N.Y. Insurance Law § 4303: Benefits

§ 4303. Benefits. (a) Every contract issued by a hospital service

corporation or health service corporation which provides coverage for

in-patient hospital care shall also provide coverage:

(1) For preadmission testing performed in hospital facilities prior to

scheduled surgery. A patient who uses the out-patient facilities of a

hospital shall be entitled to benefits for tests ordered by a physician

which are performed as a planned preliminary to admission of the patient

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

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

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

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

have been made prior to the performance of the tests,

(C) surgery actually takes place within seven days of such presurgical

tests, and

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

(2) (A) For services to treat an emergency condition in hospital

facilities:

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

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

services is a participating provider with respect to such services;

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

provider, without imposing any administrative requirement or limitation

on coverage that is more restrictive than the requirements or

limitations that apply to emergency services received from participating

providers; and

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

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

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

services were provided by a participating provider.

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

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

requirements of this paragraph with respect to coverage of emergency

services shall be applicable to every contract subject to this

paragraph.

(C) For the purpose of this provision, "emergency condition" means a

medical or behavioral condition that manifests itself by acute symptoms

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

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

reasonably expect the absence of immediate medical attention to result

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

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

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

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

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

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

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

(D) For the purpose of this provision, "emergency services" means,

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

examination as required under section 1867 of the Social Security Act,

42 U.S.C. § 1395dd, which is within the capability of the emergency

department of a hospital, including ancillary services routinely

available to the emergency department to evaluate such emergency medical

condition; and (ii) within the capabilities of the staff and facilities

available at the hospital, such further medical examination and

treatment as are required under section 1867 of the Social Security Act,

42 U.S.C. § 1395dd, to stabilize the patient.

(E) For the purpose of this provision, "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 subscriber from a

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

(3) For home care to residents in this state. Such home care coverage

shall be included at the inception of all new contracts and, with

respect to all other contracts, added at any anniversary date of the

contract subject to evidence of insurability. Such coverage may be

subject to an annual deductible of not more than fifty dollars for each

covered person and may be subject to a coinsurance provision which

provides for coverage of not less than seventy-five percent of the

reasonable cost of services for which payment may be made. No such

corporation need provide such coverage to persons eligible for medicare.

(A) Home care shall mean the care and treatment of a covered person

who is under the care of a physician but only if:

(i) hospitalization or confinement in a nursing facility as defined in

subchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq,

would otherwise have been required if home care was not provided, and

(ii) the plan covering the home health service is established and

approved in writing by such physician.

(B) 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.

(C) Home care 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, and

(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 or provided under the contract if the

covered person had been hospitalized or confined in a skilled nursing

facility as defined in subchapter XVIII of the Social Security Act, 42

U.S.C. § 1395 et seq.

(D) 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 covered person. Four hours of home health

aide service shall be considered as one home care visit. Every contract

issued by a hospital service corporation or health service corporation

which provides coverage supplementing part A and part B of subchapter

XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq, must make

available and, if requested by a subscriber holding a direct payment

contract or by all subscribers in a group remittance group or by the

contract holder in the case of group contracts issued pursuant to

section four thousand three hundred five of this article, 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 contract 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 group remitting agent or group contract holder

prior to inception of such contract 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.

The provisions of this subsection shall not apply to a contract issued

pursuant to section four thousand three hundred five of this article

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) Every contract issued by a medical expense indemnity corporation

or a health service corporation 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 contract issued pursuant to section four thousand

three hundred five of this article 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.

(c) (1) (A) Every contract issued by a corporation subject to the

provisions of this article which provides hospital service, medical

expense indemnity or both shall provide coverage for maternity care

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

hospital service, medical expense indemnity or both are provided for

illness or disease under the contract. Such maternity care coverage,

other than coverage for perinatal complications, shall include inpatient

hospital coverage for mother and for newborn for at least forty-eight

hours after childbirth for any delivery other than a caesarean section,

and for at least ninety-six hours following 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.

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

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

performance of any necessary maternal and newborn clinical assessments.

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

time periods established in subparagraph (A) of this paragraph. 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 contract. The contract

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

contract and subject to the provisions of this paragraph, and not

subject to deductibles, coinsurance or copayments.

* (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

(2) Coverage provided under this subsection for care and treatment

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

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

a separate payment for the delivery and postnatal care provided.

(c-1) Any contract issued by a medical expense indemnity corporation,

a hospital service corporation or a health services corporation 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.

(d) (1) A hospital service corporation or a health service corporation

which provides coverage for in-patient hospital care must make available

and, if requested by a person holding a direct payment individual

contract or by all persons holding individual contracts in a group whose

premiums are paid by a remitting agent or by the contract holder in the

case of a group contract issued pursuant to section four thousand three

hundred five of this article, provide coverage for care in nursing

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

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

date subject to evidence of insurability. Written notice of the

availability of such coverage shall be delivered to the group remitting

agent or group contract holder prior to inception of such contract 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) For the purpose of this subsection, care in nursing homes shall

mean 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 two thousand 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. 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. The level of benefits

to be provided for nursing home care must be reasonably related to the

benefits provided for hospital care.

(e) (1) A hospital service corporation or a health service corporation

which provides coverage for in-patient hospital care must make available

and, if requested by a person holding a direct payment individual

contract or by all persons holding individual contracts in a group whose

premiums are paid by a remitting agent or by the contract holder in the

case of a group contract issued pursuant to section four thousand three

hundred five of this article, provide coverage for ambulatory care in

hospital out-patient facilities, as a hospital is defined in section two

thousand eight hundred one of the public health law, or subchapter XVIII

of the Social Security Act, 42 U.S.C. § 1395 et seq. Written notice of

the availability of such coverage shall be delivered to the group

remitting agent or group contract holder prior to inception of such

contract 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) For the purpose of this subsection, ambulatory care in hospital

out-patient facilities shall mean 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 (i) related to and necessary for

the treatment or diagnosis of the patient's illness or injury, (ii)

ordered by a physician and (iii) in the case of physical therapy,

services are to be furnished in connection with the same illness for

which the patient had been hospitalized or in connection with surgical

care, but in no event need benefits 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. Such coverage shall be made available at the inception of all

new contracts and, with respect to all other contracts, at any

anniversary date subject to evidence of insurability.

(f) (1) A medical expense indemnity corporation or a health service

corporation which provides coverage for physicians' services must make

available and, if requested by a person holding an individual direct

payment contract or by all persons holding individual contracts in a

group whose premiums are paid by a remitting agent or by the contract

holder in the case of a group contract issued pursuant to section four

thousand three hundred five of this article, provide coverage for

ambulatory care in physicians' offices. Written notice of the

availability of such coverage shall be delivered to the group remitting

agent or group contract holder prior to inception of such contract 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) For the purpose of this subsection, ambulatory care in physicians'

offices shall mean 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 (i) related to and

necessary for the treatment or diagnosis of the patient's illness or

injury, and (ii) ordered by a physician. Such coverage shall be made

available at the inception of all new contracts and, with respect to all

other contracts at any anniversary date subject to evidence of

insurability.

(g) A medical expense indemnity corporation, hospital service

corporation or a health service corporation, that provides group, group

remittance or school blanket coverage for inpatient hospital care or

coverage for physician services shall provide as part of its contract

coverage for the diagnosis and treatment of mental health conditions

and:

* (1) where the contract provides coverage for inpatient hospital

care, benefits for in-patient care in a hospital as defined by

subdivision ten of section 1.03 of the mental hygiene law or for

inpatient care provided in other states, to similarly licensed

hospitals, and benefits for out-patient 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 out-patient care provided in other states, to

similarly certified facilities; and

* NB Effective until after the superintendent of financial services

and the commissioner of health have promulgated regulations

* (1) where the contract provides coverage for inpatient hospital

care, benefits for: in-patient 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

(2) where the contract provides coverage for physician services such

contract shall provide 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 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.

(3) Such coverage 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 contract.

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 contract.

(4) Coverage under this subsection 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 contract.

(5) The criteria for medical necessity determinations under the

contract with respect to mental health benefits shall be made available

by the corporation to any insured, prospective insured, or in-network

provider upon request.

(6) For purposes of this subsection:

(A) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(B) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement;

* (C) "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

contract; and

* NB Effective until after the superintendent of financial services

and the commissioner of health have promulgated regulations

* (C) "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

contract;

* NB Effective after the superintendent of financial services and the

commissioner of health have promulgated regulations

* (D) "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

* (D) "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

* (E) "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

* (F) "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

* (G) "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

(7) A corporation shall provide coverage under this subsection, 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).

(8) This paragraph 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 corporation's provider

network. Where the contract 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 paragraph 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 corporation 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 corporation to ensure

that the facility is using the evidence-based and peer reviewed clinical

review criteria utilized by the corporation 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 paragraph shall also not be subject to concurrent review during the

first thirty days of the inpatient or residential admission, provided

the facility notifies the corporation 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 corporation to ensure that the facility

is using the evidence-based and peer reviewed clinical review criteria

utilized by the corporation 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 paragraph 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 paragraph other than any copayment, coinsurance, or

deductible otherwise required under the contract.

(9) This paragraph 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 corporation's provider network. Benefits for

care by a crisis stabilization center shall not be subject to

preauthorization. All treatment provided under this paragraph 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 paragraph other than any copayment, coinsurance, or

deductible otherwise required under the contract.

* (10) This paragraph 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 paragraph, "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.

(A) 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 paragraph shall

prevent services provided subsequent to the provision of mobile crisis

intervention services from being subject to preauthorization.

(B) 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.

(C) If the covered services are provided by a non-participating mobile

crisis intervention services provider, a corporation 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.

(D) 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.

(E) 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 contract.

* NB Effective after the superintendent of financial services and the

commissioner of health have promulgated regulations

(11) This paragraph 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. A corporation 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

corporation 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 a

corporation 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, a corporation for the services

provided pursuant to this paragraph, except for the collection of

in-network copayments, coinsurance, or deductibles for which the insured

is responsible for under the terms of the contract.

(12) (A) This subparagraph 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 corporation's provider network. Reimbursement for

covered outpatient treatment provided by such facility shall be at rates

negotiated between the corporation 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 subparagraph, 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.

(B) 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 subparagraph shall be construed to relieve an insurer of the

obligation to reimburse at no less than the applicable minimum rate set

forth in subparagraph (A) of this paragraph. Prior to the submission of

premium rate filings and applications, the superintendent shall provide

corporations 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, corporations may account for such differences in future

premium rate filings and applications submitted to the superintendent

for approval.

(j)(1) A health service corporation or medical expense indemnity

corporation that provides medical, major-medical or similar

comprehensive-type coverage shall provide coverage for the provision of

preventive and primary care services.

(2) For purposes of this paragraph and paragraph one of this

subsection, preventive and primary care services shall mean the

following services rendered to a covered child of a subscriber from the

date of birth through the attainment of nineteen years of age:

(A) 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,

(B) 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

(C) 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.

(D) Such coverage required pursuant to this paragraph and paragraph

one of this subsection shall not be subject to annual deductibles or

coinsurance.

(E) Such coverage required pursuant to this paragraph and paragraph

one of this subsection shall not restrict or eliminate existing coverage

provided by the contract.

(3) In addition to paragraph one or two of this subsection, every

contract that provides hospital, surgical or medical care coverage,

except for a grandfathered health plan under paragraph four of this

subsection, shall provide coverage for the following preventive care and

screenings for subscribers, and such coverage shall not be subject to

annual deductibles or coinsurance:

(A) 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;

(B) 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;

(C) 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

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

screenings not described in subparagraph (A) of this paragraph and as

provided for in comprehensive guidelines supported by the health

resources and services administration.

(4) For purposes of this subsection, "grandfathered health plan" means

coverage provided by a corporation 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).

* (k)(1) Every contract 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

contract.

(2) Coverage provided under this subsection 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.

(3) Coverage provided under this subsection 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 contract.

(4) This paragraph 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 corporation's

provider network. Coverage provided under this subsection shall not be

subject to preauthorization. Coverage provided under this subsection

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 corporation 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 corporation 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 corporation 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 corporation 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 corporation which is designated by the office of

alcoholism and substance abuse services. Prior to discharge, the

facility shall indicate to the corporation whether services included in

the discharge plan are secured or determined to be reasonably available.

Any utilization review of treatment provided under this paragraph 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 corporation

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 corporation 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 paragraph other than any copayment,

coinsurance, or deductible otherwise required under the contract.

(5) The criteria for medical necessity determinations under the

contract with respect to inpatient substance use disorder benefits shall

be made available by the corporation to any insured, prospective insured

or in-network provider upon request.

(6) For purposes of this subsection:

(A) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(B) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement;

(C) "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 contract; and

(D) "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.

(7) A corporation shall provide coverage under this subsection, at a

minimum, consistent with the federal Paul Wellstone and Pete Domenici

Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §

1185a).

* NB Effective until January 1, 2027

* (k)(1) Every contract 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 contract.

(2) Coverage provided under this subsection 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.

(3) Coverage provided under this subsection 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 contract.

(4) This paragraph 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 corporation's

provider network. Coverage provided under this subsection shall not be

subject to preauthorization. Coverage provided under this subsection

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 corporation 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 corporation 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 corporation 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 corporation 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 corporation which is designated by the office of

addiction services and supports. Prior to discharge, the facility shall

indicate to the corporation whether services included in the discharge

plan are secured or determined to be reasonably available. Any

utilization review of treatment provided under this paragraph 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 corporation

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 corporation 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 paragraph other than any copayment, coinsurance, or

deductible otherwise required under the contract.

(5) The criteria for medical necessity determinations under the

contract with respect to inpatient substance-related and addictive

disorder benefits shall be made available by the corporation to any

insured, prospective insured or in-network provider upon request.

(6) For purposes of this subsection:

(A) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(B) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement;

(C) "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 contract; and

(D) "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.

(7) A corporation shall provide coverage under this subsection, at a

minimum, consistent with the federal Paul Wellstone and Pete Domenici

Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §

1185a).

* NB Effective January 1, 2027

* (l) (1) Every contract 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 contract.

(2) Coverage under this subsection may be limited to facilities in

this state that are licensed, certified or otherwise authorized by the

office of addiction services and supports to provide outpatient

substance use disorder services and crisis stabilization centers

licensed pursuant to section 36.01 of the mental hygiene law, and, in

other states, to those which are accredited by the joint commission as

alcoholism or chemical dependence substance abuse treatment programs and

are similarly licensed, certified or otherwise authorized in the state

in which the facility is located.

(3) Coverage provided under this subsection 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 contract.

(3-a) A contract that provides large group coverage under this

subsection shall not impose copayments or coinsurance for outpatient

substance use disorder services that exceed 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.

(4) A contract providing coverage for substance use disorder services

pursuant to this subsection shall provide up to twenty outpatient visits

per contract 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 contract pursuant to this subsection. The

coverage required by this subsection shall include treatment as a family

member pursuant to such family member's own contract provided such

family member:

(A) does not exceed the allowable number of family visits provided by

the applicable contract pursuant to this subsection; and

(B) is otherwise entitled to coverage pursuant to this subsection and

such family member's applicable contract.

(5) This paragraph 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 corporation's provider network. Coverage provided

under this subsection shall not be subject to preauthorization. Coverage

provided under this subsection 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 corporation 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

corporation 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 corporation 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 paragraph 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 corporation 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 corporation which is designated by the office of

alcoholism and substance abuse services. A subscriber shall not have any

financial obligation to the facility for any treatment under this

paragraph other than any copayment, coinsurance, or deductible otherwise

required under the contract.

(6) The criteria for medical necessity determinations under the

contract with respect to outpatient substance use disorder benefits

shall be made available by the corporation to any insured, prospective

insured, or in-network provider upon request.

(7) For purposes of this subsection:

(A) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(B) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement.

(C) "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 contract; and

(D) "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.

(8) A corporation shall provide coverage under this subsection, 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).

(9) This paragraph 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 corporation's provider network. Benefits for

care in a crisis stabilization center shall not be subject to

preauthorization. All treatment provided under this paragraph 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 paragraph other than any copayment, coinsurance, or

deductible otherwise required under the contract.

(10) (A) 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 corporation's provider network.

Reimbursement for covered outpatient treatment provided by such

facilities shall be at rates negotiated between the corporation 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 subparagraph, 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.

(B) 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 subparagraph shall be

construed to relieve an insurer of the obligation to reimburse at no

less than the applicable minimum rate set forth in subparagraph (A) of

this paragraph. Prior to the submission of premium rate filings and

applications, the superintendent shall provide corporations 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, corporations may account for such differences in future

premium rate filings and applications submitted to the superintendent

for approval.

* NB Effective until January 1, 2027

* (l) (1) Every contract 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 contract.

(2) Coverage under this subsection may be limited to facilities in

this state that are licensed, certified or otherwise authorized by the

office of addiction services and supports to provide outpatient

substance-related and addictive disorder services and crisis

stabilization centers licensed pursuant to section 36.01 of the mental

hygiene law, and, in other states, to those which are accredited by the

joint commission as alcoholism, addiction or chemical dependence

substance abuse treatment programs and are similarly licensed, certified

or otherwise authorized in the state in which the facility is located.

(3) Coverage provided under this subsection 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 contract.

(3-a) A contract that provides large group coverage under this

subsection shall not impose copayments or coinsurance for outpatient

substance-related and addictive disorder services that exceed 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.

(4) A contract providing coverage for substance-related and addictive

disorder services pursuant to this subsection shall provide up to twenty

outpatient visits per contract or calendar year to an individual who

identifies themselves as a family member of a person suffering from

substance-related and addictive disorder and who seeks treatment as a

family member who is otherwise covered by the applicable contract

pursuant to this subsection. The coverage required by this subsection

shall include treatment as a family member pursuant to such family

member's own contract provided such family member:

(A) does not exceed the allowable number of family visits provided by

the applicable contract pursuant to this subsection; and

(B) is otherwise entitled to coverage pursuant to this subsection and

such family member's applicable contract.

(5) This paragraph 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 corporation's provider network. Coverage provided

under this subsection shall not be subject to preauthorization. Coverage

provided under this subsection 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 corporation 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

corporation 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 corporation 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 paragraph 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 corporation 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

corporation which is designated by the office of addiction services and

supports. A subscriber shall not have any financial obligation to the

facility for any treatment under this paragraph other than any

copayment, coinsurance, or deductible otherwise required under the

contract.

(6) The criteria for medical necessity determinations under the

contract with respect to outpatient substance-related and addictive

disorder benefits shall be made available by the corporation to any

insured, prospective insured, or in-network provider upon request.

(7) For purposes of this subsection:

(A) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(B) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement.

(C) "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 contract; and

(D) "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.

(8) A corporation shall provide coverage under this subsection, 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).

(9) This paragraph 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 corporation's provider network. Benefits for

care in a crisis stabilization center shall not be subject to

preauthorization. All treatment provided under this paragraph 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 paragraph other than any copayment, coinsurance, or

deductible otherwise required under the contract.

(10) (A) 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 corporation's provider network.

Reimbursement for covered outpatient treatment provided by such

facilities shall be at rates negotiated between the corporation 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 subparagraph, 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.

(B) 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 subparagraph shall be

construed to relieve an insurer of the obligation to reimburse at no

less than the applicable minimum rate set forth in subparagraph (A) of

this paragraph. Prior to the submission of premium rate filings and

applications, the superintendent shall provide corporations 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, corporations may account for such differences in future

premium rate filings and applications submitted to the superintendent

for approval.

* NB Effective January 1, 2027

(l-1) * (A) No contract that provides medical, major medical or

similar comprehensive-type individual or 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 contract, 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

contract 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 of 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 individual covered under

the contract, 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 contract that provides medical, major medical or similar

comprehensive-type individual or 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

contract, 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 contract 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 of 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 individual covered under the

contract, 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.

(l-2) 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.

(m) A medical expense indemnity corporation or a health service

corporation which 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 all subscribers in a group

remittance group, or by a contract holder in the case of a group

contract issued pursuant to section four thousand three hundred five of

this chapter, provide reimbursement for such services when performed by

a duly licensed registered professional nurse provided, however, that

reimbursement shall not be made for nursing services provided to a

subscriber 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 group remitting agent or group

contract holder prior to inception of such contract 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.

(n) Every health service or medical expense indemnity corporation

issuing a group contract pursuant to this section or a group remittance

contract for delivery in this state which contract provides

reimbursement to subscribers or physicians, psychiatrists or

psychologists for psychiatric or psychological services or for the

diagnosis and treatment of mental health conditions, however defined in

such contract, must provide the same coverage to persons covered under

the group contract 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 a mental health counselor, marriage and family

therapist, or psychoanalyst licensed pursuant to article one hundred

sixty-three of the education law. 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. The

state board for social work shall maintain a list of all licensed

clinical social workers qualified for reimbursement under this

subsection. The state board for mental health practitioners shall

maintain a list of all licensed mental health counselors, marriage and

family therapists, or psychoanalysts qualified for reimbursement under

this subsection.

(o) A hospital service corporation or a health service corporation

which provides coverage for inpatient hospital care must make available

and, if requested by all persons holding individual contracts in a group

whose premiums are paid by a remitting agent or by the contractholder in

the case of a group contract issued pursuant to section four thousand

three hundred five of this article, provide coverage for hospice care.

For the purposes of this subsection, 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. Hospice care coverage shall be at least equal

to: (1) 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 (2) five

visits for bereavement counseling services, either before or after the

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

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

contracts and, with respect to contracts 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. 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 contract period. Written notice of the

availability of such coverage shall be delivered to the group remitting

agent or group contract holder prior to inception of such contract 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.

(p) (1) A medical expense indemnity corporation, a hospital service

corporation or a health service corporation that provides coverage for

hospital, surgical or medical care shall provide the following coverage

for mammography screening for occult breast cancer:

(A) 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;

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

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

inclusive;

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

for covered persons aged forty and older;

(D) for large group contracts offered by a medical expense indemnity

corporation, a hospital service corporation or a health service

corporation 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 corporation's determination that the mammogram is medically

necessary;

(E) 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 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; and

* (F) The coverage required in this paragraph or paragraph two of this

subsection 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

* (F) The coverage required in this paragraph or paragraph two of this

subsection 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

(2) For purposes of paragraph one of this subsection, 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 tomosythesis.

(3) In addition to paragraph one or two of this subsection, every

contract that provides coverage for hospital, surgical or medical care,

except for a grandfathered health plan under paragraph four of this

subsection, shall provide coverage for the following mammography

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

deductibles or coinsurance:

(A) 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

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

screenings for mammography not described in subparagraph (A) of this

paragraph and as provided for in comprehensive guidelines supported by

the health resources and services administration.

(4) For purposes of this subsection, "grandfathered health plan" means

coverage provided by a corporation 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).

(p-1) (1) A medical expense indemnity corporation, a hospital service

corporation or a health service corporation 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:

(A) 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;

(B) centers for medicare and medicaid services national coverage

determinations or medicare administrative contractor local coverage

determinations;

(C) nationally recognized clinical practice guidelines; or

(D) 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.

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

disruptions in care including the need for multiple biopsies or

biospecimen samples.

(3) As used in this subsection, the following terms shall have the

following meanings:

(A) "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.

(B) "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.

(C) "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.

(q) (1) Every policy issued by a medical expense indemnity

corporation, a hospital service corporation or a health service

corporation 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.

(2) Notwithstanding the provisions of this subsection, 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 subsection 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.

(q-1) (1) Every contract issued by a medical expense indemnity

corporation, a hospital service corporation or a health service

corporation for delivery in this state that provides medical, major

medical or similar comprehensive-type coverage and provides coverage for

prescription drugs and 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.

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

participating entity through which the insurer offers health services

shall not:

(A) vary the terms of the contract for the purpose or with the effect

of avoiding compliance with this paragraph;

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

person to accept less than the minimum protections available under this

paragraph;

(C) 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;

(D) 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

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

cost sharing for an intravenous or injected anticancer medication.

(q-2) (1) Every large group contract delivered or issued for delivery

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

comprehensive-type coverage and provides coverage for cancer

chemotherapy treatment shall provide coverage for scalp cooling systems

used in connection with cancer chemotherapy treatment. Coverage provided

under this subsection 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 contract.

(2) For the purposes of this subsection, "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.

(r) Consistent with federal law, a hospital service corporation or a

health service corporation 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 a person

holding a direct payment individual contract or by all persons holding

individual contracts in a group whose premiums are paid by a remitting

agent or by a contract holder in the case of a group contract issued

pursuant to section four thousand three hundred five of this article,

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 when 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 contracts and, with respect to all

other contracts at each anniversary date of the contract.

(1) Coverage shall be subject to a copayment of twenty-five dollars

per day.

(2) Brochures describing such coverage must be provided at the time of

application for all new contracts and thereafter on each anniversary

date of the contract, and with respect to all other contracts annually

at each anniversary date of the contract. Such brochures must be

approved by the superintendent in consultation with the commissioner of

health.

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.

(3) The commensurate rate for the coverage must be approved by the

superintendent.

* (s) (1) A hospital service corporation or health service corporation

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:

(A) subject to the provisions of paragraph three of this subsection,

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

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

paragraph three of this subsection, 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 subsection,

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

(C) 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 paragraph three of this subsection.

(2) A medical expense indemnity or health service corporation 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:

(A) subject to the provisions of paragraph three of this subsection,

in no case shall such coverage exclude surgical or medical procedures

which would correct malformation, disease or dysfunction resulting in

infertility; and

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

paragraph three of this subsection, 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 subsection, 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

(C) 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 paragraph three of this subsection.

(3) Coverage of diagnostic and treatment procedures, including

prescription drugs used in the diagnosis and treatment of infertility as

required by paragraphs one and two of this subsection shall be provided

in accordance with this paragraph.

(A) 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 paragraph.

(B) 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.

(C) Except as provided in subparagraphs (F) and (G) of this paragraph,

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 subparagraph (D) of this paragraph.

(D) 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 paragraph, 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.

(E)(i) For the purposes of this subsection, "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 subsection, "iatrogenic infertility" means

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

medical treatment affecting reproductive organs or processes.

(F) 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 contract.

(G) Every large group contract 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

contract. For purposes of this subparagraph, 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.

(H) No corporation providing coverage under this subsection shall

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

predicted disability, degree of medical dependency, perceived quality of

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

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

identity.

(4) Every contract issued by a medical expense indemnity corporation,

a hospital service corporation or a health services corporation 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 corporation has established for the network

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

contract shall not impose any fee, co-payment, co-insurance, deductible

or other condition on any covered person who does not elect to purchase

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 contract that is the result of a collective

bargaining agreement between an employer and a recognized or certified

employee organization.

* NB There are 2 sb (s)'s

* (s) Notwithstanding any provision of a contract issued by a medical

expense indemnity corporation, a dental expense indemnity corporation or

health service corporation, every contract which provides coverage for

care provided through licensed health professionals who can bill for

services shall provide the same coverage and reimbursement for such

service provided pursuant to a clinical practice plan established

pursuant to subdivision fourteen of section two hundred six of the

public health law.

* NB There are 2 sb (s)'s

(t) (1) A medical expense indemnity corporation, a hospital service

corporation or a health service corporation that provides coverage for

hospital, surgical, or medical care shall provide coverage for an annual

cervical cytology screening for cervical cancer and its precursor states

for women aged eighteen and older. Such coverage required by 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 contract.

(2) For purposes of paragraph one of this subsection, 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.

(3) In addition to paragraph one or two of this subsection, every

contract that provides coverage for hospital, surgical or medical care,

except for a grandfathered health plan under paragraph four of this

subsection, shall provide coverage for the following cervical cytology

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

deductibles or coinsurance:

(A) 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

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

screenings for cervical cytology not described in subparagraph (A) of

this paragraph and as provided for in comprehensive guidelines supported

by the health resources and services administration.

(4) For purposes of this subsection, "grandfathered health plan" means

coverage provided by a corporation 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).

(u) (1) A medical expense indemnity corporation or a health service

corporation 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.

(2) 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.

(3) This subsection 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.

(u-1) A medical expense indemnity corporation or a health service

corporation 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 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 subsection 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 four thousand three hundred

six-h of this article.

(v) (1) Every contract issued by a medical expense indemnity

corporation, hospital service corporation or health service corporation

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 after such

covered person has undergone a lymph node dissection or a lumpectomy for

the treatment of breast cancer or a mastectomy covered by the contract.

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

group remitting agent or group contract holder prior to the inception of

such contract and annually thereafter.

(2) A medical expense indemnity corporation, hospital service

corporation or health service corporation which provides coverage under

this subsection and any participating entity through which the insurer

offers health services shall not:

(A) deny to a covered person eligibility, or continued eligibility, to

enroll or to renew coverage under the terms of the contract or vary the

terms of the contract for the purpose or with the effect of avoiding

compliance with this subsection;

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

person to accept less than the minimum protections available under this

subsection;

(C) 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 subsection;

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

practitioner relating to the services provided pursuant to this

subsection intended to induce or have the effect of inducing such

practitioner to provide care to a covered person in a manner

inconsistent with this subsection; or

(E) restrict coverage for any portion of a period within a hospital

length of stay required under this subsection in a manner which is

inconsistent with the coverage provided for any preceding portion of

such stay.

(3) The prohibitions in paragraph two of this subsection shall be in

addition to the provisions of sections four thousand three hundred

seventeen and four thousand three hundred eighteen of this article and

nothing in this paragraph shall be construed to suspend, supersede,

amend or otherwise modify such sections.

(w)(1) Every contract issued by a medical expense indemnity

corporation or health service corporation 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 contract that requires, or provides financial

incentives for, the covered person to receive covered services from

health care providers participating in a provider network maintained by

or under contract with the corporation, the contract 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 covered person beyond what such covered

person would have paid for services from a participating appropriate

specialist. Provided however that nothing herein shall impair the

covered person's rights (if any) under the contract 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 contract for services provided by non-participating

providers. The corporation 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 contract that does not provide financial

incentives for, and does not require, the covered person to receive

covered services from health care providers participating in a provider

network maintained by or under contract with the corporation, the

contract shall include coverage for a second medical opinion from a

specialist at no additional cost to the covered person beyond what the

covered person would have paid for comparable services covered under the

contract.

(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

contract and, where applicable, consistent with the provisions of

subparagraphs (i) and (ii) of this paragraph.

Nothing in this subsection shall eliminate or diminish the

corporation's obligation to comply with the provisions of section four

thousand eight hundred four of this chapter and section forty-four

hundred three of the public health law where applicable. Written notice

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

remitting agent or group contract holder prior to the inception of such

contract and annually thereafter.

(2) A medical expense indemnity corporation or health service

corporation which provides coverage under this subsection and any

participating entity through which the insurer offers health services

shall not:

(A) deny to a covered person eligibility, or continued eligibility, to

enroll or to renew coverage under the terms of the contract or vary the

terms of the contract for the purpose or with the effect of avoiding

compliance with this subsection;

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

person to accept less than the minimum protections available under this

subsection;

(C) 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 subsection; or

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

practitioner relating to the services provided pursuant to this

subsection intended to induce or have the effect of inducing such

practitioner to provide care to a covered person in a manner

inconsistent with this subsection.

(3) The prohibitions in paragraph two of this subsection shall be in

addition to the provisions of sections four thousand three hundred

seventeen and four thousand three hundred eighteen of this article and

nothing in this paragraph shall be construed to suspend, supersede,

amend or otherwise modify such sections.

(x) (1) Every contract issued by a medical expense indemnity

corporation, hospital service corporation or health service corporation

which provides coverage for surgical or medical care shall provide the

following coverage for breast or chest wall reconstruction surgery after

a mastectomy or partial mastectomy:

(A) all stages of reconstruction of the breast or chest wall on which

the mastectomy or partial mastectomy has been performed; and

(B) 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 or

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 group remitting agent or group

contract holder prior to the inception of such contract and annually

thereafter.

(1-A) Every contract providing coverage as required by paragraph one

of this subsection 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.

(2) A medical expense indemnity corporation, hospital service

corporation or health service corporation which provides coverage under

this subsection and any participating entity through which the insurer

offers health services shall not:

(A) 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 subsection;

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

person to accept less than the minimum protections available under this

subsection;

(C) 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 subsection;

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

practitioner relating to the services provided pursuant to this

subsection intended to induce or have the affect of inducing such

practitioner to provide care to a covered person in a manner

inconsistent with this subsection;

(E) restrict coverage for any portion of a period within a hospital

length of stay required under this subsection in a manner which is

inconsistent with the coverage provided for any preceding portion of

such stay; or

(F) the prohibitions in this paragraph shall be in addition to the

provisions of sections four thousand three hundred seventeen and four

thousand three hundred eighteen of this article and nothing in this

paragraph shall be construed to suspend, supersede, amend or otherwise

modify such sections.

* (y) Every contract 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 sb§ (y)'s

* (y)(1) Every contract issued by a health service corporation or a

medical expense indemnity corporation which is a "managed care product"

as defined in paragraph four of this subsection that includes coverage

for physician services in a physician's office, and every "managed care

product" that provides major medical or similar comprehensive-type

coverage, shall include coverage for chiropractic care, as defined in

section six thousand five hundred fifty-one of the education law,

provided by a doctor of chiropractic licensed pursuant to article one

hundred thirty-two of the education law, in connection with the

detection or correction by manual or mechanical means of structural

imbalance, distortion or subluxation in the human body for the purpose

of removing nerve interference, and the effects thereof, where such

interference is the result of or related to distortion, misalignment or

subluxation of or in the vertebral column. However, chiropractic care

and services may be subject to reasonable deductible, co-payment and

co-insurance amounts, reasonable fee or benefit limits, and reasonable

utilization review, provided that any such amounts, limits and review:

(a) shall not function to direct treatment in a manner discriminative

against chiropractic care, and (b) individually and collectively shall

be no more restrictive than those applicable under the same policy to

care or services provided by other health professionals in the

diagnosis, treatment and management of the same or similar conditions,

injuries, complaints, disorders or ailments, even if differing

nomenclature is used to describe the condition, injury, complaint,

disorder or ailment. Nothing herein contained shall be construed as

impeding or preventing either the provision or coverage of chiropractic

care and services by duly licensed doctors of chiropractic, within the

lawful scope of chiropractic practice, in hospital facilities on a staff

or employee basis.

(3) Every contract issued by a health service corporation or a medical

expense indemnity corporation which includes coverage for physician

services in a physician's office, and every contract which provides

major medical or similar comprehensive-type coverage, other than a

"managed care product" as defined in paragraph four of this subsection,

shall provide coverage for chiropractic care, as defined in section six

thousand five hundred fifty-one of the education law, provided by a

doctor of chiropractic licensed pursuant to article one hundred

thirty-two of the education law, in connection with the detection or

correction by manual or mechanical means of structural imbalance,

distortion or subluxation in the human body for the purpose of removing

nerve interference, and the effects thereof, where such interference is

the result of or related to distortion, misalignment or subluxation of

or in the vertebral column. However, chiropractic care and services may

be subject to reasonable deductible, co-payment and co-insurance

amounts, reasonable fee or benefit limits, and reasonable utilization

review, provided that any such amounts, limits and review: (a) shall

not function to direct treatment in a manner discriminative against

chiropractic care, and (b) individually and collectively shall be no

more restrictive than those applicable under the same contract 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.

(4) For purposes of this subsection, a "managed care product" shall

mean 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 corporation'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

corporation's managed care provider network, in order for the insured to

be entitled to the maximum reimbursement under the contract.

(5) The coverage required by this subsection shall not be abridged by

any regulation promulgated by the superintendent.

* NB There are 2 sb§ (y)'s

(z) No contract issued by a medical expense indemnity corporation, a

hospital service corporation or a health service corporation shall

exclude coverage of a health care service, as defined in paragraph two

of subsection (e) of section four thousand nine hundred of this chapter,

rendered or proposed to be rendered to an insured on the basis that such

service is experimental or investigational, is rendered as part of a

clinical trial as defined in subsection (b-2) of section forty-nine

hundred of this chapter, or a prescribed pharmaceutical product

referenced in subparagraph (B) of paragraph two of subsection (e) of

section forty-nine hundred of this chapter provided that coverage of the

patient costs of such service has been recommended for the insured by an

external appeal agent upon an appeal conducted pursuant to subparagraph

(B) of paragraph four of subsection (b) of section four thousand nine

hundred fourteen of this chapter. The determination of the external

appeal agent shall be binding on the parties. For purposes of this

paragraph, patient costs shall have the same meaning as such term has

for purposes of subparagraph (B) of paragraph four of subsection (b) of

section four thousand nine hundred fourteen of this chapter; provided,

however, that coverage for the services required under this subsection

shall be provided subject to the terms and conditions generally

applicable to other benefits provided under the policy.

(z-1) (1) 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:

(A) 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

(B) 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.

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

coinsurance.

(aa)(1) Every contract issued by a hospital service company or health

service corporation 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.

(2) 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 subsection, except for the collection of copayments, coinsurance or

deductibles for which the insured is responsible for under the terms of

the policy.

(3) 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.

(4) The provisions of this subsection shall have no application to

transfers of patients between hospitals or health care facilities by an

ambulance service as described in paragraph one of this subsection

unless such services are covered under the policy.

(5) As used in this subsection:

(A) "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 subsection, reimbursement shall be based

on whether a prudent layperson, possessing an average knowledge of

medicine and health, could reasonably expect the absence of such

transportation to result in (i) placing the health of the person

afflicted with such condition in serious jeopardy, or in the case of a

behavioral condition placing the health of such person or others in

serious jeopardy; (ii) serious impairment to such person's bodily

functions; (iii) serious dysfunction of any bodily organ or part of such

person; (iv) serious disfigurement of such person; or (v) a condition

described in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the

Social Security Act.

(B) "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.

(bb) A health service corporation or a medical service expense

indemnity corporation 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 paragraphs

one, two and three of this subsection, 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:

(1) For purposes of paragraphs two and three of this subsection, bone

mineral density measurements or tests, drugs and devices shall include

those covered under the criteria of 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.

(2) For purposes of paragraphs one and three of this subsection, bone

mineral density measurements or tests, drugs and devices shall be

covered for individuals meeting the criteria for coverage, consistent

with 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.

(3) Such coverage required pursuant to paragraph one or two of this

subsection 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.

(4) In addition to paragraph one, two or three of this subsection,

every contract that provides hospital, surgical or medical care

coverage, except for a grandfathered health plan under paragraph five of

this subsection, 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:

(A) 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

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

screenings for bone mineral density not described in subparagraph (A) of

this paragraph and as provided for in comprehensive guidelines supported

by the health resources and services administration.

(5) For purposes of this subsection, "grandfathered health plan" means

coverage provided by a corporation 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).

(cc) (1) Every contract 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:

(A) 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:

(i) where the FDA has approved one or more therapeutic and

pharmaceutical equivalent, as defined by the FDA, versions of a

contraceptive drug, device, or product, a contract is not required to

include all such therapeutic and pharmaceutical equivalent versions in

its formulary, so long as at least one is included and covered without

cost-sharing and in accordance with this subsection;

(ii) if the covered therapeutic and pharmaceutical equivalent versions

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

inadvisable a contract shall provide coverage for an alternate

therapeutic and pharmaceutical equivalent version of the contraceptive

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

(iii) 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

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

months worth of a contraceptive at one time;

(B) 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;

(C) Patient education and counseling on contraception; and

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

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

management of side effects, counseling for continued adherence, and

device insertion and removal.

(2) A contract subject to this subsection shall not impose a

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

requirement on the coverage provided pursuant to this subsection.

(3) Except as otherwise authorized under this subsection, a contract

shall not impose any restrictions or delays on the coverage required

under this subsection.

(4) Benefits for an enrollee under this subsection shall be the same

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

nonspouse dependents.

(5) 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.

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

entity for which each of the following is true:

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

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

tenets of the entity.

(iii) The entity serves primarily persons who share the religious

tenets of the entity.

(iv) 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.

(B) 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.

(6) (A) Where a group contractholder makes an election not to purchase

coverage for contraceptive drugs or devices in accordance with paragraph

five of this subsection, each enrollee covered under the contract issued

to that group contractholder shall have the right to directly purchase

the rider required by this subsection from the insurer or health

maintenance organization which issued the group contract at the

prevailing small group community rate for such rider whether or not the

employee is part of a small group.

(B) Where a group contractholder makes an election not to purchase

coverage for contraceptive drugs or devices in accordance with paragraph

five of this subsection, the insurer or health maintenance organization

that provides such coverage shall provide written notice to enrollees

upon enrollment with the insurer or health maintenance organization of

their right to directly purchase a rider for coverage for the cost of

contraceptive drugs or devices. The notice shall also advise the

enrollees of the additional premium for such coverage.

(7) Nothing in this subsection shall be construed as authorizing a

contract which provides coverage for prescription drugs to exclude

coverage for prescription drugs prescribed for reasons other than

contraceptive purposes.

(8) 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.

(dd) No health service corporation or medical service expense

indemnity corporation 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 by such corporation 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.

(ee) (1) A medical expense indemnity corporation, a hospital service

corporation or a health service corporation 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 contract solely because the treatment is provided to

diagnose or treat autism spectrum disorder.

(2) Every contract 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 contract 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 contract. This paragraph shall not be construed as

limiting the benefits that are otherwise available to an individual

under the contract, provided however that such contract 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.

(3) For purposes of this subsection:

(A) "autism spectrum disorder" means any pervasive developmental

disorder as defined in the most recent edition of the diagnostic and

statistical manual of mental disorders.

(B) "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.

(C) "behavioral health treatment" means counseling and treatment

programs, when provided by a licensed provider, and applied behavior

analysis, when provided by a person that is 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.

(D) "diagnosis of autism spectrum disorder" means assessments,

evaluations, or tests to diagnose whether an individual has autism

spectrum disorder.

(E) "pharmacy care" means medications prescribed by a licensed health

care provider legally authorized to prescribe under title eight of the

education law.

(F) "psychiatric care" means direct or consultative services provided

by a psychiatrist licensed in the state in which the psychiatrist

practices.

(G) "psychological care" means direct or consultative services

provided by a psychologist licensed in the state in which the

psychologist practices.

(H) "therapeutic care" means services provided by licensed or

certified speech therapists, occupational therapists, social workers, or

physical therapists.

(I) "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:

(i) behavioral health treatment;

(ii) psychiatric care;

(iii) psychological care;

(iv) medical care provided by a licensed health care provider;

(v) therapeutic care, including therapeutic care which is deemed

habilitative or nonrestorative, in the event that the policy provides

coverage for therapeutic care; and

(vi) pharmacy care in the event that the contract provides coverage

for prescription drugs.

(4) 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.

(5) Nothing in this subsection 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.

(7) Nothing in this subsection shall be construed to prevent a

contract from providing services through a network of participating

providers who shall meet certain requirements for participation,

including provider credentialing.

(8) Coverage under this subsection 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.

(9) The criteria for medical necessity determinations under the

contract with respect to autism spectrum disorder benefits shall be made

available by the corporation to any insured, prospective insured, or

in-network provider upon request.

(10) For purposes of this subsection:

(A) "financial requirement" means deductible, copayments, coinsurance

and out-of-pocket expenses;

(B) "predominant" means that a financial requirement or treatment

limitation is the most common or frequent of such type of limit or

requirement; and

(C) "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 contract.

(11) A corporation shall provide coverage under this subsection, 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).

(ff) (1) No managed care contract issued by a health service

corporation, hospital service corporation or medical expense indemnity

corporation 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.

(2) No managed care contract issued by a health service corporation,

hospital service corporation or medical expense indemnity corporation

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.

(3) For purposes of this subsection, 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.

(4) For purposes of this subsection, a "managed care contract" is a

contract that requires that services be provided by a provider

participating in the corporation's network in order for the subscriber

to receive the maximum level of reimbursement under the contract.

(gg) (1) Every contract issued by a hospital service corporation,

health service corporation or medical expense indemnity corporation 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:

(A) The out-of-network provider is duly licensed to practice and

authorized to provide such treatment;

(B) The out-of-network provider is located outside the service area of

the insurer;

(C) The in-network healthcare provider treating the covered person for

the condition issues a written order for dialysis treatment stating that

in his or her opinion such treatment is necessary;

(D) The covered person has notified, in writing, the corporation 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 subparagraph (C) of this paragraph. In the

event the covered person must travel on sudden notice due to family or

other emergency, shorter notice may be permitted, provided that the

corporation has reasonable opportunity to review the travel and

treatment plans of the covered person;

(E) The corporation shall have the right to pre-approve the dialysis

treatment and schedule; and

(F) Such coverage is limited to no greater than ten out-of-network

treatments in a calendar year.

(2) Where coverage for out-of-network dialysis treatment is provided

pursuant to paragraph one of this subsection, no corporation 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 corporation shall be the responsibility of the covered person

receiving the out-of-network services.

(3) Such coverage of out-of-network dialysis services required by

paragraph one of this subsection 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.

(hh) 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 subsection,

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.

(ii) Every contract issued by a corporation subject to the provisions

of this article 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.

(jj) No medical expense indemnity corporation, a hospital service

corporation or a health service corporation 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).

(kk) (1) Definitions. For the purpose of this subsection:

(A) "Same reimbursement amount" shall mean that any coverage described

under paragraph two of this subsection 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 health benefit plan regardless of whether a

pharmacy is a mail order pharmacy or a non-mail order pharmacy.

(B) "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.

(2) Any contract issued by a medical expense indemnity corporation, a

hospital service corporation or a health services corporation that

provides coverage for prescription drugs shall permit each covered

person to fill any covered prescription that may be obtained at a

network participating mail order or other non-retail pharmacy, at the

covered person'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

corporation has established for the network participating mail order or

other non-retail pharmacy. In such a case, the contract shall not impose

a copayment fee or other condition on any covered person who elects to

purchase drugs from a network participating non-mail order retail

pharmacy which is not also imposed on covered persons 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 contract that is the result of a collective

bargaining agreement between an employer and a recognized or certified

employee organization.

(ll) Every small group contract or association group contract issued

by a corporation subject to the provisions of this article 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 four thousand

three hundred six-h of this article;

(2) "grandfathered health plan" means coverage provided by a

corporation 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); and

(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.

(mm) A corporation shall not be required to offer the contract holder

any benefits that must be made available pursuant to this section if

such benefits must be covered pursuant to subsection (kk) of this

section. For any contract issued within the health benefit exchange

established by this state, a corporation shall not be required to offer

the contract holder any benefits that must be made available pursuant to

this section.

(nn) A corporation 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 which 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.

(oo) A medical expense indemnity corporation, a hospital service

corporation or a health service corporation 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.

(pp) No contract issued by a medical expense indemnity corporation,

hospital service corporation, or health service corporation 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: (1) the registered nurse

first assistant is certified in operating room nursing; (2) the services

are within the scope of practice of a non-physician surgical first

assistant; and (3) the terms and conditions of the contract otherwise

provide for the coverage of the services. 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

are to be provided through a network of participating providers who meet

certain requirements for participation, including provider

credentialing.

* (qq) Every medical expense indemnity corporation, hospital service

corporation or health service corporation that provides coverage for

prescription drugs subject to a copayment shall charge a copayment for a

limited initial prescription of an opioid drug, which is prescribed in

accordance with paragraph (b) of subdivision five of section

thirty-three hundred one of the public health law, that is either (i)

proportional between the copayment for a thirty-day supply and the

amount of drugs the patient was prescribed; or (ii) equivalent to the

copayment for a full thirty-day supply of the opioid drug, provided that

no additional copayments may be charged for any additional prescriptions

for the remainder of the thirty-day supply.

* NB There are 2 sb§ (qq)'s

* (qq) Whenever in this section a corporation is required to provide

benefits with no coinsurance or deductible, the requirement only applies

with respect to participating providers in the corporation's network, or

with respect to non-participating providers, if the corporation 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 covered person pursuant to

subsection (d) of section four thousand three hundred six-c of this

article, or as applicable, pursuant to paragraph (a) of subdivision six

of section forty-four hundred three of the public health law.

* NB There are 2 sb§ (qq)'s

(rr) Health care forensic examinations performed pursuant to section

twenty-eight hundred five-i of the public health law covered under the

contract shall not be subject to annual deductibles or coinsurance.

(ss)(1) Every policy which provides hospital, surgical, or medical

coverage and which offers maternity care coverage pursuant to subsection

(c) of this section shall also provide coverage for abortion services

for an enrollee.

(2) 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.

(3) 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:

(A) The WHO Model Lists of Essential Medicines;

(B) The WHO Abortion Care Guidance; or

(C) The National Academies of Science, Engineering, and Medicine

Consensus Study Report.

(4) 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 paragraph

five of subsection (cc) of this section, may exclude coverage for

abortion only if the insurer:

(A) obtains an annual certification from the group policy holder that

the policy holder is a religious employer and that the religious

employer requests a contract without coverage for abortion;

(B) 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 abortions 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

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

superintendent in a form and manner acceptable to the superintendent.

* (tt) Every contract issued by a medical expense indemnity

corporation, hospital service corporation, or health service corporation

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

subsection 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

* (tt) Every contract issued by a medical expense indemnity

corporation, hospital service corporation, or health service corporation

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 subsection 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 sb (tt)'s

* (tt) Every large group contract issued by a hospital services

corporation or a health services corporation 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 contract, 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 sb (tt)'s

(uu) (1) Every large group contract 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

contract 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 subsection 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 contract shall cover colorectal cancer screenings, examinations,

and laboratory tests described in this subsection upon any contract

issuance or renewal that occurs six months after the date the guideline

described in this subsection is issued.

(2) An enrollee shall not be subject to a deductible, coinsurance, or

any other cost-sharing requirements for services consistent with

paragraph one of this subsection received from participating providers.

* (vv) Any contract issued by a medical expense indemnity corporation,

a hospital service corporation or a health services corporation 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.

* NB There are 3 sb§ (vv)'s

* (vv) (1) Every contract 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 contract.

(2) Nothing in this subsection shall be construed to prevent the

medical management or utilization review of the services or prevent a

contract from requiring that services be provided through a network of

participating providers.

* NB There are 3 sb§ (vv)'s

* (vv) (1) Every medical expense indemnity corporation, hospital

service corporation and health service corporation 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.

(2) For the purposes of this subsection, "epinephrine device" shall

have the same meaning as provided in paragraph (b) of subdivision one of

section three thousand-c of the public health law.

* NB There are 3 sb§ (vv)'s

* (ww) (1) A medical expense indemnity corporation or a health service

corporation 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.

(2) 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.

(3) 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 sb§s (ww)'s

* (ww) (1) 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.

(2) Notwithstanding any other provision of law, any policy that

provides coverage required by this subsection shall not impose patient

cost sharing for follow-up screening or diagnostic services for lung

cancer.

(3) 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.

(4) 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.

(5) 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 sb§s (ww)'s

* (xx) 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