N.Y. Insurance Law § 4306-h: Essential health benefits package and limit on cost-sharing

§ 4306-h. Essential health benefits package and limit on cost-sharing.

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

mean the following categories of benefits:

(A) ambulatory patient services;

(B) emergency services;

(C) hospitalization;

(D) maternity and newborn care;

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

behavioral health treatment;

* NB Effective until January 1, 2027

* (E) mental health and substance-related and addictive disorder

services, including behavioral health treatment;

* NB Effective January 1, 2027

(F) prescription drugs;

(G) rehabilitative and habilitative services and devices;

(H) laboratory services;

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

and

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

(2) A corporation shall not be required to provide coverage for

pediatric oral services as an essential health benefit if:

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

state, the exchange has determined sufficient coverage of the pediatric

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

the exchange; or

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

reasonable written assurance that the individual or group has obtained a

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

meeting exchange certification standards.

(b) (1) Every individual and small group contract that provides

hospital, surgical, or medical expense coverage and is not a

grandfathered health plan shall provide coverage that meets the

actuarial requirements of one of the following levels of coverage:

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

coverage that is designed to provide benefits that are actuarially

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

provided under the plan;

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

coverage that is designed to provide benefits that are actuarially

equivalent to seventy percent of the full actuarial value of the

benefits provided under the plan;

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

coverage that is designed to provide benefits that are actuarially

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

provided under the plan; or

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

of coverage that is designed to provide benefits that are actuarially

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

provided under the plan.

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

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

for the differences in actuarial estimates.

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

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

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

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

subsection nearest to, but below the actual actuarial value.

(c) Every individual or group contract that provides hospital,

surgical, or medical expense coverage and is not a grandfathered health

plan, and every student accident and health insurance contract shall

limit the insured's cost-sharing for in-network services in a contract

year to not more than the maximum out-of-pocket amount determined by the

superintendent for all contracts subject to this section. Such amount

shall not exceed any annual out-of-pocket limit on cost-sharing set by

the United States secretary of health and human services, if available.

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

describing the coverage requirements for any form that is subject to the

approval of the superintendent pursuant to section four thousand three

hundred eight of this article.

(e) For purposes of this section:

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

payments by the corporation for benefits provided to a standard

population, without regard to the population to whom the corporation

actually provides benefits;

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

or similar charges, for covered services;

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

(A) provides for essential health benefits;

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

subsection (c) of this section; and

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

of this section;

(4) "grandfathered health plan" means coverage provided by 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);

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

members exclusive of spouses and dependents; and

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

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

this chapter.