terms and

conditions applicable to those forms of benefits and to the following

conditions:

(A) continuation shall not be available for: (i) any person who is

covered, becomes covered or could be covered by title XVIII of the

United States Social Security Act (Medicare) as amended or superseded or

(ii) an employee, member or dependent who is covered, becomes covered or

could become covered as an employee, member or dependent by any other

insured or uninsured arrangement which provides hospital, surgical or

medical coverage for individuals in a group, except that the coverage

available to active duty members of the uniformed services and their

family members shall not be considered a group under the terms of this

subsection, and except that the group insurance policy conversion option

of this section shall not be considered as such an arrangement under

which an employee, member or dependent could become covered.

(B) an employee or member insured who wishes continuation of coverage

pursuant to this subsection must request such continuation in writing

within sixty days of being ordered to active duty.

(C) an employee or member insured electing continuation pursuant to

this subsection must pay to the group policyholder or his or her

employer, but not more frequently than on a monthly basis in advance,

the amount of the required premium payment, but not more than the group

rate for the benefits being continued under the group policy on the due

date of each payment.

(8) The supplementary conversion and continuation rights provided for

herein shall apply to:

(A) policies not covered by Chapter 18 of the Employee Retirement

Income Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the

Public Health Service Act, 42 U.S.C. section 300bb-1 et seq;

(B) policies covered by Chapter 18 of the Employee Retirement Income

Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the Public

Health Service Act, 42 U.S.C. section 300bb-1 et seq, when active duty

for reservists and the refusal of an employer to voluntarily maintain

coverage for such period of active duty is not considered a qualifying

event.

(o) To be entitled to the right defined in subsection (n) of this

section a person must be a member of a reserve 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.

(p)(1) Except as provided in this section, if an insurer delivers or

issues for delivery in this state a group or blanket policy which

provides hospital, surgical or medical expense coverage for other than

accident only, the insurer must renew or continue in force such coverage

at the option of the policyholder.

(2) An insurer may nonrenew or discontinue coverage under such a group

or blanket policy based only on one or more of the following:

(A) The policyholder or a participating entity has failed to pay

premiums or contributions in accordance with the terms of the policy or

the insurer has not received timely premium payments.

(B) The policyholder or a participating entity has performed an act or

practice that constitutes fraud or made an intentional misrepresentation

of material fact under the terms of the coverage.

(C) The policyholder has failed to comply with a material plan

provision relating to employer contribution or group participation

rules, as permitted under section four thousand two hundred thirty-five

of this chapter.

(D) The insurer is ceasing to offer group or blanket policies in a

market in accordance with paragraph three or seven of this subsection.

(E) The policyholder ceases to meet the requirements for a group under

section four thousand two hundred thirty-five of this chapter or a

participating employer, labor union, association or other entity ceases

membership or participation in the group to which the policy is issued.

Coverage terminated pursuant to this paragraph shall be done uniformly

without regard to any health status-related factor relating to any

covered individual.

(F) In the case of an insurer that offers a group or blanket policy in

a market through a network plan, there is no longer any enrollee in

connection with such plan who lives, resides, or works in the service

area of the insurer (or in the area for which the insurer is authorized

to do business).

(G) 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.

(3)(A) In any case in which an insurer decides to discontinue offering

a particular class of group or blanket policy of hospital, surgical or

medical expense insurance offered in the small or large group market,

the policy of such class may be discontinued by the insurer in

accordance with this chapter in such market only if:

(i) the insurer provides written notice to each policyholder provided

coverage of this class in such market (and to all employees and member

insureds covered under such coverage) of such discontinuance at least

ninety days prior to the date of discontinuance of such coverage. In

addition to any other information required of notices by the

superintendent, this written notice shall conspicuously include an

explanation, in plain language, of the policyholder's and covered

employee's or member insured's rights under this subparagraph and (B) of

this paragraph, including:

(I) a statement that if the superintendent determines that the covered

employee, member insured, or a dependent has a serious medical

condition, and the covered employee, member insured or dependent within

the previous twelve months utilized a benefit under the policy related

to the serious medical condition that is not covered by the replacement

coverage offered to the policyholder as a result of the discontinuance,

then the superintendent shall require the insurer to offer the

policyholder replacement coverage that includes a benefit that is the

same as or substantially similar to the benefit set forth in the policy

that the insurer discontinued; and

(II) an explanation as to how to contact the superintendent, and the

date by which the superintendent shall be contacted, if the

policyholder, covered employee or member insured believes that the

covered employee, member insured or a dependent has a serious medical

condition, and the covered employee, member insured or dependent within

the previous twelve months utilized a benefit related to the serious

medical condition that may not be covered by the replacement coverage

offered to the policyholder as a result of the discontinuance;

(ii) the insurer offers to each policyholder provided coverage of this

class in such market, the option to purchase all (or, in the case of the

large group market, any) other hospital, surgical and medical expense

coverage currently being offered by the insurer to a group in such

market;

(iii) in exercising the option to discontinue coverage of this class

and in offering the option of coverage under item (ii) of this

subparagraph, the insurer acts uniformly without regard to the claims

experience of those policyholders or any health status-related factor

relating to any particular covered employee, member insured or dependent

or particular new employee, member insured or dependent who may become

eligible for such coverage, and the insurer is not discontinuing the

coverage of this class with the intent or as a pretext to discontinuing

the coverage of any such employee, member insured or dependent; and

(iv) at least ninety days prior to the date of discontinuance of such

coverage, the insurer provides written notice to the superintendent of

such discontinuance, including the reason for the discontinuance, and an

officer or director of the insurer certifies to the superintendent that

the insurer has complied with items (i), (ii) and (iii) of this

paragraph. If such notice does not include the date or dates that the

insurer mailed or delivered the notice to all policyholders, covered

employers and member insureds, the insurer shall notify the

superintendent of such date within seven days of the completion of the

mailing or delivery.

(B) If the superintendent determines that the insurer has not complied

with item (iii) of subparagraph (A) of this paragraph, then the

superintendent may prohibit the insurer from discontinuing the class of

policies and require the insurer to promptly notify every policyholder,

covered employee and member insured that the insurer is not

discontinuing the policies. If the superintendent determines that the

insurer wrongfully discontinued the class of policies pursuant to item

(iii) of subparagraph (A), then the superintendent shall require that

the insurer take remedial action, including offering to group

policyholders the option of reinstating the discontinued policy forms.

If the superintendent determines that the insurer discontinued the class

of policies without compliance with items (i), (ii), or (iv) of

subparagraph (A), and an employee, member insured or dependent covered

under the discontinued policy would have been entitled to relief under

this paragraph, then the superintendent may require that the insurer

offer replacement coverage to an affected policyholder consistent with

item (ii) of subparagraph (C) of this paragraph.

(C) (i) If, within forty-five days after the insurer mails or delivers

the written notice of discontinuance required by item (i) of

subparagraph (A) of this paragraph, the superintendent is notified by a

policyholder or covered employee or member insured that a covered

employee, member insured or dependent has a serious medical condition

and that a benefit utilized by the covered employee, member insured or

dependent within the previous twelve months related to the serious

medical condition may not be covered by the replacement coverage offered

to the policyholder as a result of the discontinuance, then the

superintendent shall, within twenty days of the notification, ask the

insurer to confirm that the covered employee, member insured or

dependent utilize a benefit within the previous twelve months to treat

the medical condition that the covered employee, member insured or

dependent asserts is a serious medical condition, and that the benefit

is not covered by the replacement coverage. The superintendent may

request such additional information as the superintendent may require.

The insurer shall provide all requested information to the

superintendent within five days of receipt of the request.

(ii) If, within twenty days of the superintendent's receipt of all

additional information requested from the insurer, the superintendent

determines that (I) the covered employee, member insured or dependent

has a serious medical condition; and (II) the benefit utilized by the

covered employee, member insured or dependent within the previous twelve

months related to the serious medical condition is not covered by the

replacement coverage offered to the policyholder as a result of the

discontinuance, then the superintendent shall require the insurer to

offer to the policyholder replacement coverage that includes a benefit

that is the same as or substantially similar to the benefit set forth in

the policy that the insurer discontinued. If the replacement coverage is

not available, at the time that the policy would otherwise be

discontinued, then the insurer shall keep the existing policy in force

for the affected policyholder until the replacement coverage with the

substantially similar benefit is available.

(D) The remedies as provided in this paragraph shall be in addition to

and not in lieu of any other authority or power of the superintendent to

impose monetary or other penalties for violations of this paragraph.

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

hospital, surgical and medical expense coverage in the small group

market or the large group market, or both markets, in this state, health

insurance coverage may be discontinued by the insurer only if:

(i) the insurer provides written notice to the superintendent and to

each policyholder (and all employees and member insureds covered under

such coverage) of such discontinuance at least one hundred eighty days

prior to the date of the discontinuance of such coverage;

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

delivered for issuance in this state in such market (or markets) is

discontinued and coverage under such policies in such market (or

markets) is not renewed; and

(iii) in addition to the notice to the superintendent referred to in

item (i) of this subparagraph, the insurer shall provide the

superintendent with a written plan to minimize potential disruption in

the marketplace occasioned by the insurer's withdrawal from the market.

(F) In the case of a discontinuance under subparagraph (E of this

paragraph in a market, the insurer may not provide for the issuance of

any group or blanket policy of hospital, surgical or medical expense

insurance in that market in this state during the five year period

beginning on the date of the discontinuance of the last health insurance

policy not so renewed.

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

insurance coverage for a group or blanket policy offered to a large or

small group policyholder so long as such modification is consistent with

this chapter and effective on a uniform basis among all small group

policyholders with that policy form.

(5) 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 either with the insurer or another entity which has contracted

with the insurer.

(6) For purposes of this subsection, the term "dependent" shall

include a child as described in subsection (f) of section four thousand

two hundred thirty-five of this chapter.

(7) Notwithstanding paragraph three of this subsection, an insurer may

discontinue offering a particular class of group or blanket policy of

hospital, surgical or medical expense insurance offered in the small or

large group market, and instead offer a group or blanket policy of

hospital, surgical or medical expense insurance that complies with the

requirements of section 2707 of the public health service act, § 42

U.S.C. 300gg-6 that become applicable to such policy as of January

first, two thousand fourteen, provided that the insurer:

(A) discontinues the existing class of policy in such market as of

either December thirty-first, two thousand thirteen or the policy

renewal date occurring in two thousand fourteen in accordance with this

chapter;

(B) provides written notice to each policyholder provided coverage of

the class in the market (and to all employees and member insureds

covered under such coverage) of the discontinuance at least ninety days

prior to the date of discontinuance of such coverage. The written notice

shall be in a form satisfactory to the superintendent;

(C) offers to each policyholder provided coverage of the class in the

market, the option to purchase all (or, in the case of the large group

market, any) other hospital, surgical and medical expense coverage that

complies with the requirements of section 2707 of the public health

service act, 42 U.S.C. § 300gg-6 that become applicable to such coverage

as of January first, two thousand fourteen, currently being offered by

the insurer to a group in that market;

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

in offering the option of coverage under subparagraph (C) of this

paragraph, acts uniformly without regard to the claims experience of

those policyholders or any health status-related factor relating to any

particular covered employee, member insured or dependent, or particular

new employee, member insured, or dependent who may become eligible for

such coverage, and does not discontinue the coverage of the class with

the intent or as a pretext to discontinuing the coverage of any such

employee, member insured, or dependent; and

(E) at least one hundred twenty days prior to the date of the

discontinuance of such coverage, provides written notice to the

superintendent of the discontinuance, including certification by an

officer or director of the insurer that the reason for the

discontinuance is to replace the coverage with new coverage that

complies with the requirements of section 2707 of the public health

service act, § 42 U.S.C. 300gg-6 that become effective January first,

two thousand fourteen. The written notice shall be in such form and

contain such information the superintendent requires.

(q)(1) No insurer delivering or issuing for delivery in this state a

group or blanket policy which provides hospital, surgical or medical

expense coverage shall establish rules for eligibility (including

continued eligibility) of any individual or dependent of the individual

to enroll under the policy based on any of the following health

status-related factors:

(A) Health status.

(B) Medical condition (including both physical and mental illnesses).

(C) Claims experience.

(D) Receipt of health care.

(E) Medical history.

(F) Genetic information.

(G) Evidence of insurability (including conditions arising out of acts

of domestic violence).

(H) Disability.

(2) For purposes of paragraph one of this subsection, rules for

eligibility include rules defining any applicable waiting periods for

such enrollment.

(3) No insurer may, on the basis of any health status-related factor

in relation to the insured or dependent of the insured, require any

insured (as a condition of enrollment or continued enrollment under the

policy) to pay a premium or contribution which is greater than such

premium for a similarly situated insured enrolled in the plan.

(4) Nothing in this subsection shall require an insurer to issue a

group or blanket policy to a group comprised of fifty-one or more lives

exclusive of spouses and dependents.

(5) Where an eligible insured or dependent of an insured rejects

initial enrollment in a group or blanket policy that provides hospital,

surgical or medical expense insurance, an insurer shall permit an

insured or dependent of an insured to enroll for coverage under the

terms of the policy if each of the following conditions is met:

(A) The insured or dependent was covered under another plan or policy

at the time coverage was initially offered.

(B)(i) Coverage under the other plan or policy was provided in

accordance with continuation required by federal or state law and was

exhausted; or

(ii) Coverage under the other plan or policy was subsequently

terminated as a result of loss of eligibility for one or more of the

following reasons:

(I) termination of employment;

(II) termination of the other plan or policy;

(III) death of the spouse;

(IV) legal separation, divorce, or annulment;

(V) reduction in the number of hours of employment; or

(iii) Policyholder contributions toward the payment of premium for the

other plan or contract were terminated.

(C) Coverage must be applied for within thirty days of termination for

one of the reasons set forth in subparagraph (B) of this paragraph.

(6) With respect to group or blanket policies delivered or issued for

delivery in this state covering between two and fifty employees or

members, the provisions of this subsection shall in no way diminish the

rights of such groups pursuant to section three thousand two hundred

thirty-one of this article.

(7) For purposes of this subsection, the term "dependent" shall

include a child as described in subsection (f) of section four thousand

two hundred thirty-five of this chapter.

(r) (1) As used in this subsection, "child" means an unmarried child

through age twenty-nine of an employee or member insured under a group

policy of hospital, medical or surgical expense insurance, regardless of

financial dependence, who is not insured by or eligible for coverage

under any 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 and who is not covered under

title XVIII of the United States Social Security Act (Medicare).

(2) In addition to the conversion privilege afforded by subsection (e)

of this section and the continuation privilege afforded by subsection

(m) of this section, every group policy delivered or issued for delivery

in this state that provides hospital, medical or surgical expense

insurance coverage for other than specific diseases or accidents only,

and which provides coverage of a child that terminates at a specified

age, shall, upon application of the employee, member or child, as set

forth in subparagraph (B) of this paragraph, provide coverage to the

child after that specified age and through age twenty-nine without

evidence of insurability, subject to all of the terms and conditions of

the group policy and the following:

(A) An employer shall not be required to pay all or part of the cost

of coverage for a child provided pursuant to this subsection;

(B) An employee, member or child who wishes to elect continuation of

coverage pursuant to this subsection shall request the continuation in

writing:

(i) within sixty days following the date coverage would otherwise

terminate due to reaching the specified age set forth in the group

policy;

(ii) within sixty days after meeting the requirements for child status

set forth in paragraph one of this subsection when coverage for the

child previously terminated; or

(iii) during an annual thirty-day open enrollment period, as described

in the policy;

(C) An employee, member or child electing continuation as described in

this subsection shall pay to the group policyholder or employer, but not

more frequently than on a monthly basis in advance, the amount of the

required premium payment on the due date of each payment. The written

election of continuation, together with the first premium payment

required to establish premium payment on a monthly basis in advance,

shall be given to the group policyholder or employer within the time

periods set forth in subparagraph (B) of this paragraph. Any premium

received within the thirty-day period after the due date shall be

considered timely;

(D) For any child electing coverage within sixty days of the date the

child would otherwise lose coverage due to reaching a specified age, the

effective date of the continuation coverage shall be the date coverage

would have otherwise terminated. For any child electing to resume

coverage during an annual open enrollment period, the effective date of

the continuation coverage shall be prospective no later than thirty days

after the election and payment of first premium;

(E) Coverage for a child pursuant to this subsection shall consist of

coverage that is identical to the coverage provided to the employee or

member parent. If coverage is modified under the policy for any group of

similarly situated employees or members, then the coverage shall also be

modified in the same manner for any child;

(F) Coverage shall terminate on the first to occur of the following:

(i) the date the child no longer meets the requirements of paragraph

one of this subsection;

(ii) the end of the period for which premium payments were made, if

there is a failure to make payment of a required premium payment within

the period of grace described in subparagraph (C) of this paragraph; or

(iii) the date on which the group policy is terminated and not

replaced by coverage under another group policy; and

(G) The insurer shall provide written notification of the continuation

privilege described in this subsection and the time period in which to

request continuation to the employee or member:

(i) in each certificate of coverage; and

(ii) at least sixty days prior to termination at the specified age as

provided in the policy.

(3)(A) Insurers shall submit such reports as may be requested by the

superintendent to evaluate the effectiveness of coverage pursuant to

this subsection including, but not limited to, quarterly enrollment

reports.

(B) The superintendent may promulgate regulations to ensure the

orderly implementation and operation of the continuation coverage

provided pursuant to this subsection, including premium rate

adjustments.

(s) An insurer subject to the provisions of this article or an

insurance producer subject to this chapter shall not permit the renewal

of a small group policy that provides hospital, surgical or medical

expense coverage that renews on or after January first, two thousand

fourteen, but before July first, two thousand fourteen, so as to renew

the same policy prior to the policy's annual renewal date for the sole

purpose of evading the requirements of the affordable care act and

regulations promulgated thereunder with respect to such policy. An

isolated, inadvertent renewal date change which was not made for the

sole purpose of evading the requirements of the affordable care act

shall not be deemed a violation of this subsection.

(t) (1) Any insurer that delivers or issues for delivery in this state

hospital, surgical or medical expense group policies in the small group

or large group market shall offer to any employer in this state all such

policies in the applicable market, and shall accept at all times

throughout the year any employer that applies for any of those policies.

(2) The requirements of paragraph one of this subsection shall apply

with respect to an employer that applies for coverage either directly

from the insurer or through an association or trust to which the insurer

has issued coverage and in which the employer participates.

(u) (1) 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 subsection and shall not exclude coverage for

the screening, diagnosis or treatment of medical conditions otherwise

covered by the policy.

(2) Nothing in this subsection 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.

* (v) 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