N.Y. ISC Law § 3221 — New York Code / Act ISC / Article 32 / Section 3221
Group or blanket accident and health insurance policies; standard provisions
Status: in_force

§ 3221. Group or blanket accident and health insurance policies;\nstandard provisions. (a) No policy of group or blanket accident and\nhealth insurance shall, except as provided in subsection (d) hereof, be\ndelivered or issued for delivery in this state unless it contains in\nsubstance the following provisions or provisions which in the opinion of\nthe superintendent are more favorable to the holders of such\ncertificates or not less favorable to the holders of such certificates\nand more favorable to policyholders, provided however, that the\nprovisions set forth in paragraphs six and thirteen of this subsection\nshall not be applicable to any such policy which is issued to a\npolicyholder in accordance with subparagraph (E) of paragraph one of\nsubsection (c) of section four thousand two hundred thirty-five of this\nchapter:\n  (1) (A) No statement made by the person insured shall avoid the\ninsurance or reduce benefits thereunder unless contained in a written\ninstrument signed by the person insured.\n  (B) All statements contained in any such written instrument shall be\ndeemed representations and not warranties.\n  (2) That no agent has authority to change the policy or waive any of\nits provisions and that no change in the policy shall be valid unless\napproved by an officer of the insurer and evidenced by endorsement on\nthe policy, or by amendment to the policy signed by the policyholder and\nthe insurer.\n  (3) That all new employees or new members in the classes eligible for\ninsurance must be added to such class for which they are eligible.\n  (4) That all premiums due under the policy shall be remitted by the\nemployer or employers of the persons insured or by some other designated\nperson acting on behalf of the association or group insured, to the\ninsurer on or before the due date thereof, with such period of grace as\nmay be specified therein.\n  (5) The conditions under which the insurer may decline to renew the\npolicy.\n  (6) That the insurer shall issue either to the employer or person in\nwhose name such policy is issued, for delivery to each member of the\ninsured group, a certificate setting forth in summary form a statement\nof the essential features of the insurance coverage and in substance the\nfollowing provisions of this subsection.\n  (7) The ages, to which the insurance provided therein shall be\nlimited; and the ages, for which additional restrictions are placed on\nbenefits, and the additional restrictions placed on the benefits at such\nages.\n  (8) That written notice of claim must be given to the insurer within\ntwenty days after the occurrence or commencement of any loss covered by\nthe policy. Failure to give notice within such time shall not invalidate\nor reduce any claim if it shall be shown not to have been reasonably\npossible to give such notice and that notice was given as soon as was\nreasonably possible.\n  (9) That in the case of claim for loss of time for disability, written\nproof of such loss must be furnished to the insurer within thirty days\nafter the commencement of the period for which the insurer is liable,\nand that subsequent written proofs of the continuance of such disability\nmust be furnished to the insurer at such intervals as the insurer may\nreasonably require, and that in the case of claim for any other loss,\nwritten proof of such loss must be furnished to the insurer within one\nhundred twenty days after the date of such loss. Failure to furnish such\nproof within such time shall not invalidate or reduce any claim if it\nshall be shown not to have been reasonably possible to furnish such\nproof within such time, provided such proof was furnished as soon as\nreasonably possible.\n  (10) That the insurer will furnish to the person making claim or to\nthe policyholder for delivery to such person such forms as are usually\nfurnished by it for filing proof of loss. If such forms are not\nfurnished before the expiration of fifteen days after the insurer\nreceives notice of any claim under the policy, the person making such\nclaim shall be deemed to have complied with the requirements of the\npolicy as to proof of loss upon submitting within the time fixed in the\npolicy for filing proof of loss, written proof covering the occurrence,\ncharacter and extent of the loss for which claim is made.\n  (11) That the insurer shall have the right and opportunity to examine\nthe person of the individual for whom claim is made when and so often as\nit may reasonably require during the pendency of claim under the policy\nand also the right and opportunity to make an autopsy in case of death\nwhere it is not prohibited by law.\n  (12) That benefits payable under the policy other than benefits for\nloss of time will be payable not more than sixty days after receipt of\nproof, and that, subject to due proof of loss all accrued benefits\npayable under the policy for loss of time will be paid not less\nfrequently than monthly during the continuance of the period for which\nthe insurer is liable, and that any balance remaining unpaid at the\ntermination of such period will be paid immediately upon receipt of such\nproof.\n  (13) That indemnity for loss of life of the insured is payable in\naccordance with subsection (e) of section four thousand two hundred\nthirty-five of this chapter; and that all other indemnities of the\npolicy are payable to the insured, except as may be otherwise provided\nin accordance with such subsection; and that if a beneficiary is\ndesignated, the consent of the beneficiary shall not be requisite to\nchange of beneficiary, or to any other changes in the policy or\ncertificate, except as may be specifically provided by the policy.\n  (14) That no action at law or in equity shall be brought to recover on\nthe policy prior to the expiration of sixty days after proof of loss has\nbeen filed in accordance with the requirements of the policy and that no\nsuch action shall be brought after the expiration of two years following\nthe time such proof of loss is required by the policy.\n  (15) Any policy and certificate, other than one issued in fulfillment\nof the continuing care responsibilities of an operator of a continuing\ncare retirement community in accordance with article forty-six of the\npublic health law, made available because of residence in a particular\nfacility, housing development, or community shall contain the following\nnotice in twelve point type in bold face on the first page:\n  "NOTICE - THIS POLICY OR CERTIFICATE DOES NOT MEET THE REQUIREMENTS OF\nA CONTINUING CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE\nWILL NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT\nCOMMUNITY."\n  (16) No policy delivered or issued for delivery in this state which\nprovides coverage for prescription drugs and for which cost-sharing,\ndeductibles or co-insurance obligations are determined by category of\nprescription drugs shall impose cost-sharing, deductibles or\nco-insurance obligations for any prescription drug that exceeds the\ndollar amount of cost-sharing, deductibles or co-insurance obligations\nfor non-preferred brand drugs or its equivalent (or brand drugs if there\nis no non-preferred brand drug category).\n  (17) Every policy delivered or issued for delivery in this state which\nprovides major medical or similar comprehensive-type coverage shall\nprovide space on any enrollment, renewal or initial online portal\nprocess setup forms required of an insured or applicant for insurance so\nthat the insured or applicant for insurance shall register or decline\nregistration in the donate life registry for organ, eye and tissue\ndonations under this section of the enrollment, renewal or initial\nonline portal process setup forms and that the following is stated on\nthe form in clear and conspicuous type:\n  "You must fill out the following section: Would you like to be added\nto the Donate Life Registry? Check box for 'yes' or 'skip this\nquestion'."\n  (b) No such policy shall be delivered or issued for delivery in this\nstate unless a schedule of the premium rates pertaining to such form\nshall have been filed with the superintendent.\n  (c) Any portion of any such policy, which purports, by reason of the\ncircumstances under which a loss is incurred, to reduce any benefits\npromised thereunder to an amount less than that provided for the same\nloss occurring under ordinary circumstances, shall be printed, in such\npolicy and in each certificate issued thereunder, in bold face type and\nwith greater prominence than any other portion of the text of such\npolicy or certificate; and all other exceptions of the policy shall be\nprinted in the policy and in the certificate, with the same prominence\nas the benefits to which they apply. If any such policy contains any\nprovision which affects the liability of the insurer, on the grounds\nstated in subparagraph (J) or (K) of paragraph two of subsection (d) of\nsection three thousand two hundred sixteen of this article, then such\nprovision shall be contained in the policy and certificate in the form\nset forth in such section.\n  (d) (1) The superintendent may approve any form of certificate to be\nissued under a blanket accident and health insurance policy as defined\nin section four thousand two hundred thirty-seven of this chapter, which\nomits or modifies any of the provisions hereinbefore required, if the\nsuperintendent deems such omission or modification suitable for the\ncharacter of such insurance and not unjust to the persons insured\nthereunder. Certificates issued under a policy or contract of student\naccident and health insurance as defined in section three thousand two\nhundred forty of this article shall comply with such section.\n  (2) The superintendent may approve any form of group insurance policy\nproviding disability benefits to be issued pursuant to article nine of\nthe workers' compensation law which omits or modifies any of the\nprovisions hereinbefore required, if such omission or modification is\nnot inconsistent with the provisions of such article nine and he deems\nsuch omission or modification suitable for the character of such\ninsurance and not unjust to the persons insured thereunder.\n  (3) The superintendent may also approve any form of group insurance\npolicy to be issued to a social services district pursuant to\nsubdivision two of section three hundred sixty-seven-a of the social\nservices law, which omits or modifies any of the provisions hereinbefore\nrequired, if he deems such omission or modification suitable for the\ncharacter of such insurance.\n  (e) (1) A group policy providing hospital, medical or surgical expense\ninsurance for other than specific diseases or accident only, shall\nprovide that if the insurance on an employee or member insured under the\ngroup policy ceases because of termination of (A) employment or of\nmembership in the class or classes eligible for coverage under the\npolicy or (B) the policy, for any reason whatsoever, unless the\npolicyholder has replaced the group policy with similar and continuous\ncoverage for the same group whether insured or self-insured, such\nemployee or member who has been insured under the group policy shall be\nentitled to have issued to the insured by the insurer without evidence\nof insurability upon application made to the insurer within sixty days\nafter such termination, and payment of the quarterly, or, at the option\nof the employee or member, a less frequent premium applicable to the\nform and amount of insurance, an individual policy of insurance. The\ninsurer may, at its option elect to provide the insurance coverage under\na group insurance policy, delivered in this state, in lieu of the\nissuance of a converted individual policy of insurance. Such individual\npolicy, or group policy, as the case may be is hereafter referred to as\nthe converted policy. The benefits provided under the converted policy\nshall be those required by subsection (f) and (g) of this section, in\nthe event of termination of the converted group policy of insurance,\neach insured thereunder shall have a right of conversion to a converted\nindividual policy of insurance.\n  (2) The insurer shall not be required to issue a converted policy\ncovering any person if such person is covered for similar benefits by\nanother hospital or surgical or medical expense insurance policy or\nhospital or medical service subscriber contract or medical practice or\nother prepayment plan or by any other plan or program or such person is\neligible for similar benefits, whether or not covered therefor, under\nany arrangement of coverage for individuals in a group, other than under\nthe converted policy, whether on an insured or uninsured basis or\nsimilar benefits are provided for or available to such person pursuant\nto any statute; and the benefits provided or available under any of such\nsources which together with the benefits provided under the converted\npolicy would result in overinsurance or duplication of benefits\naccording to standards on file with the superintendent.\n  (3) The converted policy shall, at the option of the employee or\nmember, provide identical coverage for the dependents of such employee\nor member who were covered under the group policy. Provided, however,\nthat if the employee or member chooses the option of dependent coverage\nthen dependents acquired after the permitted time to convert stated in\nparagraph one of this subsection shall be added to the converted family\npolicy in accordance with the provisions of subsection (c) of section\nthirty-two hundred sixteen of this article and any regulations\npromulgated or guidelines issued by the superintendent. The effective\ndate of the individual's coverage under the converted policy shall be\nthe date of the termination of the individual's insurance under the\ngroup policy as to those persons covered under the group policy.\n  (4) If delivery of an individual converted policy is to be made\noutside this state, it may be on such form as the insurer may then be\noffering for such conversion in the jurisdiction where such delivery is\nto be made.\n  (5) The conversion provision shall also be available upon the death of\nthe employee or member, to the surviving spouse with respect to such of\nthe spouse and children as are then covered by the group policy, and\nshall be available to a child solely with respect to himself upon his\nattaining the limiting age of coverage under the group policy while\ncovered as a dependent thereunder. It shall also be available upon the\ndivorce or annulment of the marriage of the employee or member, to the\nformer spouse of such employee or member.\n  (6) (A) Each certificate holder shall be given written notice of such\nconversion privilege and its duration within fifteen days before or\nafter the date of termination of group coverage, provided that if such\nnotice be given more than fifteen days but less than ninety days after\nthe date of termination of group coverage, the time allowed for the\nexercise of such privilege of conversion shall be extended for\nforty-five days after the giving of such notice. If such notice be not\ngiven within ninety days after the date of termination of group\ncoverage, the time allowed for the exercise of such conversion privilege\nshall expire at the end of such ninety days.\n  (B) Written notice by the policyholder given to the certificate holder\nor mailed to the certificate holder's last known address, or written\nnotice by the insurer be sent by first class mail to the certificate\nholder at the last address furnished to the insurer by the policyholder,\nshall be deemed full compliance with the provisions of this subsection\nfor the giving of notice.\n  (C) A group contract issued by an insurer may contain a provision to\nthe effect that notice of such conversion privilege and its duration\nshall be given by the policyholder to each certificate holder upon\ntermination of his group coverage.\n  (7) In addition to the right of conversion herein, the employee or\nmember insured under the policy shall at his option, as an alternative\nto conversion, be entitled to have his coverage continued under the\ngroup policy in accordance with the conditions and limitations contained\nin subsection (m) of this section, and have issued at the end of the\nperiod of continuation an individual conversion policy subject to the\nterms of this subsection. The effective date for the conversion policy\nshall be the day following the termination of insurance under the group\npolicy, or if there is a continuation of coverage, on the day following\nthe end of the period of continuation. Notwithstanding the foregoing,\nthe superintendent may require conversion or continuation of insurance\nunder conditions as set forth in a regulation for insureds under a\npolicy issued in accordance with subparagraph (E) of paragraph one of\nsubsection (c) of section four thousand two hundred thirty-five of this\nchapter.\n  (8) For purposes of this subsection, the term "dependent" shall\ninclude a child as described in subsection (f) of section four thousand\ntwo hundred thirty-five of this chapter.\n  (f) If the group insurance policy insures the employee or member for\nhospital, medical or surgical expense insurance, or if the group\ninsurance policy insures the employee or member for major medical or\nsimilar comprehensive-type coverage, then the conversion privilege shall\nentitle the employee or member to obtain coverage under a converted\npolicy providing, at the insured's option, coverage under any one of the\nplans described in subsection (g) of this section on an expense incurred\nbasis.\n  (g) For conversion purposes, an insurer shall offer to the employee or\nmember a policy at each level of coverage as defined in subsection (b)\nof section three thousand two hundred seventeen-i of this article that\ncontains the essential health benefits package described in paragraph\nthree of subsection (e) of section three thousand two hundred\nseventeen-i of this article. Provided, however, the superintendent may,\nafter giving due consideration to the public interest, approve a request\nmade by an insurer for the insurer to satisfy the requirements of this\nsubsection and subsections (e) and (f) of this section through the\noffering of policies that comply with this subsection by another\ninsurer, corporation or health maintenance organization within the\ninsurer's holding company system, as defined in article fifteen of this\nchapter.\n  (h) Every small group policy or association group policy delivered or\nissued for delivery in this state that provides coverage for hospital,\nmedical or surgical expense insurance and is not a grandfathered health\nplan shall provide coverage for the essential health benefits package.\nFor purposes of this subsection:\n  (1) "essential health benefits package" shall have the meaning set\nforth in paragraph three of subsection (e) of section three thousand two\nhundred seventeen-i of this article;\n  (2) "grandfathered health plan" means coverage provided by an insurer\nin which an individual was enrolled on March twenty-third, two thousand\nten for as long as the coverage maintains grandfathered status in\naccordance with section 1251(e) of the affordable care act, 42 U.S.C. §\n18011(e);\n  (3) "small group" means a group of one hundred or fewer employees or\nmembers exclusive of spouses and dependents; and\n  (4) "association group" means a group defined in subparagraphs (B),\n(D), (H), (K), (L) or (M) of paragraph one of subsection (c) of section\nfour thousand two hundred thirty-five of this chapter, provided that:\n  (A) the group includes one or more individual members; or\n  (B) the group includes one or more member employers or other member\ngroups that are small groups.\n  (i) An insurer shall not be required to offer the policyholder any\nbenefits that must be made available pursuant to this section if the\nbenefits must be covered pursuant to subsection (h) of this section. For\nany policy issued within the health benefit exchange established by this\nstate, an insurer shall not be required to offer the policyholder any\nbenefits that must be made available pursuant to this section.\n  (j) No policy of group or blanket accident and health insurance shall\nbe issued as excess coverage for volunteer firefighters over and above\nthe coverage provided for pursuant to the volunteer firefighters'\nbenefit law unless such excess policy provides for each of the types of\ncoverages set forth in subdivision one of section five of such law. Any\nexcess policy which does not contain such provisions shall be construed\nas if such coverages were embodied therein.\n  (k) (1) (A) Every group policy delivered or issued for delivery in\nthis state which provides coverage for in-patient hospital care shall\nprovide coverage for home care to residents in this state, except that\nthis provision shall not apply to a policy which covers persons employed\nin more than one state or the benefit structure of which was the subject\nof collective bargaining affecting persons who are employed in more than\none state. Such home care coverage shall be included at the inception of\nall new policies and, with respect to all other policies, added at any\nanniversary date of the policy subject to evidence of insurability.\n  (B) Such coverage may be subject to an annual deductible of not more\nthan fifty dollars for each person covered under the policy and may be\nsubject to a coinsurance provision which provides for coverage of not\nless than seventy-five percent of the reasonable charges for such\nservices.\n  (C) Home care means the care and treatment of a covered person who is\nunder the care of a physician but only if hospitalization or confinement\nin a nursing facility as defined in subchapter XVIII of the federal\nSocial Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been\nrequired if home care was not provided, and the plan covering the home\nhealth service is established and approved in writing by such physician.\n  (D) Home care shall be provided by an agency possessing a valid\ncertificate of approval or license issued pursuant to article thirty-six\nof the public health law and shall consist of one or more of the\nfollowing:\n  (i) Part-time or intermittent home nursing care by or under the\nsupervision of a registered professional nurse (R.N.).\n  (ii) Part-time or intermittent home health aide services which consist\nprimarily of caring for the patient.\n  (iii) Physical, occupational or speech therapy if provided by the home\nhealth service or agency.\n  (iv) Medical supplies, drugs and medications prescribed by a\nphysician, and laboratory services by or on behalf of a certified home\nhealth agency or licensed home care services agency to the extent such\nitems would have been covered under the contract if the covered person\nhad been hospitalized or confined in a skilled nursing facility as\ndefined in subchapter XVIII of the federal Social Security Act, 42\nU.S.C. §§ 1395 et seq.\n  (E) For the purpose of determining the benefits for home care\navailable to a covered person, each visit by a member of a home care\nteam shall be considered as one home care visit; the contract may\ncontain a limitation on the number of home care visits, but not less\nthan forty such visits in any calendar year or in any continuous period\nof twelve months, for each person covered under the contract; four hours\nof home health aide service shall be considered as one home care visit.\n  (2) (A) Every insurer issuing a group policy delivered or issued for\ndelivery in this state which provides coverage for in-patient hospital\ncare shall include coverage for preadmission tests performed in hospital\nfacilities prior to scheduled surgery, except that this provision shall\nnot apply to a policy which covers persons employed in more than one\nstate or the benefit structure of which was the subject of collective\nbargaining affecting persons who are employed in more than one state.\n  (B) Such policy shall provide benefits for tests ordered by a\nphysician which are performed in the out-patient facilities of a\nhospital as a planned preliminary to admission of the patient as an\nin-patient for surgery in the same hospital, provided that:\n  (i) tests are necessary for and consistent with the diagnosis and\ntreatment of the condition for which surgery is to be performed;\n  (ii) reservations for a hospital bed and for an operating room were\nmade prior to the performance of the tests;\n  (iii) the surgery actually takes place within seven days of such\npresurgical tests; and\n  (iv) the patient is physically present at the hospital for the tests.\n  (C) Coverage for abortion shall include coverage of any drug\nprescribed for the purpose of an abortion, including both generic and\nbrand name drugs, even if such drug has not been approved by the food\nand drug administration for abortion, provided, however, that such drug\nshall be a recognized medication for abortion in one of the following\nestablished reference compendia:\n  (i) The WHO Model Lists of Essential Medicines;\n  (ii) The WHO Abortion Care Guidance; or\n  (iii) The National Academies of Science, Engineering, and Medicine\nConsensus Study Report.\n  (3) Every group policy delivered or issued for delivery in this state\nwhich provides coverage for in-patient surgical care shall include\ncoverage for a second surgical opinion by a qualified physician on the\nneed for surgery, except that this provision shall not apply to a policy\nwhich covers persons employed in more than one state or the benefit\nstructure of which was the subject of collective bargaining affecting\npersons who are employed in more than one state.\n  (4) (A) Every group policy delivered or issued for delivery in this\nstate that provides coverage for inpatient hospital care shall include\ncoverage for services to treat an emergency condition provided in\nhospital facilities, except that this provision shall not apply to a\npolicy which covers persons employed in more than one state or the\nbenefit structure of which was the subject of collective bargaining\naffecting persons who are employed in more than one state unless the\npolicy otherwise provides coverage for services to treat an emergency\ncondition provided in hospital facilities:\n  (i) without the need for any prior authorization determination;\n  (ii) regardless of whether the health care provider furnishing such\nservices is a participating provider with respect to such services;\n  (iii) if the emergency services are provided by a non-participating\nprovider, without imposing any administrative requirement or limitation\non coverage that is more restrictive than the requirements or\nlimitations that apply to emergency services received from participating\nproviders; and\n  (iv) if the emergency services are provided by a non-participating\nprovider, the cost-sharing requirement (expressed as a copayment or\ncoinsurance) shall be the same requirement that would apply if such\nservices were provided by a participating provider.\n  (B) Any requirements of section 2719A(b) of the Public Health Service\nAct, 42 U.S.C. § 300gg19a(b) and regulations thereunder that exceed the\nrequirements of this paragraph with respect to coverage of emergency\nservices shall be applicable to every policy subject to this paragraph.\n  (C) In this paragraph, an "emergency condition" means a medical or\nbehavioral condition that manifests itself by acute symptoms of\nsufficient severity, including severe pain, such that a prudent\nlayperson, possessing an average knowledge of medicine and health, could\nreasonably expect the absence of immediate medical attention to result\nin (i) placing the health of the person afflicted with such condition in\nserious jeopardy, or in the case of a behavioral condition placing the\nhealth of such person or others in serious jeopardy; (ii) serious\nimpairment to such person's bodily functions; (iii) serious dysfunction\nof any bodily organ or part of such person; (iv) serious disfigurement\nof such person; or (v) a condition described in clause (i), (ii) or\n(iii) of section 1867(e)(1)(A) of the Social Security Act.\n  (D) In this paragraph, "emergency services" means, with respect to an\nemergency condition: (i) a medical screening examination as required\nunder section 1867 of the Social Security Act, 42 U.S.C. § 1395dd, which\nis within the capability of the emergency department of a hospital,\nincluding ancillary services routinely available to the emergency\ndepartment to evaluate such emergency medical condition: and (ii) within\nthe capabilities of the staff and facilities available at the hospital,\nsuch further medical examination and treatment as are required under\nsection 1867 of the Social Security Act, 42 U.S.C. § 1395dd, to\nstabilize the patient.\n  (E) In this paragraph, "to stabilize" means, with respect to an\nemergency condition, to provide such medical treatment of the condition\nas may be necessary to assure, within reasonable medical probability,\nthat no material deterioration of the condition is likely to result from\nor occur during the transfer of the insured from a facility or to\ndeliver a newborn child (including the placenta).\n  (5) (A) (i) Every group or blanket policy delivered or issued for\ndelivery in this state which provides hospital, surgical or medical\ncoverage shall include coverage for maternity care, including hospital,\nsurgical or medical care to the same extent that coverage is provided\nfor illness or disease under the policy. Such maternity care coverage,\nother than coverage for perinatal complications, shall include inpatient\nhospital coverage for mother and newborn for at least forty-eight hours\nafter childbirth for any delivery other than a caesarean section, and\nfor at least ninety-six hours after a caesarean section. Such coverage\nfor maternity care shall include the services of a midwife licensed\npursuant to article one hundred forty of the education law, practicing\nconsistent with section sixty-nine hundred fifty-one of the education\nlaw and affiliated or practicing in conjunction with a facility licensed\npursuant to article twenty-eight of the public health law, but no\ninsurer shall be required to pay for duplicative routine services\nactually provided by both a licensed midwife and a physician.\n  (ii) Maternity care coverage shall also include, at minimum, parent\neducation, assistance and training in breast or bottle feeding, and the\nperformance of any necessary maternal and newborn clinical assessments.\n  (iii) The mother shall have the option to be discharged earlier than\nthe time periods established in item (i) of this subparagraph. In such\ncase, the inpatient hospital coverage must include at least one home\ncare visit which shall be in addition to, rather than in lieu of, any\nhome health care coverage available under the policy. The policy must\ncover the home care visit, which may be requested at any time within\nforty-eight hours of the time of delivery (ninety-six hours in the case\nof caesarean section), and shall be delivered within twenty-four hours,\n(I) after discharge, or (II) of the time of the mother's request,\nwhichever is later. Such home care coverage shall be pursuant to the\npolicy and subject to the provisions of this subparagraph, and not\nsubject to deductibles, coinsurance or copayments.\n  (B) Coverage provided under this paragraph for care and treatment\nduring pregnancy shall include provision for not less than two payments,\nat reasonable intervals and for services rendered, for prenatal care and\na separate payment for the delivery and postnatal care provided.\n  * (D) Coverage provided under this paragraph for care and treatment\nduring pregnancy shall include medically necessary transvaginal\nultrasounds when recommended by nationally recognized clinical practice\nguidelines. For the purposes of this subparagraph, "nationally\nrecognized clinical practice guidelines" means evidence-based clinical\npractice guidelines informed by a systematic review of evidence and an\nassessment of the benefits, and risks of alternative care options\nintended to optimize patient care developed by independent organizations\nor medical professional societies utilizing a transparent methodology\nand reporting structure and with a conflict of interest policy.\n  * NB Effective January 1, 2027\n  (5-a) Every policy that provides medical, major medical, or similar\ncomprehensive-type coverage shall provide coverage for prenatal vitamins\nwhen prescribed by a health care practitioner licensed, certified, or\nauthorized under title eight of the education law, and acting within\ntheir lawful scope of practice.\n  (6) (A) Every group policy issued or delivered in this state which\nprovides coverage for hospital care shall not exclude coverage for\nhospital care for diagnosis and treatment of correctable medical\nconditions otherwise covered by the policy solely because the medical\ncondition results in infertility; provided, however that:\n  (i) subject to the provisions of subparagraph (C) of this paragraph,\nin no case shall such coverage exclude surgical or medical procedures\nprovided as part of such hospital care which would correct malformation,\ndisease or dysfunction resulting in infertility; and\n  (ii) provided, further however, that subject to the provisions of\nsubparagraph (C) of this paragraph, in no case shall such coverage\nexclude diagnostic tests and procedures provided as part of such\nhospital care that are necessary to determine infertility or that are\nnecessary in connection with any surgical or medical treatments or\nprescription drug coverage provided pursuant to this paragraph,\nincluding such diagnostic tests and procedures as hysterosalpingogram,\nhysteroscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post\ncoital tests, testis biopsy, semen analysis, blood tests and ultrasound;\nand\n  (iii) provided, further however, every such policy which provides\ncoverage for prescription drugs shall include, within such coverage,\ncoverage for prescription drugs approved by the federal Food and Drug\nAdministration for use in the diagnosis and treatment of infertility in\naccordance with subparagraph (C) of this paragraph.\n  (B) Every group policy issued or delivered in this state which\nprovides coverage for surgical and medical care shall not exclude\ncoverage for surgical and medical care for diagnosis and treatment of\ncorrectable medical conditions otherwise covered by the policy solely\nbecause the medical condition results in infertility; provided, however\nthat:\n  (i) subject to the provisions of subparagraph (C) of this paragraph,\nin no case shall such coverage exclude surgical or medical procedures\nwhich would correct malformation, disease or dysfunction resulting in\ninfertility; and\n  (ii) provided, further however, that subject to the provisions of\nsubparagraph (C) of this paragraph, in no case shall such coverage\nexclude diagnostic tests and procedures that are necessary to determine\ninfertility or that are necessary in connection with any surgical or\nmedical treatments or prescription drug coverage provided pursuant to\nthis paragraph, including such diagnostic tests and procedures as\nhysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy,\nsono-hysterogram, post coital tests, testis biopsy, semen analysis,\nblood tests and ultrasound; and\n  (iii) provided, further however, every such policy which provides\ncoverage for prescription drugs shall include, within such coverage,\ncoverage for prescription drugs approved by the federal Food and Drug\nAdministration for use in the diagnosis and treatment of infertility in\naccordance with subparagraph (C) of this paragraph.\n  (C) Coverage of diagnostic and treatment procedures, including\nprescription drugs, used in the diagnosis and treatment of infertility\nas required by subparagraphs (A) and (B) of this paragraph shall be\nprovided in accordance with the provisions of this subparagraph.\n  (i) Diagnosis and treatment of infertility shall be prescribed as part\nof a physician's overall plan of care and consistent with the guidelines\nfor coverage as referenced in this subparagraph.\n  (ii) Coverage may be subject to co-payments, coinsurance and\ndeductibles as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\npolicy.\n  (iii) Except as provided in items (vi) and (vii) of this subparagraph,\ncoverage shall not be required to include the diagnosis and treatment of\ninfertility in connection with: (I) in vitro fertilization, gamete\nintrafallopian tube transfers or zygote intrafallopian tube transfers;\n(II) the reversal of elective sterilizations; (III) sex change\nprocedures; (IV) cloning; or (V) medical or surgical services or\nprocedures that are deemed to be experimental in accordance with\nclinical guidelines referenced in item (iv) of this subparagraph.\n  (iv) The superintendent, in consultation with the commissioner of\nhealth, shall promulgate regulations which shall stipulate the\nguidelines and standards which shall be used in carrying out the\nprovisions of this subparagraph, which shall include:\n  (I) The identification of experimental procedures and treatments not\ncovered for the diagnosis and treatment of infertility determined in\naccordance with the standards and guidelines established and adopted by\nthe American College of Obstetricians and Gynecologists and the American\nSociety for Reproductive Medicine;\n  (II) The identification of the required training, experience and other\nstandards for health care providers for the provision of procedures and\ntreatments for the diagnosis and treatment of infertility determined in\naccordance with the standards and guidelines established and adopted by\nthe American College of Obstetricians and Gynecologists and the American\nSociety for Reproductive Medicine; and\n  (III) The determination of appropriate medical candidates by the\ntreating physician in accordance with the standards and guidelines\nestablished and adopted by the American College of Obstetricians and\nGynecologists and/or the American Society for Reproductive Medicine.\n  (v)(I) For the purposes of this paragraph, "infertility" means a\ndisease or condition characterized by the incapacity to impregnate\nanother person or to conceive, defined by the failure to establish a\nclinical pregnancy after twelve months of regular, unprotected sexual\nintercourse or therapeutic donor insemination, or after six months of\nregular, unprotected sexual intercourse or therapeutic donor\ninsemination for a female thirty-five years of age or older. Earlier\nevaluation and treatment may be warranted based on an individual's\nmedical history or physical findings.\n  (II) For purposes of this paragraph, "iatrogenic infertility" means an\nimpairment of fertility by surgery, radiation, chemotherapy or other\nmedical treatment affecting reproductive organs or processes.\n  (vi) Coverage shall also include standard fertility preservation\nservices when a medical treatment may directly or indirectly cause\niatrogenic infertility to an insured. Coverage may be subject to annual\ndeductibles and coinsurance, including copayments, as may be deemed\nappropriate by the superintendent and as are consistent with those\nestablished for other benefits within a given policy.\n  (vii) Every large group policy delivered or issued for delivery in\nthis state that provides medical, major medical or similar\ncomprehensive-type coverage shall provide coverage for three cycles of\nin-vitro fertilization used in the treatment of infertility. Coverage\nmay be subject to annual deductibles and coinsurance, including\ncopayments, as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\npolicy. For purposes of this item, a "cycle" is defined as either all\ntreatment that starts when: preparatory medications are administered for\novarian stimulation for oocyte retrieval with the intent of undergoing\nin-vitro fertilization using a fresh embryo transfer; or medications are\nadministered for endometrial preparation with the intent of undergoing\nin-vitro fertilization using a frozen embryo transfer.\n  (viii) No insurer providing coverage under this paragraph shall\ndiscriminate based on an insured's expected length of life, present of\npredicted disability, degree of medical dependency, perceived quality of\nlife, or other health conditions, nor based on personal characteristics,\nincluding age, sex, sexual orientation, marital status or gender\nidentity.\n  (D) Every policy that provides coverage for prescription fertility\ndrugs and requires or permits prescription drugs to be purchased through\na network participating mail order or other non-retail pharmacy shall\nprovide the same coverage for prescription fertility drugs when such\ndrugs are purchased from a network participating non-mail order retail\npharmacy provided that the network participating non-mail order retail\npharmacy agrees in advance through a contractual network agreement, to\nthe same reimbursement amount, as well as the same applicable terms and\nconditions, that the insurer has established for a network participating\nmail order or other non-retail pharmacy. In such case, the policy shall\nnot impose any fee, co-payment, co-insurance, deductible or other\ncondition on any covered person who elects to purchase prescription\nfertility drugs through a network participating non-mail order retail\npharmacy that it does not impose on any covered person who purchases\nprescription fertility drugs through a network participating mail order\nor other non-retail pharmacy; provided, however, that the provisions of\nthis section shall not supersede the terms of a collective bargaining\nagreement or apply to a policy that is the result of a collective\nbargaining agreement between an employer and a recognized or certified\nemployee organization.\n  (7)(A) Every group or blanket accident and health insurance policy\nissued or issued for delivery in this state which provides medical\ncoverage that includes coverage for physician services in a physician's\noffice and every policy which provides major medical or similar\ncomprehensive-type coverage shall include coverage for the following\nequipment and supplies for the treatment of diabetes, if recommended or\nprescribed by a physician or other licensed health care provider legally\nauthorized to prescribe under title eight of the education law: blood\nglucose monitors and blood glucose monitors for the visually impaired,\ndata management systems, test strips for glucose monitors and visual\nreading and urine testing strips, insulin, injection aids, cartridges\nfor the visually impaired, syringes, insulin pumps and appurtenances\nthereto, insulin infusion devices, and oral agents for controlling blood\nsugar. In addition, the commissioner of the department of health shall\nprovide and periodically update by rule or regulation a list of\nadditional diabetes equipment and related supplies such as are medically\nnecessary for the treatment of diabetes, for which there shall also be\ncoverage. Such policies shall also include coverage for diabetes\nself-management education to ensure that persons with diabetes are\neducated as to the proper self-management and treatment of their\ndiabetic condition, including information on proper diets. Such coverage\nfor self-management education and education relating to diet shall be\nlimited to visits medically necessary upon the diagnosis of diabetes,\nwhere a physician diagnoses a significant change in the patient's\nsymptoms or conditions which necessitate changes in a patient's\nself-management, or where reeducation or refresher education is\nnecessary. Such education may be provided by the physician or other\nlicensed health care provider legally authorized to prescribe under\ntitle eight of the education law, or their staff, as part of an office\nvisit for diabetes diagnosis or treatment, or by a certified diabetes\nnurse educator, certified nutritionist, certified dietitian or\nregistered dietitian upon the referral of a physician or other licensed\nhealth care provider legally authorized to prescribe under title eight\nof the education law. Education provided by the certified diabetes nurse\neducator, certified nutritionist, certified dietitian or registered\ndietitian may be limited to group settings wherever practicable.\nCoverage for self-management education and education relating to diet\nshall also include home visits when medically necessary.\n  (B) Such coverage may be subject to annual deductibles and coinsurance\nas may be deemed appropriate by the superintendent and as are consistent\nwith those established for other benefits within a given policy;\nprovided, however, that covered prescription insulin drugs shall not be\nsubject to a deductible, copayment, coinsurance or any other cost\nsharing requirement.\n  (C) This paragraph shall not apply to a policy which covers persons\nemployed in more than one state or the benefit structure of which was\nthe subject of collective bargaining affecting persons employed in more\nthan one state unless such policy is issued under the New York state\nhealth insurance plan established under article eleven of the civil\nservice law or issued to or through a local government.\n  (8) (A) Every group or blanket policy delivered or issued for delivery\nin this state which provides coverage for inpatient hospital care shall\nprovide such coverage for such period as is determined by the attending\nphysician in consultation with the patient to be medically appropriate\nfor such covered person undergoing a lymph node dissection or a\nlumpectomy for the treatment of breast cancer or a mastectomy covered by\nthe policy. Such coverage may be subject to annual deductibles and\ncoinsurance as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\npolicy. Written notice of the availability of such coverage shall be\ndelivered to the policyholder prior to inception of such policy and\nannually thereafter.\n  (B) An insurer providing coverage under this paragraph and any\nparticipating entity through which the insurer offers health services\nshall not:\n  (i) deny to a covered person eligibility, or continued eligibility, to\nenroll or to renew coverage under the terms of the policy or vary the\nterms of the policy for the purpose or with the effect of avoiding\ncompliance with this paragraph;\n  (ii) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nparagraph;\n  (iii) penalize in any way or reduce or limit the compensation of a\nhealth care practitioner for recommending or providing care to a covered\nperson in accordance with this paragraph;\n  (iv) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nparagraph intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this paragraph; or\n  (v) restrict coverage for any portion of a period within a hospital\nlength of stay required under this paragraph in a manner which is\ninconsistent with the coverage provided for any preceding portion of\nsuch stay.\n  (C) The prohibitions in subparagraph (B) of this paragraph shall be in\naddition to the provisions of sections three thousand two hundred\nthirty-one and three thousand two hundred thirty-two of this article and\nnothing in this subparagraph shall be construed to suspend, supersede,\namend or otherwise modify such sections.\n  (9)(A) Every policy which provides medical, major medical, or similar\ncomprehensive-type coverage must provide coverage for a second medical\nopinion by an appropriate specialist, including but not limited to a\nspecialist affiliated with a specialty care center for the treatment of\ncancer, in the event of a positive or negative diagnosis of cancer or a\nrecurrence of cancer or a recommendation of a course of treatment for\ncancer, subject to the following:\n  (i) In the case of a policy that requires, or provides financial\nincentives for, the insured to receive covered services from health care\nproviders participating in a provider network maintained by or under\ncontract with the insurer, the policy shall include coverage for a\nsecond medical opinion from a non-participating specialist, including\nbut not limited to a specialist affiliated with a specialty care center\nfor the treatment of cancer, when the attending physician provides a\nwritten referral to a non-participating specialist, at no additional\ncost to the insured beyond what such insured would have paid for\nservices from a participating appropriate specialist. Provided, however\nthat nothing herein shall impair an insured's rights (if any) under the\npolicy to obtain the second medical opinion from a non-participating\nspecialist without a written referral, subject to the payment of\nadditional coinsurance (if any) required by the policy for services\nprovided by non-participating providers. The insurer shall compensate\nthe non-participating specialist at the usual, customary and reasonable\nrate, or at a rate listed on a fee schedule filed and approved by the\nsuperintendent which provides a comparable level of reimbursement.\n  (ii) In the case of a policy that does not provide financial\nincentives for, and does not require, the insured to receive covered\nservices from health care providers participating in a provider network\nmaintained by or under contract with the insurer, the policy shall\ninclude coverage for a second medical opinion from a specialist at no\nadditional cost to the insured beyond what the insured would have paid\nfor comparable services covered under the policy.\n  (iii) Such coverage may be subject to annual deductibles and\ncoinsurance as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\npolicy, and, where applicable, consistent with the provisions of clauses\n(i) and (ii) of this subparagraph.\n  Nothing in this paragraph shall eliminate or diminish an insurer's\nobligation to comply with the provisions of section four thousand eight\nhundred four of this chapter where applicable. Written notice of the\navailability of such coverage shall be delivered to the policyholder\nprior to the inception of such policy and annually thereafter.\n  (B) An insurer providing coverage under this paragraph and any\nparticipating entity through which an insurer offers health services\nshall not:\n  (i) deny to a covered person eligibility, or continued eligibility, to\nenroll or to renew coverage under the terms of the policy or vary the\nterms of the policy for the purpose or with the effect of avoiding\ncompliance with this paragraph;\n  (ii) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nparagraph;\n  (iii) penalize in any way or reduce or limit the compensation of a\nhealth care practitioner for recommending or providing care to a covered\nperson in accordance with this paragraph; or\n  (iv) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the coverage provided pursuant to this\nparagraph intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this paragraph.\n  (C) The prohibitions in subparagraph (B) of this paragraph shall be in\naddition to the provisions of sections three thousand two hundred\nthirty-one and three thousand two hundred thirty-two of this article and\nnothing in this subparagraph shall be construed to suspend, supersede,\namend or otherwise modify such sections.\n  (10) (A) Every group or blanket policy delivered or issued for\ndelivery in this state which provides medical, major medical, or similar\ncomprehensive-type coverage shall provide the following coverage for\nbreast or chest wall reconstruction surgery after a mastectomy or\npartial mastectomy:\n  (i) all stages of reconstruction of the breast or chest wall on which\nthe mastectomy or partial mastectomy has been performed; and\n  (ii) surgery and reconstruction of the other breast or chest wall to\nproduce a symmetrical appearance;\nin the manner determined by the attending physician and the patient to\nbe appropriate. Chest wall reconstruction surgery shall include\naesthetic flat closure as such term is defined by the National Cancer\nInstitute. Such coverage may be subject to annual deductibles and\ncoinsurance provisions as may be deemed appropriate by the\nsuperintendent and as are consistent with those established for other\nbenefits within a given policy. Written notice of the availability of\nsuch coverage shall be delivered to the policyholder prior to inception\nof such policy and annually thereafter.\n  (A-1) Every group or blanket policy providing coverage as required by\nsubparagraph (A) of this paragraph shall also provide coverage for the\ntattooing of the nipple-areolar complex pursuant to or as part of such\nreconstruction if such tattooing is performed by a licensed physician or\nother health care practitioner licensed, certified, or authorized\npursuant to title eight of the education law and acting within their\nscope of practice.\n  (B) An insurer providing coverage under this paragraph and any\nparticipating entity through which the insurer offers health services\nshall not:\n  (i) deny to a covered person eligibility, or continued eligibility, to\nenroll or to renew coverage under the terms of the policy or vary the\nterms of the policy for the purpose or with the effect of avoiding\ncompliance with this paragraph;\n  (ii) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nparagraph;\n  (iii) penalize in any way or reduce or limit the compensation of a\nhealth care practitioner for recommending or providing care to a covered\nperson in accordance with this paragraph;\n  (iv) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nparagraph intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this paragraph; or\n  (v) restrict coverage for any portion of a period within a hospital\nlength of stay required under this paragraph in a manner which is\ninconsistent with the coverage provided for any preceding portion of\nsuch stay.\n  (C) The prohibitions in this paragraph shall be in addition to the\nprovisions of sections three thousand two hundred thirty-one and three\nthousand two hundred thirty-two of this article and nothing in this\nparagraph shall be construed to suspend, supersede, amend or otherwise\nmodify such sections.\n  * (11) Every policy that provides coverage for prescription drugs\nshall include coverage for the cost of enteral formulas for home use,\nwhether administered orally or via tube feeding, for which a physician\nor other licensed health care provider legally authorized to prescribe\nunder title eight of the education law has issued a written order. Such\nwritten order shall state that the enteral formula is clearly medically\nnecessary and has been proven effective as a disease-specific treatment\nregimen. Specific diseases and disorders for which enteral formulas have\nbeen proven effective shall include, but are not limited to, inherited\ndiseases of amino-acid or organic acid metabolism; Crohn's Disease;\ngastroesophageal reflux; disorders of gastrointestinal motility such as\nchronic intestinal pseudo-obstruction; and multiple, severe food\nallergies including, but not limited to immunoglobulin E and\nnonimmunoglobulin E-mediated allergies to multiple food proteins; severe\nfood protein induced enterocolitis syndrome; eosinophilic disorders and\nimpaired absorption of nutrients caused by disorders affecting the\nabsorptive surface, function, length, and motility of the\ngastrointestinal tract. Enteral formulas that are medically necessary\nand taken under written order from a physician for the treatment of\nspecific diseases shall be distinguished from nutritional supplements\ntaken electively. Coverage for certain inherited diseases of amino acid\nand organic acid metabolism as well as severe protein allergic\nconditions shall include modified solid food products that are low\nprotein, contain modified protein, or are amino acid based that are\nmedically necessary.\n  * NB There are 2 par (11)'s\n  * (11)(A) Every policy which is a "managed care product" as defined in\nsubparagraph (D) of this paragraph that includes coverage for physician\nservices in a physician's office, and every policy which is a "managed\ncare product" that provides major medical or similar comprehensive-type\ncoverage shall include coverage for chiropractic care, as defined in\nsection six thousand five hundred fifty-one of the education law,\nprovided by a doctor of chiropractic licensed pursuant to article one\nhundred thirty-two of the education law, in connection with the\ndetection or correction by manual or mechanical means of structural\nimbalance, distortion or subluxation in the human body for the purpose\nof removing nerve interference, and the effects thereof, where such\ninterference is the result of or related to distortion, misalignment or\nsubluxation of or in the vertebral column. However, chiropractic care\nand services may be subject to reasonable deductible, co-payment and\nco-insurance amounts, reasonable fee or benefit limits, and reasonable\nutilization review, provided that any such amounts, limits and review:\n(a) shall not function to direct treatment in a manner discriminative\nagainst chiropractic care, and (b) individually and collectively shall\nbe no more restrictive than those applicable under the same policy to\ncare or services provided by other health professionals in the\ndiagnosis, treatment and management of the same or similar conditions,\ninjuries, complaints, disorders or ailments, even if differing\nnomenclature is used to describe the condition, injury, complaint,\ndisorder or ailment. Nothing herein contained shall be construed as\nimpeding or preventing either the provision or coverage of chiropractic\ncare and services by duly licensed doctors of chiropractic, within the\nlawful scope of chiropractic practice, in hospital facilities on a staff\nor employee basis.\n  (C) Every policy which includes coverage for physician services in a\nphysician's office, and every policy which provides major medical or\nsimilar comprehensive-type coverage, other than a "managed care product"\nas defined in subparagraph (D) of this paragraph, shall provide coverage\nfor chiropractic care, as defined in section six thousand five hundred\nfifty-one of the education law, provided by a doctor of chiropractic\nlicensed pursuant to article one hundred thirty-two of the education\nlaw, in connection with the detection or correction by manual or\nmechanical means of structural imbalance, distortion or subluxation in\nthe human body for the purpose of removing nerve interference, and the\neffects thereof, where such interference is the result of or related to\ndistortion, misalignment or subluxation of or in the vertebral column.\nHowever, chiropractic care and services may be subject to reasonable\ndeductible, co-payment and co-insurance amounts, reasonable fee or\nbenefit limits, and reasonable utilization review, provided that any\nsuch amounts, limits and review: (a) shall not function to direct\ntreatment in a manner discriminative against chiropractic care, and (b)\nindividually and collectively shall be no more restrictive that those\napplicable under the same policy to care or services provided by other\nhealth professionals in the diagnosis, treatment and management of the\nsame or similar conditions, injuries, complaints, disorders or ailments,\neven if differing nomenclature is used to describe the condition,\ninjury, complaint, disorder or ailment. Nothing herein contained shall\nbe construed as impeding or preventing either the provision or coverage\nof chiropractic care and services by duly licensed doctors of\nchiropractic, within the lawful scope of chiropractic practice, in\nhospital facilities on a staff or employee basis.\n  (D) For purposes of this paragraph, a "managed care product" shall\nmean a policy which requires that medical or other health care services\ncovered under the policy, other than emergency care services, be\nprovided by, or pursuant to a referral from, a primary care provider,\nand that services provided pursuant to such a referral be rendered by a\nhealth care provider participating in the insurer's managed care\nprovider network. In addition, a managed care product shall also mean\nthe in-network portion of a contract which requires that medical or\nother health care services covered under the contract, other than\nemergency care services, be provided by, or pursuant to a referral from,\na primary care provider, and that services provided pursuant to such a\nreferral be rendered by a health care provider participating in the\ninsurer's managed care provider network, in order for the insured to be\nentitled to the maximum reimbursement under the contract.\n  (E) The coverage required by this paragraph shall not be abridged by\nany regulation promulgated by the superintendent.\n  * NB There are 2 par (11)'s\n  (12) No policy of group or blanket accident and health insurance\ndelivered or issued for delivery in this state shall exclude coverage of\na health care service, as defined in paragraph two of such subdivision\n(e) of section four thousand nine hundred of this chapter, rendered or\nproposed to be rendered to an insured on the basis that such service is\nexperimental or investigational, is rendered as part of a clinical trial\nas defined in subsection (b-2) of section forty-nine hundred of this\nchapter, or a prescribed pharmaceutical product referenced in\nsubparagraph (B) of paragraph two of subsection (e) of section\nforty-nine hundred of this chapter provided that coverage of the patient\ncosts of such service has been recommended for the insured by an\nexternal appeal agent upon an appeal conducted pursuant to subparagraph\n(B) of paragraph four of subsection (b) of section four thousand nine\nhundred fourteen of this chapter. The determination of the external\nappeal agent shall be binding on the parties. For purposes of this\nparagraph, patient costs shall have the same meaning as such term has\nfor purposes of subparagraph (B) of paragraph four of subsection (b) of\nsection four thousand nine hundred fourteen of this chapter; provided,\nhowever, that coverage for the services required under this paragraph\nshall be provided subject to the terms and conditions generally\napplicable to other benefits provided under the policy.\n  (13) Every group or blanket policy delivered or issued for delivery in\nthis state that provides major medical or similar comprehensive-type\ncoverage shall provide such coverage for bone mineral density\nmeasurements or tests, and if such contract otherwise includes coverage\nfor prescription drugs, drugs and devices approved by the federal food\nand drug administration or generic equivalents as approved substitutes.\nIn determining appropriate coverage provided by subparagraphs (A), (B)\nand (C) of this paragraph, the insurer or health maintenance\norganization shall adopt standards that include the criteria of the\nfederal Medicare program and the criteria of the national institutes of\nhealth for the detection of osteoporosis, provided that such coverage\nshall be further determined as follows:\n  (A) for purposes of subparagraphs (B) and (C) of this paragraph, bone\nmineral density measurements or tests, drugs and devices shall include\nthose covered under the federal Medicare program as well as those in\naccordance with the criteria of the national institutes of health,\nincluding, as consistent with such criteria, dual-energy x-ray\nabsorptiometry.\n  (B) for purposes of subparagraphs (A) and (C) of this paragraph, bone\nmineral density measurements or tests, drugs and devices shall be\ncovered for individuals meeting the criteria under the federal Medicare\nprogram or the criteria of the national institutes of health; provided\nthat, to the extent consistent with such criteria, individuals\nqualifying for coverage shall at a minimum, include individuals:\n  (i) previously diagnosed as having osteoporosis or having a family\nhistory of osteoporosis; or\n  (ii) with symptoms or conditions indicative of the presence, or the\nsignificant risk, of osteoporosis; or\n  (iii) on a prescribed drug regimen posing a significant risk of\nosteoporosis; or\n  (iv) with lifestyle factors to such a degree as posing a significant\nrisk of osteoporosis; or\n  (v) with such age, gender and/or other physiological characteristics\nwhich pose a significant risk for osteoporosis.\n  (C) Such coverage required pursuant to subparagraph (A) or (B) of this\nparagraph may be subject to annual deductibles and coinsurance as may be\ndeemed appropriate by the superintendent and as are consistent with\nthose established for other benefits within a given policy.\n  (D) In addition to subparagraph (A), (B) or (C) of this paragraph,\nevery group or blanket policy that provides hospital, surgical or\nmedical care coverage, except for a grandfathered health plan under\nsubparagraph (E) of this paragraph, shall provide coverage for the\nfollowing items or services for bone mineral density and such coverage\nshall not be subject to annual deductibles or coinsurance:\n  (i) evidence-based items or services for bone mineral density that\nhave in effect a rating of 'A' or 'B' in the current recommendations of\nthe United States preventive services task force; and\n  (ii) with respect to women, such additional preventive care and\nscreenings for bone mineral density not described in item (i) of this\nsubparagraph and as provided for in comprehensive guidelines supported\nby the health resources and services administration.\n  (E) For purposes of this paragraph, "grandfathered health plan" means\ncoverage provided by an insurer in which an individual was enrolled on\nMarch twenty-third, two thousand ten for as long as the coverage\nmaintains grandfathered status in accordance with section 1251(e) of the\nAffordable Care Act, 42 U.S.C. § 18011(e).\n  (14) No group or blanket policy delivered or issued for delivery in\nthis state which provides medical, major medical or similar\ncomprehensive-type coverage shall exclude coverage for services covered\nunder such policy when provided by a comprehensive care center for\neating disorders pursuant to article thirty of the mental hygiene law;\nprovided, however, that reimbursement under such policy for services\nprovided through such comprehensive care centers shall, to the extent\npossible and practicable, be structured in a manner to facilitate the\nindividualized, comprehensive and integrated plans of care which such\ncenters' network of practitioners and providers are required to provide.\n  (15)(A) No group or blanket managed care health insurance policy that\nprovides coverage for hospital, medical or surgical care shall provide\nthat services of a participating hospital will be covered as\nout-of-network services solely on the basis that the health care\nprovider admitting or rendering services to the insured is not a\nparticipating provider.\n  (B) No group or blanket managed care health insurance policy that\nprovides coverage for hospital, medical or surgical care shall provide\nthat services of a participating health care provider will be covered as\nout-of-network services solely on the basis that the services are\nrendered in a non-participating hospital.\n  (C) For purposes of this paragraph, a "health care provider" is a\nhealth care professional licensed, registered or certified pursuant to\ntitle eight of the education law or a health care professional\ncomparably licensed, registered or certified by another state.\n  (D) For purposes of this paragraph, a "managed care health insurance\npolicy" is a policy that requires that services be provided by a\nprovider participating in the insurer's network in order for the insured\nto receive the maximum level of reimbursement under the policy.\n  (16)(A) Every group or blanket policy that includes coverage for\ndialysis treatment that requires such services to be provided by an\nin-network provider and that does not provide coverage for\nout-of-network dialysis treatment shall not deny coverage of such\nservices because the services are provided by an out-of-network\nprovider, provided that each of the following conditions are met:\n  (i) The out-of-network provider is duly licensed to practice and\nauthorized to provide such treatment;\n  (ii) The out-of-network provider is located outside the service area\nof the insurer;\n  (iii) The in-network healthcare provider treating the insured for the\ncondition issues a written order for dialysis treatment stating that in\nhis or her opinion such treatment is necessary;\n  (iv) The insured has notified, in writing, the insurer at least thirty\ndays in advance of the proposed date or dates of such out-of-network\ndialysis treatment. The notice shall include the authorization required\nby clause (iii) of this subparagraph. In the event the insured must\ntravel on sudden notice due to family or other emergency, shorter notice\nmay be permitted, provided that the insurer has reasonable opportunity\nto review the travel and treatment plans of the insured;\n  (v) The insurer shall have the right to pre-approve the dialysis\ntreatment and schedule; and\n  (vi) Such coverage is limited to no greater than ten out-of-network\ntreatments in a calendar year.\n  (B) Where coverage for out-of-network dialysis treatment is provided\npursuant to subparagraph (A) of this paragraph, no insurer shall be\nobligated to reimburse the out-of-network provider at an amount greater\nthan it would have paid for the same treatment within a network,\nincluding all drugs and ancillary services tied to dialysis treatment,\nand any amount charged by a provider in excess of the amount reimbursed\nby the insurer shall be the responsibility of the insured receiving the\nout-of-network services.\n  (C) Such coverage of out-of-network dialysis services required by\nsubparagraph (A) of this paragraph shall otherwise be subject to the\nlimitations, exclusions and terms of the policy, including, but not\nlimited to, utilization review, annual deductibles, copayments, and\ncoinsurance, consistent with those required for other similar benefits\nunder the policy.\n  (17) Notwithstanding title eleven of article five of the social\nservices law or any other law to the contrary, every policy which\nprovides coverage for prescription drugs shall, with regard to eye drop\nmedication requiring a prescription that has been approved by the\ninsurer for coverage, allow for the limited refilling of the\nprescription prior to the last day of the approved dosage period without\nregard to any coverage restrictions on early refill of renewals.\nProvided, however, that any refill dispensed prior to the expiration of\nthe prescribed and approved coverage period pursuant to this paragraph,\nshall, to the extent practicable, be limited in quantity so as not to\nexceed the remaining dosage initially approved for coverage. Provided,\nfurther, that such limited refilling shall not limit or restrict\ncoverage with regard to any previously or subsequently approved\nprescription for eye drop medication and shall be subject to the terms\nand conditions of the policy otherwise applicable to this coverage.\nProvided, further, that a pharmacist may contact the prescribing\nphysician or health care provider to verity the prescription.\n  (18) Every group or blanket policy which provides medical, major\nmedical or similar comprehensive-type coverage that includes coverage\nfor a physical or well care visit once in every three hundred sixty-five\ndays shall be interpreted to mean that such physical or well care visit\ncan be had once every calendar year, regardless of whether or not a\nperiod of three hundred sixty-five days has passed since the previous\nphysical or well care visit.\n  (19) Every group or blanket accident and health insurance policy\ndelivered or issued for delivery in this state that provides medical\ncoverage that includes coverage for physician services in a physician's\noffice and every policy that provides major medical or similar\ncomprehensive-type coverage shall include coverage for equipment and\nsupplies used for the treatment of ostomies, if prescribed by a\nphysician or other licensed health care provider legally authorized to\nprescribe under title eight of the education law. Such coverage shall be\nsubject to annual deductibles and coinsurance as deemed appropriate by\nthe superintendent. The coverage required by this paragraph shall be\nidentical to, and shall not enhance or increase the coverage required as\npart of essential health benefits as defined in subsection (a) of\nsection three thousand two hundred seventeen-i of this article.\n  (20) No group or blanket policy delivered or issued for delivery in\nthis state that provides reimbursement for non-physician surgical first\nassistant services when the services are provided by a non-physician\nsurgical first assistant shall exclude such coverage on the basis that\nthe non-physician surgical first assistant services were performed by a\nregistered nurse first assistant provided that: (A) the registered nurse\nfirst assistant is certified in operating room nursing; (B) the services\nare within the scope of practice of a non-physician surgical first\nassistant; and (C) the terms and conditions of the policy otherwise\nprovide for the coverage of the services. Nothing in this paragraph\nshall be construed to prevent the medical management or utilization\nreview of the services or prevent a policy from requiring that services\nare to be provided through a network of participating providers who meet\ncertain requirements for participation, including provider\ncredentialing.\n  (21) Every group or blanket policy delivered or issued for delivery in\nthis state that provides coverage for prescription drugs subject to a\ncopayment shall charge a copayment for a limited initial prescription of\nan opioid drug, which is prescribed in accordance with paragraph (b) of\nsubdivision five of section thirty-three hundred one of the public\nhealth law, that is either (i) proportional between the copayment for a\nthirty-day supply and the amount of drugs the patient was prescribed; or\n(ii) equivalent to the copayment for a full thirty-day supply of the\nopioid drug, provided that no additional copayments may be charged for\nany additional prescriptions for the remainder of the thirty-day supply.\n  (22) (A) Every policy which provides hospital, surgical, or medical\ncoverage and which offers maternity care coverage pursuant to paragraph\nfive of this subsection shall also provide coverage for abortion\nservices for an enrollee.\n  (B) Coverage for abortion shall not be subject to annual deductibles\nor coinsurance, including co-payments, unless the policy is a high\ndeductible health plan as defined in section 223(c)(2) of the internal\nrevenue code of 1986, in which case coverage for abortion may be subject\nto the plan's annual deductible.\n  (C) Notwithstanding any other provision, a group policy that provides\nhospital, surgical, or medical expense coverage delivered or issued for\ndelivery in this state to a religious employer, as defined in item one\nof subparagraph (E) of paragraph sixteen of subsection (l) of this\nsection, may exclude coverage for abortion only if the insurer:\n  (i) obtains an annual certification from the group policyholder that\nthe policyholder is a religious employer and that the religious employer\nrequests a policy without coverage for abortion;\n  (ii) issues a rider to each certificate holder at no premium to be\ncharged to the certificate holder or religious employer for the rider,\nthat provides coverage for abortion subject to the same rules as would\nhave been applied to the same category of treatment in the policy issued\nto the religious employer. The rider shall clearly and conspicuously\nspecify that the religious employer does not administer abortion\nbenefits, but that the insurer is issuing a rider for coverage of\nabortion, and shall provide the insurer's contact information for\nquestions; and\n  (iii) provides notice of the issuance of the policy and rider to the\nsuperintendent in a form and manner acceptable to the superintendent.\n  (23) (A) Every group or blanket policy of accident and health\ninsurance delivered or issued for delivery in this state which provides\nmajor medical or similar comprehensive-type coverage and provides\ncoverage for prescription drugs shall provide coverage for medically\nnecessary epinephrine devices for the emergency treatment of\nlife-threatening allergic reactions. Such coverage may be subject to\nannual deductibles and coinsurance as may be deemed appropriate by the\nsuperintendent; provided however, the total amount that an insured is\nrequired to pay out-of-pocket for such devices shall be capped at an\namount not to exceed one hundred dollars annually regardless of the\ninsured's deductible, copayment, coinsurance or any other cost-sharing\nrequirement. If under federal law, application of the annual cap would\nresult in health savings account ineligibility under 26 USC 223, such\ncoverage may be subject to the plan's annual deductible, except for with\nrespect to items or services that are preventive care pursuant to 26 USC\n223(c)(2)(C), in which case the requirements of this paragraph shall\napply regardless of whether the minimum deductible under 26 USC 223 has\nbeen satisfied.\n  (B) For the purposes of this paragraph, "epinephrine device" shall\nhave the same meaning as provided in paragraph (b) of subdivision one of\nsection three thousand-c of the public health law.\n  (l) (1) Every insurer delivering a group policy or issuing a group\npolicy for delivery in this state which provides coverage supplementing\npart A and part B of subchapter XVIII of the federal Social Security\nAct, 42 U.S.C. §§ 1395 et seq, must make available and, if requested by\nthe policyholder, provide coverage of supplemental home care visits\nbeyond those provided by part A and part B, sufficient to produce an\naggregate coverage of three hundred sixty-five home care visits per\npolicy year. Such coverage shall be provided pursuant to regulations\nprescribed by the superintendent. Written notice of the availability of\nsuch coverage shall be delivered to the policyholder prior to inception\nof such group policy and annually thereafter, except that this notice\nshall not be required where a policy covers two hundred or more\nemployees or where the benefit structure was the subject of collective\nbargaining affecting persons who are employed in more than one state.\n  (2) (A) Every insurer delivering a group policy or issuing a group\npolicy for delivery, in this state, which provides coverage for\nin-patient hospital care must make available, and if requested by the\npolicyholder, provide coverage for care in a nursing home. Written\nnotice of the availability of such coverage shall be delivered to the\npolicyholder prior to inception of such group policy and annually\nthereafter, except that this notice shall not be required where a policy\ncovers two hundred or more employees or where the benefit structure was\nthe subject of collective bargaining affecting persons who are employed\nin more than one state.\n  (B) Such coverage shall be made available at the inception of all new\npolicies and, with respect to all other policies at any anniversary date\nof the policy subject to evidence of insurability.\n  (C) In this paragraph, care in a nursing home means the continued care\nand treatment of a covered person who is under the care of a physician\nbut only if:\n  (i) the care is provided in a nursing home as defined in section\ntwenty-eight hundred one of the public health law or a skilled nursing\nfacility as defined in subchapter XVIII of the federal Social Security\nAct, 42 U.S.C. §§ 1395 et seq;\n  (ii) the covered person has been in a hospital for at least three days\nimmediately preceding admittance to the nursing home or the skilled\nnursing facility; and\n  (iii) further hospitalization would otherwise be necessary.\n  (D) In determining the total days of coverage for nursing home care\nthe aggregate of the number of covered days of care in a hospital and\nthe number of covered days of care in a nursing home, with two days of\ncare in a nursing home equivalent to one day of care in a hospital, need\nnot exceed the number of covered days of hospital care provided under\nthe contract in a benefit period.\n  (E) The level of benefits to be provided for nursing home care must be\nreasonably related to the benefits provided for hospital care.\n  (3) (A) Every insurer delivering a group policy or issuing a group\npolicy for delivery, in this state, which provides coverage for\nin-patient hospital care must make available and if requested by the\npolicyholder provide coverage to residents in this state for ambulatory\ncare in hospital out-patient facilities, as a hospital is defined in\nsection twenty-eight hundred one of the public health law, or subchapter\nXVIII of the federal Social Security Act, 42 U.S.C. §§ 1395 et seq, and\nphysicians' offices. Written notice of the availability of such coverage\nshall be delivered to the policyholder prior to inception of such group\npolicy and annually thereafter, except that this notice shall not be\nrequired where a policy covers two hundred or more employees or where\nthe benefit structure was the subject of collective bargaining affecting\npersons who are employed in more than one state.\n  (B) In this paragraph:\n  (i) "Ambulatory care in hospital out-patient facilities" means\nservices for diagnostic X-rays, laboratory and pathological\nexaminations, physical and occupational therapy and radiation therapy,\nand services and medications used for nonexperimental cancer\nchemotherapy and cancer hormone therapy, provided that such services and\nmedications are related to and necessary for the treatment or diagnosis\nof the patient's illness or injury, are ordered by a physician and, in\nthe case of physical therapy services, are to be furnished in connection\nwith the same illness for which the patient had been hospitalized or in\nconnection with surgical care, but in no event need benefits for\nphysical therapy be provided which commences more than six months after\ndischarge from a hospital or the date surgical care was rendered, and in\nno event need benefits for physical therapy be provided after three\nhundred sixty-five days from the date of discharge from a hospital or\nthe date surgical care was rendered.\n  (ii) "Ambulatory care in physicians' offices" means services for\ndiagnostic X-rays, radiation therapy, laboratory and pathological\nexaminations, and services and medications used for nonexperimental\ncancer chemotherapy and cancer hormone therapy, provided that such\nservices and medications are related to and necessary for the treatment\nor diagnosis of the patient's illness or injury, and ordered by a\nphysician.\n  (C) Such coverage shall be made available at the inception of all new\npolicies and, with respect to policies issued before January first,\nnineteen hundred eighty-three, at the first annual anniversary date\nthereafter, without evidence of insurability and at any subsequent\nannual anniversary date subject to evidence of insurability.\n  (4) (A) Every insurer delivering a group policy or issuing a group\npolicy for delivery, in this state, that provides reimbursement for\npsychiatric or psychological services or for the diagnosis and treatment\nof mental health conditions, however defined in such policy, by\nphysicians, psychiatrists or psychologists, shall provide the same\ncoverage to insureds for such services when performed by a licensed\nclinical social worker, within the lawful scope of his or her practice,\nwho is licensed pursuant to article one hundred fifty-four of the\neducation law and mental health counselors, marriage and family\ntherapists, and psychoanalysts licensed pursuant to article one hundred\nsixty-three of the education law, within the lawful scope of his or her\npractice.  Nothing herein shall be construed to modify or expand the\nscope of practice of a mental health counselor, marriage and family\ntherapist, or psychoanalyst licensed pursuant to article one hundred\nsixty-three of the education law. Further, nothing herein shall be\nconstrued to create a new mandated health benefit.\n  (B) The state board for social work shall maintain a list of all\nlicensed clinical social workers qualified for reimbursement under this\nparagraph.\n  (C) Such coverage shall be made available at the inception of all new\npolicies and, with respect to all other policies at any subsequent\nannual anniversary date of the policy subject to evidence of\ninsurability.\n  (E) The state board for social work shall maintain a list of all\nlicensed clinical social workers qualified for reimbursement under\nsubparagraph (D) of this paragraph.\n  (5) (A) Every insurer delivering a group or school blanket policy or\nissuing a group or school blanket policy for delivery, in this state,\nwhich provides coverage for inpatient hospital care or coverage for\nphysician services shall provide coverage for the diagnosis and\ntreatment of mental health conditions and:\n  * (i) where the policy provides coverage for inpatient hospital care,\nbenefits for inpatient care in a hospital as defined by subdivision ten\nof section 1.03 of the mental hygiene law and benefits for outpatient\ncare provided in a facility issued an operating certificate by the\ncommissioner of mental health pursuant to the provisions of article\nthirty-one of the mental hygiene law, or in a facility operated by the\noffice of mental health or in a crisis stabilization center licensed\npursuant to section 36.01 of the mental hygiene law or, for care\nprovided in other states, to similarly licensed or certified hospitals\nor facilities; and\n  * NB Effective until after the superintendent of financial services\nand the commissioner of health have promulgated regulations\n  * (i) where the policy provides coverage for inpatient hospital care,\nbenefits for: inpatient care in a hospital as defined by subdivision ten\nof section 1.03 of the mental hygiene law; sub-acute care in a\nresidential facility licensed or operated by the office of mental\nhealth; outpatient care provided by a facility issued an operating\ncertificate by the commissioner of mental health pursuant to the\nprovisions of article thirty-one of the mental hygiene law, or by a\nfacility operated by the office of mental health; outpatient care\nprovided by a crisis stabilization center licensed pursuant to section\n36.01 of the mental hygiene law; outpatient care provided by a mobile\ncrisis intervention services provider licensed, certified, or designated\nby the office of mental health or the office of addiction services and\nsupports; outpatient and inpatient care for critical time intervention\nservices and outpatient care for assertive community treatment services\nprovided by facilities issued an operating certificate by the\ncommissioner of mental health pursuant to the provisions of article\nthirty-one of the mental hygiene law, beginning no later than thirty\ndays following discharge from a hospital as defined by subdivision ten\nof section 1.03 of the mental hygiene law or the emergency department of\na hospital licensed pursuant to article twenty-eight of the public\nhealth law; or, for care provided in other states, to similarly licensed\nor certified hospitals, facilities, or licensed, certified or designated\nproviders; and\n  * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n  (ii) where the policy provides coverage for physician services, it\nshall include benefits for outpatient care provided by a psychiatrist or\npsychologist licensed to practice in this state, or a mental health\ncounselor, marriage and family therapist, or psychoanalyst licensed\npursuant to article one hundred sixty-three of the education law, or a\nlicensed clinical social worker within the lawful scope of his or her\npractice, who is licensed pursuant to article one hundred fifty-four of\nthe education law, a nurse practitioner licensed to practice in this\nstate, or a professional corporation or university faculty practice\ncorporation thereof. Nothing herein shall be construed to modify or\nexpand the scope of practice of a mental health counselor, marriage and\nfamily therapist, or psychoanalyst licensed pursuant to article one\nhundred sixty-three of the education law. Further, nothing herein shall\nbe construed to create a new mandated health benefit.\n  (B) Coverage required by this paragraph may be subject to annual\ndeductibles, co-pays and coinsurance as may be deemed appropriate by the\nsuperintendent and shall be consistent with those imposed on other\nbenefits under the policy. Provided that no copayment or coinsurance\nimposed for outpatient mental health services provided in a facility\nlicensed, certified or otherwise authorized by the office of mental\nhealth shall exceed the copayments or coinsurance imposed for a primary\ncare office visit under the policy.\n  (C) Coverage under this paragraph shall not apply financial\nrequirements or treatment limitations to mental health benefits that are\nmore restrictive than the predominant financial requirements and\ntreatment limitations applied to substantially all medical and surgical\nbenefits covered by the policy.\n  (D) The criteria for medical necessity determinations under the policy\nwith respect to mental health benefits shall be made available by the\ninsurer to any insured, prospective insured, or in-network provider upon\nrequest.\n  (E) For purposes of this paragraph:\n  (i) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n  (ii) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n  * (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy; and\n  * NB Effective until after the superintendent of financial services\nand the commissioner of health have promulgated regulations\n  * (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy;\n  * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n  * (iv) "mental health condition" means any mental health disorder as\ndefined in the most recent edition of the diagnostic and statistical\nmanual of mental disorders or the most recent edition of another\ngenerally recognized independent standard of current medical practice\nsuch as the international classification of diseases.\n  * NB Effective until after the superintendent of financial services\nand the commissioner of health have promulgated regulations\n  * (iv) "mental health condition" means any mental health disorder as\ndefined in the most recent edition of the diagnostic and statistical\nmanual of mental disorders or the most recent edition of another\ngenerally recognized independent standard of current medical practice\nsuch as the international classification of diseases;\n  * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n  * (v) "assertive community treatment services" means a comprehensive\nand integrated combination of treatment, rehabilitation, case\nmanagement, and support services primarily provided in an insured's\nresidence or other community locations by a mobile multidisciplinary\nmental health treatment team licensed pursuant to article thirty-one of\nthe mental hygiene law;\n  * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n  * (vi) "critical time intervention services" means services rendered\nby a provider licensed under article thirty-one of the mental hygiene\nlaw that provides evidence-based, therapeutic interventions that include\nintensive outreach, engagement, and care coordination services that are\nprovided to an insured before the insured is discharged from inpatient\ncare in a hospital as defined by subdivision ten of section 1.03 of the\nmental hygiene law or the emergency department of a hospital licensed\npursuant to article twenty-eight of the public health law and continue\nafter discharge until the insured is stabilized; and\n  * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n  * (vii) "residential facility" means crisis residence facilities and\ncommunity residences for eating disorder integrated treatment programs\nlicensed pursuant to article thirty-one of the mental hygiene law.\n  * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n  (F) An insurer shall provide coverage under this paragraph, at a\nminimum, consistent with the federal Paul Wellstone and Pete Domenici\nMental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §\n1185a).\n  (G) This subparagraph shall apply to hospitals and crisis residence\nfacilities in this state that are licensed or operated by the office of\nmental health that are participating in the insurer's provider network.\nWhere the policy provides coverage for inpatient hospital care, benefits\nfor inpatient hospital care in a hospital as defined by subdivision ten\nof section 1.03 of the mental hygiene law and benefits for sub-acute\ncare in a crisis residence facility licensed or operated by the office\nof mental health shall not be subject to preauthorization. Coverage\nprovided under this subparagraph shall also not be subject to concurrent\nutilization review for individuals who have not attained the age of\neighteen during the first fourteen days of the inpatient admission,\nprovided the facility notifies the insurer of both the admission and the\ninitial treatment plan within two business days of the admission,\nperforms daily clinical review of the insured, and participates in\nperiodic consultation with the insurer to ensure that the facility is\nusing the evidence-based and peer reviewed clinical review criteria\nutilized by the insurer which is approved by the office of mental health\nand appropriate to the age of the insured to ensure that the inpatient\ncare is medically necessary for the insured. For individuals who have\nattained age eighteen, coverage provided under this subparagraph shall\nalso not be subject to concurrent review during the first thirty days of\nthe inpatient or residential admission, provided the facility notifies\nthe insurer of both the admission and the initial treatment plan within\ntwo business days of the admission, performs daily clinical review of\nthe insured, and participates in periodic consultation with the insurer\nto ensure that the facility is using the evidence-based and peer\nreviewed clinical review criteria utilized by the insurer which is\napproved by the office of mental health and appropriate to the age of\nthe insured, to ensure that the inpatient or residential care is\nmedically necessary for the insured. However, concurrent review may be\nperformed during the first thirty days if an insured meets clinical\ncriteria designated by the office of mental health or where the insured\nis admitted to a hospital or facility which has been designated by the\noffice of mental health for concurrent review, in consultation with the\ncommissioner of health and the superintendent. All treatment provided\nunder this subparagraph may be reviewed retrospectively. Where care is\ndenied retrospectively, an insured shall not have any financial\nobligation to the facility for any treatment under this subparagraph\nother than any copayment, coinsurance, or deductible otherwise required\nunder the policy.\n  (H) This subparagraph shall apply to crisis stabilization centers in\nthis state that are licensed pursuant to section 36.01 of the mental\nhygiene law and participate in the insurer's provider network. Benefits\nfor care by a crisis stabilization center shall not be subject to\npreauthorization. All treatment provided under this subparagraph may be\nreviewed retrospectively. Where care is denied retrospectively, an\ninsured shall not have any financial obligation to the facility for any\ntreatment under this subparagraph other than any copayment, coinsurance,\nor deductible otherwise required under the policy.\n  * (I) This subparagraph shall apply to mobile crisis intervention\nservices providers licensed, certified, or designated by the office of\nmental health or the office of addiction services and supports. For\npurposes of this subparagraph, "mobile crisis intervention services"\nmeans mental health and substance use disorder services, consisting of:\n(1) telephonic crisis triage and response; (2) mobile crisis response to\nprovide intervention and facilitate access to other behavioral health\nservices; and (3) mobile and telephonic follow-up services after the\ninitial crisis response until the insured is stabilized provided to an\ninsured who is experiencing, or is at imminent risk of experiencing, a\nbehavioral health crisis, which includes instances in which an insured\ncannot manage their primarily psychiatric or substance use related\nsymptoms without de-escalation or intervention. Mobile crisis\nintervention services do not include services provided to an insured\nafter the insured has been stabilized.\n  (i) Benefits for covered services provided by a mobile crisis\nintervention services provider shall not be subject to preauthorization.\nExcept where otherwise required by law, nothing in this subparagraph\nshall prevent services provided subsequent to the provision of mobile\ncrisis intervention services from being subject to preauthorization.\n  (ii) Benefits for covered services provided by a mobile crisis\nintervention services provider shall be covered regardless of whether\nthe mobile crisis intervention services provider is a participating\nprovider.\n  (iii) If the covered services are provided by a non-participating\nmobile crisis intervention services provider, an insurer shall not\nimpose any administrative requirement or limitation on coverage that is\nmore restrictive than the requirements or limitations that apply to\ncovered services received from a participating mobile crisis\nintervention services provider.\n  (iv) If the covered services are provided by a non-participating\nmobile crisis intervention services provider, the insured's copayment,\ncoinsurance, and deductible shall be the same as would apply if such\ncovered services were provided by a participating mobile crisis\nintervention services provider.\n  (v) A mobile crisis intervention services provider reimbursed pursuant\nto this section shall not charge or seek any reimbursement from, or have\nany recourse against, an insured for the services provided pursuant to\nthis subparagraph, except for the collection of in-network copayments,\ncoinsurance, or deductibles for which the insured is responsible for\nunder the terms of the policy.\n  * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n  (J) This subparagraph shall apply to school-based mental health\nclinics that are licensed pursuant to article thirty-one of the mental\nhygiene law and provide outpatient care in pre-school, elementary, or\nsecondary schools. An insurer shall provide reimbursement for covered\noutpatient care when provided by such school-based mental health clinics\nat a pre-school, elementary, or secondary school, regardless of whether\nthe school-based mental health clinic furnishing such services is a\nparticipating provider with respect to such services. Reimbursement for\nsuch covered services shall be at the rate negotiated between the\ninsurer and school-based mental health clinic or, in the absence of a\nnegotiated rate, an amount no less than the rate that would be paid for\nsuch services pursuant to the medical assistance program under title\neleven of article five of the social services law. Payment by an insurer\npursuant to this section shall be payment in full for the services\nprovided. The school-based mental health clinic reimbursed pursuant to\nthis section shall not charge or seek any reimbursement from or have any\nrecourse against, an insured for the services provided pursuant to this\nsubparagraph, except for the collection of in-network copayments,\ncoinsurance, or deductibles for which the insured is responsible for\nunder the terms of the policy.\n  (K) (i) This clause shall apply to outpatient treatment provided in a\nfacility issued an operating certificate by the commissioner of mental\nhealth pursuant to the provisions of article thirty-one of the mental\nhygiene law, or in a facility operated by the office of mental health,\nor in a crisis stabilization center licensed pursuant to section 36.01\nof the mental hygiene law, that is participating in the insurer's\nprovider network. Reimbursement for covered outpatient treatment\nprovided by such a facility shall be at rates negotiated between the\ninsurer and the participating facility, provided that such rates are not\nless than the rates that would be paid for such treatment pursuant to\nthe medical assistance program under title eleven of article five of the\nsocial services law. For the purposes of this clause, the rates that\nwould be paid for such treatment pursuant to the medical assistance\nprogram under title eleven of article five of the social services law\nshall be the rates with an effective date of April first of the\npreceding year, which shall be established prior to October first of the\npreceding calendar year.\n  (ii) The office of mental health shall publish information adequate to\ncalculate the rates that would be paid for such treatment pursuant to\nthe medical assistance program under title eleven of article five of the\nsocial services law. Such information shall be provided in a form and\nmanner to be determined by the commissioner of mental health. Nothing in\nthis clause shall be construed to relieve an insurer of the obligation\nto reimburse at no less than the applicable minimum rate set forth in\nclause (i) of this subparagraph. Prior to the submission of premium rate\nfilings and applications, the superintendent shall provide insurers with\nguidance on factors to consider in calculating the impact of rate\nchanges for the purposes of submitting premium rate filings and\napplications to the superintendent for the subsequent policy year. To\nthe extent that the rates with an effective date of April first differ\nfrom the estimated rates incorporated in premium rate filings and\napplications, insurers may account for such differences in future\npremium rate filings and applications submitted to the superintendent\nfor approval.\n  (6) * (A) Every policy that provides hospital, major medical or\nsimilar comprehensive coverage shall provide inpatient coverage for the\ndiagnosis and treatment of substance use disorder, including\ndetoxification and rehabilitation services. Such inpatient coverage\nshall include unlimited medically necessary treatment for substance use\ndisorder treatment services provided in residential settings. Further,\nsuch inpatient coverage shall not apply financial requirements or\ntreatment limitations, including utilization review requirements, to\ninpatient substance use disorder benefits that are more restrictive than\nthe predominant financial requirements and treatment limitations applied\nto substantially all medical and surgical benefits covered by the\npolicy.\n  * NB Effective until January 1, 2027\n  * (A) Every policy that provides hospital, major medical or similar\ncomprehensive coverage shall provide inpatient coverage for the\ndiagnosis and treatment of substance-related and addictive disorder,\nincluding detoxification and rehabilitation services. Such inpatient\ncoverage shall include unlimited medically necessary treatment for\nsubstance-related and addictive disorder treatment services provided in\nresidential settings. Further, such inpatient coverage shall not apply\nfinancial requirements or treatment limitations, including utilization\nreview requirements, to inpatient substance-related and addictive\ndisorder benefits that are more restrictive than the predominant\nfinancial requirements and treatment limitations applied to\nsubstantially all medical and surgical benefits covered by the policy.\n  * NB Effective January 1, 2027\n  * (B) Coverage provided under this paragraph may be limited to\nfacilities in New York state that are licensed, certified or otherwise\nauthorized by the office of alcoholism and substance abuse services and,\nin other states, to those which are accredited by the joint commission\nas alcoholism, substance abuse or chemical dependence treatment programs\nand are similarly licensed, certified, or otherwise authorized in the\nstate in which the facility is located.\n  * NB Effective until January 1, 2027\n  * (B) Coverage provided under this paragraph may be limited to\nfacilities in New York state that are licensed, certified or otherwise\nauthorized by the office of addiction services and supports and, in\nother states, to those which are accredited by the joint commission as\nalcoholism, addiction, substance abuse or chemical dependence treatment\nprograms and are similarly licensed, certified, or otherwise authorized\nin the state in which the facility is located.\n  * NB Effective January 1, 2027\n  (C) Coverage provided under this paragraph may be subject to annual\ndeductibles and co-insurance as deemed appropriate by the superintendent\nand that are consistent with those imposed on other benefits within a\ngiven policy.\n  * (D) This subparagraph shall apply to facilities in this state that\nare licensed, certified or otherwise authorized by the office of\nalcoholism and substance abuse services that are participating in the\ninsurer's provider network. Coverage provided under this paragraph shall\nnot be subject to preauthorization. Coverage provided under this\nparagraph shall also not be subject to concurrent utilization review\nduring the first twenty-eight days of the inpatient admission provided\nthat the facility notifies the insurer of both the admission and the\ninitial treatment plan within two business days of the admission. The\nfacility shall perform daily clinical review of the patient, including\nperiodic consultation with the insurer at or just prior to the\nfourteenth day of treatment to ensure that the facility is using the\nevidence-based and peer reviewed clinical review tool utilized by the\ninsurer which is designated by the office of alcoholism and substance\nabuse services and appropriate to the age of the patient, to ensure that\nthe inpatient treatment is medically necessary for the patient. Prior to\ndischarge, the facility shall provide the patient and the insurer with a\nwritten discharge plan which shall describe arrangements for additional\nservices needed following discharge from the inpatient facility as\ndetermined using the evidence-based and peer-reviewed clinical review\ntool utilized by the insurer which is designated by the office of\nalcoholism and substance abuse services. Prior to discharge, the\nfacility shall indicate to the insurer whether services included in the\ndischarge plan are secured or determined to be reasonably available. Any\nutilization review of treatment provided under this subparagraph may\ninclude a review of all services provided during such inpatient\ntreatment, including all services provided during the first twenty-eight\ndays of such inpatient treatment. Provided, however, the insurer shall\nonly deny coverage for any portion of the initial twenty-eight day\ninpatient treatment on the basis that such treatment was not medically\nnecessary if such inpatient treatment was contrary to the evidence-based\nand peer reviewed clinical review tool utilized by the insurer which is\ndesignated by the office of alcoholism and substance abuse services. An\ninsured shall not have any financial obligation to the facility for any\ntreatment under this subparagraph other than any copayment, coinsurance,\nor deductible otherwise required under the policy.\n  * NB Effective until January 1, 2027\n  * (D) This subparagraph shall apply to facilities in this state that\nare licensed, certified or otherwise authorized by the office of\naddiction services and supports that are participating in the insurer's\nprovider network. Coverage provided under this paragraph shall not be\nsubject to preauthorization. Coverage provided under this paragraph\nshall also not be subject to concurrent utilization review during the\nfirst twenty-eight days of the inpatient admission provided that the\nfacility notifies the insurer of both the admission and the initial\ntreatment plan within two business days of the admission. The facility\nshall perform daily clinical review of the patient, including periodic\nconsultation with the insurer at or just prior to the fourteenth day of\ntreatment to ensure that the facility is using the evidence-based and\npeer reviewed clinical review tool utilized by the insurer which is\ndesignated by the office of addiction services and supports and\nappropriate to the age of the patient, to ensure that the inpatient\ntreatment is medically necessary for the patient. Prior to discharge,\nthe facility shall provide the patient and the insurer with a written\ndischarge plan which shall describe arrangements for additional services\nneeded following discharge from the inpatient facility as determined\nusing the evidence-based and peer-reviewed clinical review tool utilized\nby the insurer which is designated by the office of addiction services\nand supports. Prior to discharge, the facility shall indicate to the\ninsurer whether services included in the discharge plan are secured or\ndetermined to be reasonably available. Any utilization review of\ntreatment provided under this subparagraph may include a review of all\nservices provided during such inpatient treatment, including all\nservices provided during the first twenty-eight days of such inpatient\ntreatment. Provided, however, the insurer shall only deny coverage for\nany portion of the initial twenty-eight day inpatient treatment on the\nbasis that such treatment was not medically necessary if such inpatient\ntreatment was contrary to the evidence-based and peer reviewed clinical\nreview tool utilized by the insurer which is designated by the office of\naddiction services and supports. An insured shall not have any financial\nobligation to the facility for any treatment under this subparagraph\nother than any copayment, coinsurance, or deductible otherwise required\nunder the policy.\n  * NB Effective January 1, 2027\n  * (E) The criteria for medical necessity determinations under the\npolicy with respect to inpatient substance use disorder benefits shall\nbe made available by the insurer to any insured, prospective insured, or\nin-network provider upon request.\n  * NB Effective until January 1, 2027\n  * (E) The criteria for medical necessity determinations under the\npolicy with respect to inpatient substance-related and addictive\ndisorder benefits shall be made available by the insurer to any insured,\nprospective insured, or in-network provider upon request.\n  * NB Effective January 1, 2027\n  * (F) For purposes of this paragraph:\n  (i) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n  (ii) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n  (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy; and\n  (iv) "substance use disorder" shall have the meaning set forth in the\nmost recent edition of the diagnostic and statistical manual of mental\ndisorders or the most recent edition of another generally recognized\nindependent standard of current medical practice such as the\ninternational classification of diseases.\n  * NB Effective until January 1, 2027\n  * (F) For purposes of this paragraph:\n  (i) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n  (ii) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n  (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy; and\n  (iv) "substance-related and addictive disorder" shall have the meaning\nset forth in the most recent edition of the diagnostic and statistical\nmanual of mental disorders or the most recent edition of another\ngenerally recognized independent standard of current medical practice\nsuch as the international classification of diseases.\n  * NB Effective January 1, 2027\n  (G) An insurer shall provide coverage under this paragraph, at a\nminimum, consistent with the federal Paul Wellstone and Pete Domenici\nMental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §\n1185a).\n  * (7) (A) Every policy that provides medical, major medical or similar\ncomprehensive-type coverage shall provide outpatient coverage for the\ndiagnosis and treatment of substance use disorder, including\ndetoxification and rehabilitation services. Such coverage shall not\napply financial requirements or treatment limitations to outpatient\nsubstance use disorder benefits that are more restrictive than the\npredominant financial requirements and treatment limitations applied to\nsubstantially all medical and surgical benefits covered by the policy.\n  (B) Coverage under this paragraph may be limited to facilities in this\nstate that are licensed, certified or otherwise authorized by the office\nof addiction services and supports to provide outpatient substance use\ndisorder services and crisis stabilization centers licensed pursuant to\nsection 36.01 of the mental hygiene law, and, in other states, to those\nwhich are accredited by the joint commission as alcoholism or chemical\ndependence treatment programs and similarly licensed, certified or\notherwise authorized in the state in which the facility is located.\n  (C) Coverage provided under this paragraph may be subject to annual\ndeductibles and co-insurance as deemed appropriate by the superintendent\nand that are consistent with those imposed on other benefits within a\ngiven policy.\n  (C-1) A large group policy that provides coverage under this paragraph\nshall not impose copayments or coinsurance for outpatient substance use\ndisorder services that exceeds the copayment or coinsurance imposed for\na primary care office visit. Provided that no greater than one such\ncopayment may be imposed for all services provided in a single day by a\nfacility licensed, certified or otherwise authorized by the office of\nalcoholism and substance abuse services to provide outpatient substance\nuse disorder services.\n  (D) A policy providing coverage for substance use disorder services\npursuant to this paragraph shall provide up to twenty outpatient visits\nper policy or calendar year to an individual who identifies him or\nherself as a family member of a person suffering from substance use\ndisorder and who seeks treatment as a family member who is otherwise\ncovered by the applicable policy pursuant to this paragraph. The\ncoverage required by this paragraph shall include treatment as a family\nmember pursuant to such family member's own policy provided such family\nmember:\n  (i) does not exceed the allowable number of family visits provided by\nthe applicable policy pursuant to this paragraph; and\n  (ii) is otherwise entitled to coverage pursuant to this paragraph and\nsuch family member's applicable policy.\n  (E) This subparagraph shall apply to facilities in this state that are\nlicensed, certified or otherwise authorized by the office of alcoholism\nand substance abuse services for the provision of outpatient, intensive\noutpatient, outpatient rehabilitation and opioid treatment that are\nparticipating in the insurer's provider network. Coverage provided under\nthis paragraph shall not be subject to preauthorization. Coverage\nprovided under this paragraph shall not be subject to concurrent review\nfor the first four weeks of continuous treatment, not to exceed\ntwenty-eight visits, provided the facility notifies the insurer of both\nthe start of treatment and the initial treatment plan within two\nbusiness days. The facility shall perform clinical assessment of the\npatient at each visit, including periodic consultation with the insurer\nat or just prior to the fourteenth day of treatment to ensure that the\nfacility is using the evidence-based and peer reviewed clinical review\ntool utilized by the insurer which is designated by the office of\nalcoholism and substance abuse services and appropriate to the age of\nthe patient, to ensure that the outpatient treatment is medically\nnecessary for the patient. Any utilization review of the treatment\nprovided under this subparagraph may include a review of all services\nprovided during such outpatient treatment, including all services\nprovided during the first four weeks of continuous treatment, not to\nexceed twenty-eight visits, of such outpatient treatment. Provided,\nhowever, the insurer shall only deny coverage for any portion of the\ninitial four weeks of continuous treatment, not to exceed twenty-eight\nvisits, for outpatient treatment on the basis that such treatment was\nnot medically necessary if such outpatient treatment was contrary to the\nevidence-based and peer reviewed clinical review tool utilized by the\ninsurer which is designated by the office of alcoholism and substance\nabuse services. An insured shall not have any financial obligation to\nthe facility for any treatment under this subparagraph other than any\ncopayment, coinsurance, or deductible otherwise required under the\npolicy.\n  (F) The criteria for medical necessity determinations under the policy\nwith respect to outpatient substance use disorder benefits shall be made\navailable by the insurer to any insured, prospective insured, or\nin-network provider upon request.\n  (G) For purposes of this paragraph:\n  (i) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n  (ii) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n  (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy; and\n  (iv) "substance use disorder" shall have the meaning set forth in the\nmost recent edition of the diagnostic and statistical manual of mental\ndisorders or the most recent edition of another generally recognized\nindependent standard of current medical practice such as the\ninternational classification of diseases.\n  (H) An insurer shall provide coverage under this paragraph, at a\nminimum, consistent with the federal Paul Wellstone and Pete Domenici\nMental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §\n1185a).\n  (I) This subparagraph shall apply to crisis stabilization centers in\nthis state that are licensed pursuant to section 36.01 of the mental\nhygiene law and participate in the insurer's provider network. Benefits\nfor care in a crisis stabilization center shall not be subject to\npreauthorization. All treatment provided under this subparagraph may be\nreviewed retrospectively. Where care is denied retrospectively, an\ninsured shall not have any financial obligation to the facility for any\ntreatment under this subparagraph other than any copayment, coinsurance,\nor deductible otherwise required under the policy.\n  (J) (i) This clause shall apply to facilities in this state that are\nlicensed, certified, or otherwise authorized by the office of addiction\nservices and supports for the provision of outpatient, intensive\noutpatient, outpatient rehabilitation and opioid treatment that are\nparticipating in the insurer's provider network. Reimbursement for\ncovered outpatient treatment provided by such facilities shall be at\nrates negotiated between the insurer and the participating facility,\nprovided that such rates are not less than the rates that would be paid\nfor such treatment pursuant to the medical assistance program under\ntitle eleven of article five of the social services law. For the\npurposes of this clause, the rates that would be paid for such treatment\npursuant to the medical assistance program under title eleven of article\nfive of the social services law shall be the rates with an effective\ndate of April first of the preceding year, which shall be established\nprior to October first of the preceding calendar year.\n  (ii) The office of addiction services and supports shall publish\ninformation adequate to calculate the rates that would be paid for such\ntreatment pursuant to the medical assistance program under title eleven\nof article five of the social services law. Such information shall be\nprovided in a form and manner to be determined by the commissioner of\naddiction services and supports. Nothing in this clause shall be\nconstrued to relieve an insurer of the obligation to reimburse at no\nless than the applicable minimum rate set forth in clause (i) of this\nsubparagraph. Prior to the submission of premium rate filings and\napplications, the superintendent shall provide insurers with guidance on\nfactors to consider in calculating the impact of rate changes for the\npurposes of submitting premium rate filings and applications to the\nsuperintendent for the subsequent policy year. To the extent that the\nrates with an effective date of April first differ from the estimated\nrates incorporated in premium rate filings and applications, insurers\nmay account for such differences in future premium rate filings and\napplications submitted to the superintendent for approval.\n  * NB Effective until January 1, 2027\n  * (7) (A) Every policy that provides medical, major medical or similar\ncomprehensive-type coverage shall provide outpatient coverage for the\ndiagnosis and treatment of substance-related and addictive disorder,\nincluding detoxification and rehabilitation services. Such coverage\nshall not apply financial requirements or treatment limitations to\noutpatient substance-related and addictive disorder benefits that are\nmore restrictive than the predominant financial requirements and\ntreatment limitations applied to substantially all medical and surgical\nbenefits covered by the policy.\n  (B) Coverage under this paragraph may be limited to facilities in this\nstate that are licensed, certified or otherwise authorized by the office\nof addiction services and supports to provide outpatient\nsubstance-related and addictive disorder services and crisis\nstabilization centers licensed pursuant to section 36.01 of the mental\nhygiene law, and, in other states, to those which are accredited by the\njoint commission as alcoholism, addiction or chemical dependence\ntreatment programs and similarly licensed, certified or otherwise\nauthorized in the state in which the facility is located.\n  (C) Coverage provided under this paragraph may be subject to annual\ndeductibles and co-insurance as deemed appropriate by the superintendent\nand that are consistent with those imposed on other benefits within a\ngiven policy.\n  (C-1) A large group policy that provides coverage under this paragraph\nshall not impose copayments or coinsurance for outpatient\nsubstance-related and addictive disorder services that exceeds the\ncopayment or coinsurance imposed for a primary care office visit.\nProvided that no greater than one such copayment may be imposed for all\nservices provided in a single day by a facility licensed, certified or\notherwise authorized by the office of addiction services and supports to\nprovide outpatient substance-related and addictive disorder services.\n  (D) A policy providing coverage for substance-related and addictive\ndisorder services pursuant to this paragraph shall provide up to twenty\noutpatient visits per policy or calendar year to an individual who\nidentifies themselves as a family member of a person suffering from a\nsubstance-related and addictive disorder and who seeks treatment as a\nfamily member who is otherwise covered by the applicable policy pursuant\nto this paragraph. The coverage required by this paragraph shall include\ntreatment as a family member pursuant to such family member's own policy\nprovided such family member:\n  (i) does not exceed the allowable number of family visits provided by\nthe applicable policy pursuant to this paragraph; and\n  (ii) is otherwise entitled to coverage pursuant to this paragraph and\nsuch family member's applicable policy.\n  (E) This subparagraph shall apply to facilities in this state that are\nlicensed, certified or otherwise authorized by the office of addiction\nservices and supports for the provision of outpatient, intensive\noutpatient, outpatient rehabilitation and opioid treatment that are\nparticipating in the insurer's provider network. Coverage provided under\nthis paragraph shall not be subject to preauthorization. Coverage\nprovided under this paragraph shall not be subject to concurrent review\nfor the first four weeks of continuous treatment, not to exceed\ntwenty-eight visits, provided the facility notifies the insurer of both\nthe start of treatment and the initial treatment plan within two\nbusiness days. The facility shall perform clinical assessment of the\npatient at each visit, including periodic consultation with the insurer\nat or just prior to the fourteenth day of treatment to ensure that the\nfacility is using the evidence-based and peer reviewed clinical review\ntool utilized by the insurer which is designated by the office of\naddiction services and supports and appropriate to the age of the\npatient, to ensure that the outpatient treatment is medically necessary\nfor the patient. Any utilization review of the treatment provided under\nthis subparagraph may include a review of all services provided during\nsuch outpatient treatment, including all services provided during the\nfirst four weeks of continuous treatment, not to exceed twenty-eight\nvisits, of such outpatient treatment. Provided, however, the insurer\nshall only deny coverage for any portion of the initial four weeks of\ncontinuous treatment, not to exceed twenty-eight visits, for outpatient\ntreatment on the basis that such treatment was not medically necessary\nif such outpatient treatment was contrary to the evidence-based and peer\nreviewed clinical review tool utilized by the insurer which is\ndesignated by the office of addiction services and supports. An insured\nshall not have any financial obligation to the facility for any\ntreatment under this subparagraph other than any copayment, coinsurance,\nor deductible otherwise required under the policy.\n  (F) The criteria for medical necessity determinations under the policy\nwith respect to outpatient substance-related and addictive disorder\nbenefits shall be made available by the insurer to any insured,\nprospective insured, or in-network provider upon request.\n  (G) For purposes of this paragraph:\n  (i) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n  (ii) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n  (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy; and\n  (iv) "substance-related and addictive disorder" shall have the meaning\nset forth in the most recent edition of the diagnostic and statistical\nmanual of mental disorders or the most recent edition of another\ngenerally recognized independent standard of current medical practice\nsuch as the international classification of diseases.\n  (H) An insurer shall provide coverage under this paragraph, at a\nminimum, consistent with the federal Paul Wellstone and Pete Domenici\nMental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §\n1185a).\n  (I) This subparagraph shall apply to crisis stabilization centers in\nthis state that are licensed pursuant to section 36.01 of the mental\nhygiene law and participate in the insurer's provider network. Benefits\nfor care in a crisis stabilization center shall not be subject to\npreauthorization. All treatment provided under this subparagraph may be\nreviewed retrospectively. Where care is denied retrospectively, an\ninsured shall not have any financial obligation to the facility for any\ntreatment under this subparagraph other than any copayment, coinsurance,\nor deductible otherwise required under the policy.\n  (J) (i) This clause shall apply to facilities in this state that are\nlicensed, certified, or otherwise authorized by the office of addiction\nservices and supports for the provision of outpatient, intensive\noutpatient, outpatient rehabilitation and opioid treatment that are\nparticipating in the insurer's provider network. Reimbursement for\ncovered outpatient treatment provided by such facilities shall be at\nrates negotiated between the insurer and the participating facility,\nprovided that such rates are not less than the rates that would be paid\nfor such treatment pursuant to the medical assistance program under\ntitle eleven of article five of the social services law. For the\npurposes of this clause, the rates that would be paid for such treatment\npursuant to the medical assistance program under title eleven of article\nfive of the social services law shall be the rates with an effective\ndate of April first of the preceding year, which shall be established\nprior to October first of the preceding calendar year.\n  (ii) The office of addiction services and supports shall publish\ninformation adequate to calculate the rates that would be paid for such\ntreatment pursuant to the medical assistance program under title eleven\nof article five of the social services law. Such information shall be\nprovided in a form and manner to be determined by the commissioner of\naddiction services and supports. Nothing in this clause shall be\nconstrued to relieve an insurer of the obligation to reimburse at no\nless than the applicable minimum rate set forth in clause (i) of this\nsubparagraph. Prior to the submission of premium rate filings and\napplications, the superintendent shall provide insurers with guidance on\nfactors to consider in calculating the impact of rate changes for the\npurposes of submitting premium rate filings and applications to the\nsuperintendent for the subsequent policy year. To the extent that the\nrates with an effective date of April first differ from the estimated\nrates incorporated in premium rate filings and applications, insurers\nmay account for such differences in future premium rate filings and\napplications submitted to the superintendent for approval.\n  * NB Effective January 1, 2027\n  (7-a) * (A) No policy that provides medical, major medical or similar\ncomprehensive-type small group coverage and provides coverage for\nprescription drugs for medication for the treatment of a substance use\ndisorder shall require prior authorization for an initial or renewal\nprescription for the detoxification or maintenance treatment of a\nsubstance use disorder, including all buprenorphine products, methadone,\nlong acting injectable naltrexone, or medication for opioid overdose\nreversal prescribed or dispensed to an insured covered under the policy,\nincluding federal food and drug administration-approved over-the-counter\nopioid overdose reversal medication as prescribed, dispensed or as\notherwise authorized under state or federal law, except where otherwise\nprohibited by law. Every policy that provides medical, major medical or\nsimilar comprehensive-type large group coverage shall provide coverage\nfor prescription drugs for medication for the treatment of a substance\nuse disorder and shall not require prior authorization for an initial or\nrenewal prescription for the detoxification or maintenance treatment of\na substance use disorder, including all buprenorphine products,\nmethadone, long acting injectable naltrexone, or medication for opioid\noverdose reversal prescribed or dispensed to an insured covered under\nthe policy, including federal food and drug administration-approved\nover-the-counter opioid overdose reversal medication as prescribed,\ndispensed or as otherwise authorized under state or federal law, except\nwhere otherwise prohibited by law.\n  * NB Effective until January 1, 2027\n  * (A) No policy that provides medical, major medical or similar\ncomprehensive-type small group coverage and provides coverage for\nprescription drugs for medication for the treatment of a\nsubstance-related and addictive disorder shall require prior\nauthorization for an initial or renewal prescription for the\ndetoxification or maintenance treatment of a substance-related and\naddictive disorder, including all buprenorphine products, methadone,\nlong acting injectable naltrexone, or medication for opioid overdose\nreversal prescribed or dispensed to an insured covered under the policy,\nincluding federal food and drug administration-approved over-the-counter\nopioid overdose reversal medication as prescribed, dispensed or as\notherwise authorized under state or federal law, except where otherwise\nprohibited by law. Every policy that provides medical, major medical or\nsimilar comprehensive-type large group coverage shall provide coverage\nfor prescription drugs for medication for the treatment of a\nsubstance-related and addictive disorder and shall not require prior\nauthorization for an initial or renewal prescription for the\ndetoxification or maintenance treatment of a substance-related and\naddictive disorder, including all buprenorphine products, methadone,\nlong acting injectable naltrexone, or medication for opioid overdose\nreversal prescribed or dispensed to an insured covered under the policy,\nincluding federal food and drug administration-approved over-the-counter\nopioid overdose reversal medication as prescribed, dispensed or as\notherwise authorized under state or federal law, except where otherwise\nprohibited by law.\n  * NB Effective January 1, 2027\n  (B) Coverage provided under this paragraph may be subject to\ncopayments, coinsurance, and annual deductibles that are consistent with\nthose imposed on other benefits within the policy.\n  (7-b) Every policy that provides coverage for treatment at an opioid\ntreatment program shall not impose a co-payment fee during the course of\ntreatment on any insured for such treatment. For the purposes of this\nsection "opioid treatment program" means a program or practitioner\nengaged in opioid treatment of individuals with an opioid agonist\ntreatment medication.\n  (8) (A) Every insurer issuing a group policy for delivery in this\nstate that provides medical, major-medical or similar comprehensive-type\ncoverage shall provide coverage for the provision of preventive and\nprimary care services.\n  (B) In subparagraphs (A), (C) and (D) of this paragraph, preventive\nand primary care services means the following services rendered to a\ncovered child of an insured from the date of birth through the\nattainment of nineteen years of age:\n  (i) an initial hospital check-up and well-child visits scheduled in\naccordance with the prevailing clinical standards of a national\nassociation of pediatric physicians designated by the commissioner of\nhealth (except for any standard that would limit the specialty or forum\nof licensure of the practitioner providing the service other than the\nlimits under state law). Coverage for such services rendered shall be\nprovided only to the extent that such services are provided by or under\nthe supervision of a physician, or other professional licensed under\narticle one hundred thirty-nine of the education law whose scope of\npractice pursuant to such law includes the authority to provide the\nspecified services. Coverage shall be provided for such services\nrendered in a hospital, as defined in section twenty-eight hundred one\nof the public health law, or in an office of a physician or other\nprofessional licensed under article one hundred thirty-nine of the\neducation law whose scope of practice pursuant to such law includes the\nauthority to provide the specified services;\n  (ii) at each visit, services in accordance with the prevailing\nclinical standards of such designated association, including a medical\nhistory, a complete physical examination, developmental assessment,\nanticipatory guidance, appropriate immunizations and laboratory tests\nwhich tests are ordered at the time of the visit and performed in the\npractitioner's office, as authorized by law, or in a clinical\nlaboratory; and\n  (iii) necessary immunizations, as determined by the superintendent in\nconsultation with the commissioner of health, consisting of at least\nadequate dosages of vaccine against diphtheria, pertussis, tetanus,\npolio, measles, rubella, mumps, haemophilus influenzae type b and\nhepatitis b, which meet the standards approved by the United States\npublic health service for such biological products.\n  (C) Such coverage required pursuant to subparagraph (A) or (B) of this\nparagraph shall not be subject to annual deductibles or coinsurance.\n  (D) Such coverage required pursuant to subparagraph (A) or (B) of this\nparagraph shall not restrict or eliminate existing coverage provided by\nthe policy.\n  (E) In addition to subparagraph (A), (B), (C) or (D) of this\nparagraph, every group policy that provides hospital, surgical or\nmedical care coverage, except for a grandfathered health plan under\nsubparagraph (G) of this paragraph, shall provide coverage for the\nfollowing preventive care and screenings for insureds, and such coverage\nshall not be subject to annual deductibles or coinsurance:\n  (i) evidence-based items or services for preventive care and\nscreenings that have in effect a rating of 'A' or 'B' in the current\nrecommendations of the United States preventive services task force;\n  (ii) immunizations that have in effect a recommendation from the\nadvisory committee on immunization practices of the centers for disease\ncontrol and prevention with respect to the individual involved, or that\nare recommended by the commissioner of health to the superintendent\nutilizing generally accepted medical standards and taking into\nconsideration recommendations of the American Academy of Pediatrics, the\nAmerican Academy of Family Physicians, the American College of\nObstetricians and Gynecologists, and the American College of Physicians\nand/or other similar nationally or internationally recognized scientific\norganizations;\n  (iii) with respect to children, including infants and adolescents,\nevidence-informed preventive care and screenings provided for in\ncomprehensive guidelines supported by the health resources and services\nadministration; and\n  (iv) with respect to women, such additional preventive care and\nscreenings not described in item (i) of this subparagraph and as\nprovided for in comprehensive guidelines supported by the health\nresources and services administration.\n  (F) The requirements of this paragraph shall also be applicable to a\nblanket policy of hospital, medical or surgical expense insurance\ncovering students pursuant to subparagraph (C) of paragraph three of\nsubsection (a) of section four thousand two hundred thirty-seven of this\nchapter.\n  (G) For purposes of this paragraph, "grandfathered health plan" means\ncoverage provided by an insurer in which an individual was enrolled on\nMarch twenty-third, two thousand ten for as long as the coverage\nmaintains grandfathered status in accordance with section 1251(e) of the\nAffordable Care Act, 42 U.S.C. § 18011(e).\n  (9) Every insurer issuing a group policy for delivery in this state\nwhich policy provides coverage for any service within the lawful scope\nof practice of a duly licensed registered professional nurse, must make\navailable, and if requested by the contract holder, provide\nreimbursement for such service when such service is performed by a duly\nlicensed registered professional nurse provided, however, that\nreimbursement shall not be made for nursing services provided to an\ninsured in a general hospital, nursing home or a facility providing\nhealth related services, as such terms are defined in section\ntwenty-eight hundred one of the public health law, or in a facility, as\nsuch term is defined in subdivision six of section 1.03 of the mental\nhygiene law, or in a physician's office. Such coverage may be subject to\nannual deductibles and co-insurance as may be deemed appropriate by the\nsuperintendent and are consistent with those imposed on other benefits\nwithin a given policy. Such coverage shall not replace, restrict or\neliminate existing coverage provided by the policy. Coverage for the\nservices of a duly licensed registered professional nurse need be\nprovided only if the nature of the patient's illness or condition\nrequires nursing care which can appropriately be provided by a person\nwith the education and professional skill of a registered professional\nnurse and the nursing care is necessary in the treatment of the\npatient's illness or condition. Written notice of the availability of\nsuch coverage shall be delivered to the policyholder prior to inception\nof such group policy and annually thereafter, except that this notice\nshall not be required where a policy covers two hundred or more\nemployees or where the benefit structure was the subject of collective\nbargaining affecting persons who are employed in more than one state.\n  (10) (A) Every insurer issuing a group policy for delivery in this\nstate which provides coverage for inpatient hospital care must make\navailable and if requested by the policyholder provide coverage for\nhospice care.  Written notice of the availability of such coverage shall\nbe delivered to the policyholder prior to inception of such group policy\nand annually thereafter, except that this notice shall not be required\nwhere a policy covers two hundred or more employees or where the benefit\nstructure was the subject of collective bargaining affecting persons who\nare employed in more than one state.\n  (B) For the purposes of this paragraph, hospice care shall mean the\ncare and treatment of a covered person who has been certified by such\nperson's primary attending physician as having a life expectancy of six\nmonths or less and which is provided by a hospice organization certified\npursuant to article forty of the public health law or under a similar\ncertification process required by the state in which the hospice\norganization is located.\n  (C) Hospice care coverage shall be at least equal to: (i) a total of\ntwo hundred ten days of coverage beginning with the first day on which\ncare is provided, for inpatient hospice care in a hospice or in a\nhospital and home care and outpatient services provided by the hospice,\nincluding drugs and medical supplies, and (ii) five visits for\nbereavement counseling services, either before or after the insured's\ndeath, provided to the family of the terminally ill insured.\n  (D) Such coverage shall be made available at the inception of all new\npolicies and, with respect to policies issued before the effective date\nof this provision, at the first annual anniversary date thereafter,\nwithout evidence of insurability and at any subsequent annual\nanniversary date subject to evidence of insurability.\n  (E) Such coverage may be subject to annual deductibles and coinsurance\nas may be deemed appropriate by the superintendent and are consistent\nwith those imposed on other benefits within a given policy period.\n  (11) (A) Every insurer delivering a group or blanket policy or issuing\na group or blanket policy for delivery in this state that provides\ncoverage for hospital, surgical or medical care shall provide the\nfollowing coverage for mammography screening for occult breast cancer:\n  (i) upon the recommendation of a physician, a mammogram, which may be\nprovided by breast tomosynthesis, at any age for covered persons having\na prior history of breast cancer or who have a first degree relative\nwith a prior history of breast cancer;\n  (ii) a single baseline mammogram, which may be provided by breast\ntomosynthesis, for covered persons aged thirty-five through thirty-nine,\ninclusive;\n  (iii) an annual mammogram, which may be provided by breast\ntomosynthesis, for covered persons aged forty and older;\n  (iv) for large group policies that provide coverage for hospital,\nsurgical or medical care, an annual mammogram for covered persons aged\nthirty-five through thirty-nine, inclusive, upon the recommendation of a\nphysician, subject to the insurer's determination that the mammogram is\nmedically necessary; and\n  (v) upon the recommendation of a physician, screening and diagnostic\nimaging, including diagnostic mammograms, breast ultrasounds, or\nmagnetic resonance imaging, recommended by nationally recognized\nclinical practice guidelines for the detection of breast cancer. For the\npurposes of this item, "nationally recognized clinical practice\nguidelines" means evidence-based clinical practice guidelines informed\nby a systematic review of evidence and an assessment of the benefits,\nand risks of alternative care options intended to optimize patient care\ndeveloped by independent organizations or medical professional societies\nutilizing a transparent methodology and reporting structure and with a\nconflict of interest policy.\n  * (B) Such coverage required pursuant to subparagraph (A) or (C) of\nthis paragraph shall not be subject to annual deductibles or\ncoinsurance. If under federal law, application of this requirement would\nresult in health savings account ineligibility under 26 USC 223, this\nrequirement shall apply for health savings account-qualified high\ndeductible health plans with respect to the deductible of such a plan\nafter the enrollee has satisfied the minimum deductible under 26 USC\n223, except for with respect to items or services that are preventive\ncare pursuant to 26 USC 223(c)(2)(C), in which case the requirements of\nthis paragraph shall apply regardless of whether the minimum deductible\nunder 26 USC 223 has been satisfied.\n  * NB Effective until January 1, 2027\n  * (B) Such coverage required pursuant to subparagraph (A) or (C) of\nthis paragraph shall not be subject to annual deductibles or\ncoinsurance. If under federal law, application of this requirement would\nresult in health savings account ineligibility under 26 USC 223, this\nrequirement shall apply for health savings account-qualified high\ndeductible health plans with respect to the deductible of such a plan\nafter the enrollee has satisfied the plan deductible, except for with\nrespect to items or services that are preventive care pursuant to 26 USC\n223(c)(2)(C), in which case the requirements of this paragraph shall\napply regardless of whether the plan deductible has been satisfied.\n  * NB Effective January 1, 2027\n  (C) For purposes of subparagraphs (A) and (B) of this paragraph,\nmammography screening means an X-ray examination of the breast using\ndedicated equipment, including X-ray tube, filter, compression device,\nscreens, films and cassettes, with an average glandular radiation dose\nless than 0.5 rem per view per breast; provided, however, that\nmammography screening shall also include breast tomosynthesis.\n  (D) In addition to subparagraph (A), (B) or (C) of this paragraph,\nevery group or blanket policy that provides coverage for hospital,\nsurgical or medical care, except for a grandfathered health plan under\nsubparagraph (E) of this paragraph, shall provide coverage for the\nfollowing mammography screening services, and such coverage shall not be\nsubject to annual deductibles or coinsurance:\n  (i) evidence-based items or services for mammography that have in\neffect a rating of 'A' or 'B' in the current recommendations of the\nUnited States preventive services task force; and\n  (ii) with respect to women, such additional preventive care and\nscreenings for mammography not described in item (i) of this\nsubparagraph and as provided for in comprehensive guidelines supported\nby the health resources and services administration.\n  (E) For purposes of this paragraph, "grandfathered health plan" means\ncoverage provided by an insurer in which an individual was enrolled on\nMarch twenty-third, two thousand ten for as long as the coverage\nmaintains grandfathered status in accordance with section 1251(e) of the\nAffordable Care Act, 42 U.S.C. § 18011(e).\n  (11-a) (A) Every policy delivered or issued for delivery in this state\nwhich provides medical coverage that includes coverage for physician\nservices in a physician's office and every policy which provides major\nmedical or similar comprehensive-type coverage shall provide, upon the\nprescription of a health care provider legally authorized to prescribe\nunder title eight of the education law, the following coverage for\ndiagnostic screening for prostatic cancer:\n  (i) standard diagnostic testing including, but not limited to, a\ndigital rectal examination and a prostate-specific antigen test at any\nage for men having a prior history of prostate cancer; and\n  (ii) an annual standard diagnostic examination including, but not\nlimited to, a digital rectal examination and a prostate-specific antigen\ntest for men age fifty and over who are asymptomatic and for men age\nforty and over with a family history of prostate cancer or other\nprostate cancer risk factors.\n  (B) Such coverage shall not be subject to annual deductibles or\ncoinsurance.\n  (11-b) (A) Every large group policy delivered or issued for delivery\nin this state which provides medical coverage that includes coverage for\nphysician services in a physician's office and every large group policy\nwhich provides major medical or similar comprehensive-type coverage\nshall provide, upon the prescription of a health care provider acting\nwithin the provider's scope of practice pursuant to title eight of the\neducation law, coverage for colorectal cancer preventive screenings in\naccordance with the American Cancer Society Guidelines for colorectal\ncancer screening of average risk individuals. The coverage required by\nthis paragraph shall also include coverage for all additional colorectal\ncancer examinations and laboratory tests recommended in accordance with\nthe American Cancer Society Guidelines for colorectal cancer screening\nof average risk individuals, including an initial colonoscopy or other\nmedical test or procedure for colorectal cancer screening and a\nfollow-up colonoscopy performed as a result of a positive result on a\nnon-colonoscopy preventive screening test. A large group policy shall\ncover colorectal cancer screenings, examinations, and laboratory tests\ndescribed in this paragraph upon any policy issuance or renewal that\noccurs six months after the date the guideline described in this\nparagraph is issued.\n  (B) An insured shall not be subject to a deductible, coinsurance, or\nany other cost-sharing requirements for services consistent with\nsubparagraph (A) of this paragraph received from participating\nproviders.\n  (11-c) (A) Every insurer delivering a group or blanket policy or\nissuing a group or blanket policy for delivery in this state that\nprovides coverage for medical, major medical, or similar\ncomprehensive-type coverage shall provide coverage for biomarker\nprecision medical testing for the purposes of diagnosis, treatment, or\nappropriate management of, or ongoing monitoring to guide treatment\ndecisions for, an insured's disease or condition when one or more of the\nfollowing recognizes the efficacy and appropriateness of biomarker\nprecision medical testing for diagnosis, treatment, appropriate\nmanagement, or guiding treatment decisions for an insured's disease or\ncondition:\n  (i) labeled indications for a test approved or cleared by the federal\nfood and drug administration or indicated tests for a food and drug\nadministration approved drug;\n  (ii) centers for medicare and medicaid services national coverage\ndeterminations or medicare administrative contractor local coverage\ndeterminations;\n  (iii) nationally recognized clinical practice guidelines; or\n  (iv) peer-reviewed literature and peer-reviewed scientific studies\npublished in or accepted for publication by medical journals that meet\nnationally recognized requirements for scientific manuscripts and that\nsubmit most of their published articles for review by experts who are\nnot part of the editorial staff.\n  (B) Such coverage shall be provided in a manner that shall limit\ndisruptions in care including the need for multiple biopsies or\nbiospecimen samples.\n  (C) As used in this paragraph, the following terms shall have the\nfollowing meanings:\n  (i) "Biomarker" means a characteristic that is measured as an\nindicator of normal biological processes, pathogenic processes, or\nresponses to an exposure or intervention, including therapeutic\ninterventions.\n  (ii) "Biomarker precision medical testing" means the analysis of a\npatient's tissue, blood, or other biospecimen for the presence of a\nbiomarker. Biomarker testing includes but is not limited to\nsingle-analyte tests and multi-plex panel tests performed at a\nparticipating in-network laboratory facility that is either CLIA\ncertified or CLIA waived by the federal food and drug administration.\n  (iii) "Nationally recognized clinical practice guidelines" means\nevidence-based clinical practice guidelines informed by a systematic\nreview of evidence and an assessment of the benefits, and risks of\nalternative care options intended to optimize patient care developed by\nindependent organizations or medical professional societies utilizing a\ntransparent methodology and reporting structure and with a conflict of\ninterest policy.\n  (12) (A) Every insurer delivering a group or blanket policy or issuing\na group or blanket policy for delivery in this state which provides\ncoverage for prescribed drugs approved by the food and drug\nadministration of the United States government for the treatment of\ncertain types of cancer shall not exclude coverage of any such drug on\nthe basis that such drug has been prescribed for the treatment of a type\nof cancer for which the drug has not been approved by the food and drug\nadministration. Provided, however, that such drug must be recognized for\ntreatment of the specific type of cancer for which the drug has been\nprescribed in one of the following established reference compendia:\n  (i) the American Hospital Formulary Service-Drug Information\n(AHFS-DI);\n  (ii) National Comprehensive Cancer Networks Drugs and Biologics\nCompendium;\n  (iii) Thomson Micromedex DrugDex;\n  (iv) Elsevier Gold Standard's Clinical Pharmacology; or other\nauthoritative compendia as identified by the Federal Secretary of Health\nand Human Services or the Centers for Medicare & Medicaid Services\n(CMS); or recommended by review article or editorial comment in a major\npeer reviewed professional journal.\n  (B) Notwithstanding the provisions of this paragraph, coverage shall\nnot be required for any experimental or investigational drugs or any\ndrug which the food and drug administration has determined to be\ncontraindicated for treatment of the specific type of cancer for which\nthe drug has been prescribed. The provisions of this paragraph shall\napply to cancer drugs only and nothing herein shall be construed to\ncreate, impair, alter, limit, modify, enlarge, abrogate or prohibit\nreimbursement for drugs used in the treatment of any other disease or\ncondition.\n  (12-a) (A) Every policy delivered or issued for delivery in this state\nthat provides medical, major medical, or similar comprehensive-type\ncoverage and provides coverage for prescription drugs and also provides\ncoverage for cancer chemotherapy treatment shall provide coverage for\nprescribed, orally administered anticancer medications used to kill or\nslow the growth of cancerous cells. Such coverage may be subject to\nco-pays, coinsurance or deductibles, provided that the co-pays,\ncoinsurance or deductibles are at least as favorable to an insured as\nthe co-pays, coinsurance or deductibles that apply to coverage for\nintravenous or injected anticancer medications.\n  (B) An insurer providing coverage under this paragraph and any\nparticipating entity through which the insurer offers health services\nshall not:\n  (i) vary the terms of the policy for the purpose or with the effect of\navoiding compliance with this paragraph;\n  (ii) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nparagraph;\n  (iii) penalize in any way or reduce or limit the compensation of a\nhealth care practitioner for recommending or providing care to a covered\nperson in accordance with this paragraph;\n  (iv) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nparagraph intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this paragraph; or\n  (v) achieve compliance with this paragraph by imposing an increase in\ncost sharing for an intravenous or injected anticancer medication.\n  (12-b) (A) Every large group policy delivered or issued for delivery\nin this state that provides medical, major medical, or similar\ncomprehensive-type coverage and provides coverage cancer chemotherapy\ntreatment shall provide coverage for scalp cooling systems used in\nconnection with cancer chemotherapy treatment. Coverage provided under\nthis paragraph may be subject to annual deductibles and coinsurance,\nincluding copayments, as may be deemed appropriate by the superintendent\nand as are consistent with those established for other benefits within a\ngiven policy.\n  (B) For the purposes of this paragraph, "scalp cooling system" means\nany device used to cool the human scalp to prevent or reduce hair loss\nduring cancer chemotherapy treatment, provided that such device is\ndesigned and intended for repeated use and is primarily and customarily\nused to serve a medical purpose.\n  (13) Consistent with federal law every insurer delivering a group\npolicy or issuing a group policy for delivery in this state which\nprovides coverage supplementing part A and part B of subchapter XVIII of\nthe federal Social Security Act, 42 USC §§ 1395 et seq., shall make\navailable and, if requested by the policyholder, provide coverage for at\nleast ninety days of care in a nursing home as defined in section\ntwenty-eight hundred one of the public health law, except where such\ncoverage would duplicate coverage that is available under the\naforementioned subchapter XVIII. Such coverage shall be made available\nat the inception of all new policies and, with respect to all other\npolicies at each anniversary date of the policy.\n  (A) Coverage shall be subject to a copayment of twenty-five dollars\nper day.\n  (B) Brochures describing such coverage must be provided to the\npolicyholder at the inception of all new policies and thereafter on each\nanniversary date of the policy, and with respect to all other policies\nannually at each anniversary date of the policy. Such brochures must be\napproved by the superintendent in consultation with the commissioner of\nhealth.\n  (C) The commensurate rate for the coverage must be approved by the\nsuperintendent.\n  (D) Such insurers shall report to the superintendent each year the\nnumber of contract holders to whom such insurers have issued such\npolicies for nursing home coverage and the approximate number of persons\ncovered by such policies.\n  (14) (A) Every group or blanket policy delivered or issued for\ndelivery in this state that provides hospital, surgical or medical\ncoverage shall provide coverage for an annual cervical cytology\nscreening for cervical cancer and its precursor states for women aged\neighteen and older.\n  (B) For purposes of subparagraphs (A) and (C) of this paragraph,\ncervical cytology screening shall include an annual pelvic examination,\ncollection and preparation of a Pap smear, and laboratory and diagnostic\nservices provided in connection with examining and evaluating the Pap\nsmear.\n  (C) Such coverage required pursuant to subparagraph (A) or (B) of this\nparagraph may be subject to annual deductibles and coinsurance as may be\ndeemed appropriate by the superintendent and as are consistent with\nthose established for other benefits within a given policy.\n  (D) In addition to subparagraph (A), (B) or (C) of this paragraph,\nevery group or blanket policy that provides hospital, surgical or\nmedical coverage, except for a grandfathered health plan under\nsubparagraph (E) of this paragraph, shall provide coverage for the\nfollowing cervical cytology screening services, and such coverage shall\nnot be subject to annual deductibles or coinsurance:\n  (i) evidence-based items or services for cervical cytology that have\nin effect a rating of 'A' or 'B' in the current recommendations of the\nUnited States preventive services task force; and\n  (ii) with respect to women, such additional preventive care and\nscreenings for cervical cytology not described in item (i) of this\nsubparagraph and as provided for in comprehensive guidelines supported\nby the health resources and services administration.\n  (E) For purposes of this paragraph, "grandfathered health plan" means\ncoverage provided by an insurer in which an individual was enrolled on\nMarch twenty-third, two thousand ten for as long as the coverage\nmaintains grandfathered status in accordance with section 1251(e) of the\nAffordable Care Act, 42 U.S.C. § 18011(e).\n  (15)(A) Every group or blanket policy delivered or issued for delivery\nin this state which provides major medical or similar comprehensive-type\ncoverage shall include coverage for prehospital emergency medical\nservices for the treatment of an emergency condition when such services\nare provided by an ambulance service issued a certificate to operate\npursuant to section three thousand five of the public health law.\n  (B) Payment by an insurer pursuant to this section shall be payment in\nfull for the services provided. An ambulance service reimbursed pursuant\nto this section shall not charge or seek any reimbursement from, or have\nany recourse against an insured for the services provided pursuant to\nthis paragraph, except for the collection of copayments, coinsurance or\ndeductibles for which the insured is responsible for under the terms of\nthe policy.\n  (C) An insurer shall provide reimbursement for those services\nprescribed by this section at rates negotiated between the insurer and\nthe provider of such services. In the absence of agreed upon rates, an\ninsurer shall pay for such services at the usual and customary charge,\nwhich shall not be excessive or unreasonable. The insurer shall send\nsuch payments directly to the provider of such ambulance services, if\nthe ambulance service has on file an executed assignment of benefits\nform with the claim.\n  (D) The provisions of this paragraph shall have no application to\ntransfers of patients between hospitals or health care facilities by an\nambulance service as described in subparagraph (A) of this paragraph\nunless such services are covered under the policy.\n  (E) As used in this paragraph:\n  (i) "Prehospital emergency medical services" means the prompt\nevaluation and treatment of an emergency medical condition, and/or\nnon-air-borne transportation of the patient to a hospital, provided\nhowever, where the patient utilizes non-air-borne emergency\ntransportation pursuant to this paragraph, reimbursement shall be based\non whether a prudent layperson, possessing an average knowledge of\nmedicine and health, could reasonably expect the absence of such\ntransportation to result in (I) placing the health of the person\naffected with such condition in serious jeopardy, or in the case of a\nbehavioral condition placing the health of such person or others in\nserious jeopardy; (II) serious impairment to such person's bodily\nfunctions; (III) serious dysfunction of any bodily organ or part of such\nperson; (IV) serious disfigurement of such person; or (V) a condition\ndescribed in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the\nSocial Security Act.\n  (ii) "Emergency condition" means a medical or behavioral condition\nthat manifests itself by acute symptoms of sufficient severity,\nincluding severe pain, such that a prudent layperson, possessing an\naverage knowledge of medicine and health, could reasonably expect the\nabsence of immediate medical attention to result in (I) placing the\nhealth of the person afflicted with such condition in serious jeopardy,\nor in the case of a behavioral condition placing the health of such\nperson or others in serious jeopardy; (II) serious impairment to such\nperson's bodily functions; ( (III) serious dysfunction of any bodily\norgan or part of such person; (IV) serious disfigurement of such person;\nor (V) a condition described in clause (i), (ii) or (iii) of section\n1867(e)(1)(A) of the Social Security Act.\n  (16) (A) Every group or blanket policy that provides medical, major\nmedical, or similar comprehensive type coverage that is issued, amended,\nrenewed, effective or delivered on or after January first, two thousand\ntwenty, shall provide coverage for all of the following services and\ncontraceptive methods:\n  (1) All FDA-approved contraceptive drugs, devices, and other products.\nThis includes all FDA-approved over-the-counter contraceptive drugs,\ndevices, and products as prescribed or as otherwise authorized under\nstate or federal law. The following applies to this coverage:\n  (a) where the FDA has approved one or more therapeutic and\npharmaceutical equivalent, as defined by the FDA, versions of a\ncontraceptive drug, device, or product, a group or blanket policy is not\nrequired to include all such therapeutic and pharmaceutical equivalent\nversions in its formulary, so long as at least one is included and\ncovered without cost-sharing and in accordance with this paragraph;\n  (b) if the covered therapeutic and pharmaceutical equivalent versions\nof a drug, device, or product are not available or are deemed medically\ninadvisable a group or blanket policy shall provide coverage for an\nalternate therapeutic and pharmaceutical equivalent version of the\ncontraceptive drug, device, or product without cost-sharing. If the\nattending health care provider, in his or her reasonable professional\njudgment, determines that the use of a non-covered therapeutic or\npharmaceutical equivalent of a drug, device, or product is warranted,\nthe health care provider's determination shall be final. The\nsuperintendent shall promulgate regulations establishing a process,\nincluding timeframes, for an insured, an insured's designee or an\ninsured's health care provider to request coverage of a non-covered\ncontraceptive drug, device, or product. Such regulations shall include a\nrequirement that insurers use an exception form that shall meet criteria\nestablished by the superintendent;\n  (c) this coverage shall include emergency contraception without\ncost-sharing when provided pursuant to a prescription or order under\nsection sixty-eight hundred thirty-one of the education law or when\nlawfully provided over the counter; and\n  (d) this coverage must allow for the dispensing of up to twelve months\nworth of a contraceptive at one time;\n  (2) Voluntary sterilization procedures pursuant to 42 U.S.C. 18022 and\nidentified in the comprehensive guidelines supported by the health\nresources and services administration and thereby incorporated in the\nessential health benefits benchmark plan;\n  (3) Patient education and counseling on contraception; and\n  (4) Follow-up services related to the drugs, devices, products, and\nprocedures covered under this paragraph, including, but not limited to,\nmanagement of side effects, counseling for continued adherence, and\ndevice insertion and removal.\n  (B) A group or blanket policy subject to this paragraph shall not\nimpose a deductible, coinsurance, copayment, or any other cost-sharing\nrequirement on the coverage provided pursuant to this paragraph.\n  (C) Except as otherwise authorized under this paragraph, a group or\nblanket policy shall not impose any restrictions or delays on the\ncoverage required under this paragraph.\n  (D) Benefits for an enrollee under this paragraph shall be the same\nfor an enrollee's covered spouse or domestic partner and covered\nnonspouse dependents.\n  (E) Notwithstanding any other provision of this subsection, a\nreligious employer may request a contract without coverage for federal\nfood and drug administration approved contraceptive methods that are\ncontrary to the religious employer's religious tenets. If so requested,\nsuch contract shall be provided without coverage for contraceptive\nmethods.  This paragraph shall not be construed to deny an enrollee\ncoverage of, and timely access to, contraceptive methods.\n  (1) For purposes of this subsection, a "religious employer" is an\nentity for which each of the following is true:\n  (a) The inculcation of religious values is the purpose of the entity.\n  (b) The entity primarily employs persons who share the religious\ntenets of the entity.\n  (c) The entity serves primarily persons who share the religious tenets\nof the entity.\n  (d) The entity is a nonprofit organization as described in Section\n6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.\n  (2) Every religious employer that invokes the exemption provided under\nthis paragraph shall provide written notice to prospective enrollees\nprior to enrollment with the plan, listing the contraceptive health care\nservices the employer refuses to cover for religious reasons.\n  (F) (1) Where a group policyholder makes an election not to purchase\ncoverage for contraceptive drugs or devices in accordance with\nsubparagraph (E) of this paragraph each certificateholder covered under\nthe policy issued to that group policyholder shall have the right to\ndirectly purchase the rider required by this paragraph from the insurer\nwhich issued the group policy at the prevailing small group community\nrate for such rider whether or not the employee is part of a small\ngroup.\n  (2) Where a group policyholder makes an election not to purchase\ncoverage for contraceptive drugs or devices in accordance with\nsubparagraph (E) of this paragraph, the insurer that provides such\ncoverage shall provide written notice to certificateholders upon\nenrollment with the insurer of their right to directly purchase a rider\nfor coverage for the cost of contraceptive drugs or devices. The notice\nshall also advise the certificateholders of the additional premium for\nsuch coverage.\n  (G) Nothing in this paragraph shall be construed as authorizing a\ngroup or blanket policy which provides coverage for prescription drugs\nto exclude coverage for prescription drugs prescribed for reasons other\nthan contraceptive purposes.\n  (H) For the purposes of this paragraph, "over-the-counter\ncontraceptive products" shall mean those products provided for in\ncomprehensive guidelines supported by the health resources and services\nadministration as of January twenty-first, two thousand nineteen.\n  (17) (A) Every group or blanket accident and health insurance policy\ndelivered or issued for delivery in this state which provides coverage\nfor hospital or surgical care coverage shall not exclude coverage for\nscreening, diagnosis and treatment of medical conditions otherwise\ncovered by the policy because the treatment is provided to diagnose or\ntreat autism spectrum disorder.\n  (B) Every group or blanket policy that provides physician services,\nmedical, major medical or similar comprehensive-type coverage shall\nprovide coverage for the screening, diagnosis and treatment of autism\nspectrum disorder in accordance with this paragraph and shall not\nexclude coverage for the screening, diagnosis or treatment of medical\nconditions otherwise covered by the policy because the individual is\ndiagnosed with autism spectrum disorder. Such coverage may be subject to\nannual deductibles, copayments and coinsurance as may be deemed\nappropriate by the superintendent and shall be consistent with those\nimposed on other benefits under the group or blanket policy. This\nparagraph shall not be construed as limiting the benefits that are\notherwise available to an individual under the group or blanket policy,\nprovided however that such policy shall not contain any limitations on\nvisits that are solely applied to the treatment of autism spectrum\ndisorder. No insurer shall terminate coverage or refuse to deliver,\nexecute, issue, amend, adjust, or renew coverage to an individual solely\nbecause the individual is diagnosed with autism spectrum disorder or has\nreceived treatment for autism spectrum disorder. Coverage shall be\nsubject to utilization review and external appeals of health care\nservices pursuant to article forty-nine of this chapter as well as case\nmanagement and other managed care provisions.\n  (C) For purposes of this paragraph:\n  (i) "autism spectrum disorder" means any pervasive developmental\ndisorder as defined in the most recent edition of the diagnostic and\nstatistical manual of mental disorders.\n  (ii) "applied behavior analysis" means the design, implementation, and\nevaluation of environmental modifications, using behavioral stimuli and\nconsequences, to produce socially significant improvement in human\nbehavior, including the use of direct observation, measurement, and\nfunctional analysis of the relationship between environment and\nbehavior.\n  (iii) "behavioral health treatment" means counseling and treatment\nprograms, when provided by a licensed provider, and applied behavior\nanalysis, when provided by a person licensed, certified or otherwise\nauthorized to provide applied behavior analysis, that are necessary to\ndevelop, maintain, or restore, to the maximum extent practicable, the\nfunctioning of an individual.\n  (iv) "diagnosis of autism spectrum disorder" means assessments,\nevaluations, or tests to diagnose whether an individual has autism\nspectrum disorder.\n  (v) "pharmacy care" means medications prescribed by a licensed health\ncare provider legally authorized to prescribe under title eight of the\neducation law.\n  (vi) "psychiatric care" means direct or consultative services provided\nby a psychiatrist licensed in the state in which the psychiatrist\npractices.\n  (vii) "psychological care" means direct or consultative services\nprovided by a psychologist licensed in the state in which the\npsychologist practices.\n  (viii) "therapeutic care" means services provided by licensed or\ncertified speech therapists, occupational therapists, social workers, or\nphysical therapists.\n  (ix) "treatment of autism spectrum disorder" shall include the\nfollowing care and assistive communication devices prescribed or ordered\nfor an individual diagnosed with autism spectrum disorder by a licensed\nphysician or a licensed psychologist:\n  (1) behavioral health treatment;\n  (2) psychiatric care;\n  (3) psychological care;\n  (4) medical care provided by a licensed health care provider;\n  (5) therapeutic care, including therapeutic care which is deemed\nhabilitative or nonrestorative, in the event that the policy provides\ncoverage for therapeutic care; and\n  (6) pharmacy care in the event that the policy provides coverage for\nprescription drugs.\n  (D) Coverage may be denied on the basis that such treatment is being\nprovided to the covered person pursuant to an individualized education\nplan under article eighty-nine of the education law. The provision of\nservices pursuant to an individualized family service plan under section\ntwenty-five hundred forty-five of the public health law, an\nindividualized education plan under article eighty-nine of the education\nlaw, or an individualized service plan pursuant to regulations of the\noffice for persons with developmental disabilities shall not affect\ncoverage under the policy for services provided on a supplemental basis\noutside of an educational setting if such services are prescribed by a\nlicensed physician or licensed psychologist.\n  (E) Nothing in this paragraph shall be construed to affect any\nobligation to provide services to an individual under an individualized\nfamily service plan under section twenty-five hundred forty-five of the\npublic health law, an individualized education plan under article\neighty-nine of the education law, or an individualized service plan\npursuant to regulations of the office for persons with developmental\ndisabilities.\n  (G) Nothing in this paragraph shall be construed to prevent a group or\nblanket policy from providing services through a network of\nparticipating providers who shall meet certain requirements for\nparticipation, including provider credentialing.\n  (H) Coverage under this paragraph shall not apply financial\nrequirements or treatment limitations to autism spectrum disorder\nbenefits that are more restrictive than the predominant financial\nrequirements and treatment limitations applied to substantially all\nmedical and surgical benefits covered by the policy.\n  (I) The criteria for medical necessity determinations under the policy\nwith respect to autism spectrum disorder benefits shall be made\navailable by the insurer to any insured, prospective insured, or\nin-network provider upon request.\n  (J) For purposes of this paragraph:\n  (i) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n  (ii) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement; and\n  (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy.\n  (K) An insurer shall provide coverage under this paragraph, at a\nminimum, consistent with the federal Paul Wellstone and Pete Domenici\nMental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §\n1185a).\n  (18) (A) Definitions. For the purpose of this paragraph:\n  (i) "Same reimbursement amount" shall mean that any coverage described\nunder subparagraph (B) of this paragraph shall provide the same\nbenchmark index, including the same average wholesale price, maximum\nallowable cost and national prescription drug codes to reimburse all\npharmacies participating in the insurance network regardless of whether\na pharmacy is a mail order pharmacy or a non-mail order pharmacy.\n  (ii) "Mail order pharmacy" means a pharmacy whose primary business is\nto receive prescriptions by mail, telefax or through electronic\nsubmissions and to dispense medication to patients through the use of\nthe United States mail or other common or contract carrier services and\nprovides any consultation with patients electronically rather than\nface-to-face.\n  (B) Any insurer delivering a group or blanket policy or issuing a\ngroup or blanket policy for delivery in this state that provides\ncoverage for prescription drugs shall permit each insured to fill any\ncovered prescription that may be obtained at a network participating\nmail order or other non-retail pharmacy, at the insured's option, at a\nnetwork participating non-mail order retail pharmacy provided that the\nnetwork participating non-mail order retail pharmacy agrees to the same\nreimbursement amount that the insurer has established for the network\nparticipating mail order or other non-retail pharmacy. In such a case,\nthe policy shall not impose a co-payment fee or other condition on any\ninsured who elects to purchase drugs from a network participating\nnon-mail order retail pharmacy which is not also imposed on insureds\nelecting to purchase drugs from a network participating mail order or\nother non-retail pharmacy; provided, however, that the provisions of\nthis section shall not supersede the terms of a collective bargaining\nagreement or apply to a policy that is the result of a collective\nbargaining agreement between an employer and a recognized or certified\nemployee organization.\n  (19) Whenever in this section an insurer is required to provide\nbenefits with no coinsurance or deductible, the requirement only applies\nwith respect to participating providers in the insurer's network, or\nwith respect to non-participating providers, if the insurer does not\nhave a participating provider in the in-network benefits portion of its\nnetwork with the appropriate training and experience to meet the\nparticular health care needs of the insured pursuant to subsection (d)\nof section three thousand two hundred seventeen-d of this article.\n  * (20) Health care forensic examinations performed pursuant to section\ntwenty-eight hundred five-i of the public health law covered under the\npolicy shall not be subject to annual deductibles or coinsurance.\n  * NB There are 2 par (20)'s\n  * (20) Every insurer delivering a group or blanket policy or issuing a\ngroup or blanket policy for delivery in this state that provides\ncoverage for hospital, surgical or medical care shall provide the\nfollowing coverage for pasteurized donor human milk (PDHM), which may\ninclude fortifiers as medically indicated, for which a licensed medical\npractitioner has issued an order for an infant who is medically or\nphysically unable to receive maternal breast milk or participate in\nbreast feeding or whose mother is medically or physically unable to\nproduce maternal breast milk at all or in sufficient quantities or\nparticipate in breast feeding despite optimal lactation support. Such\ninfant shall: (i) have a documented birth weight of less than one\nthousand five hundred grams; or (ii) have a congenital or acquired\ncondition that places the infant at a high risk for development of\nnecrotizing enterocolitis.\n  * NB There are 2 par (20)'s\n  * (21) Every large group policy which provides medical, major medical,\nor comprehensive-type coverage shall include coverage for the cost of\npre-exposure prophylaxis (PrEP) for the prevention of HIV and\npost-exposure prophylaxis to prevent HIV infection. Such coverage may be\nsubject to annual deductibles, coinsurance, and copayments as may be\ndeemed appropriate by the superintendent and as are consistent with\nthose established for other benefits within a given policy, unless the\npre-exposure prophylaxis (PrEP) or post-exposure prophylaxis has in\neffect a rating of 'A' or 'B' in the current recommendations of the\nUnited States preventive services task force.\n  * NB There are 2 par (21)'s\n  * (21) Every group or blanket policy delivered or issued for delivery\nin this state that provides coverage for a prescription drug shall apply\nany third-party payments, financial assistance, discount, voucher or\nother price reduction instrument for out-of-pocket expenses made on\nbehalf of an insured individual for the cost of prescription drugs to\nthe insured's deductible, copayment, coinsurance, out-of-pocket maximum,\nor any other cost-sharing requirement when calculating such insured\nindividual's overall contribution to any out-of-pocket maximum or any\ncost-sharing requirement. If under federal law, application of this\nrequirement would result in health savings account ineligibility under\n26 USC 223, this requirement shall apply for health savings\naccount-qualified high deductible health plans with respect to the\ndeductible of such a plan after the enrollee has satisfied the minimum\ndeductible under 26 USC 223, except for with respect to items or\nservices that are preventive care pursuant to 26 USC 223(c)(2)(C), in\nwhich case the requirements of this paragraph shall apply regardless of\nwhether the minimum deductible under 26 USC 223 has been satisfied. This\nparagraph only applies to a prescription drug that is either (A) a\nbrand-name drug without an AB rated generic equivalent, as determined by\nthe United States Food and Drug Administration; or (B) a brand-name drug\nwith an AB rated generic equivalent, as determined by the United States\nFood and Drug Administration, and the insured has access to the\nbrand-name drug through prior authorization by the insurer or through\nthe insurer's appeal process, including any step-therapy process; or (C)\na generic drug the insurer will cover, with or without prior\nauthorization or an appeal process.\n  * NB Effective until January 1, 2027\n  * (21) Every group or blanket policy delivered or issued for delivery\nin this state that provides coverage for a prescription drug shall apply\nany third-party payments, financial assistance, discount, voucher or\nother price reduction instrument for out-of-pocket expenses made on\nbehalf of an insured individual for the cost of prescription drugs to\nthe insured's deductible, copayment, coinsurance, out-of-pocket maximum,\nor any other cost-sharing requirement when calculating such insured\nindividual's overall contribution to any out-of-pocket maximum or any\ncost-sharing requirement. If under federal law, application of this\nrequirement would result in health savings account ineligibility under\n26 USC 223, this requirement shall apply for health savings\naccount-qualified high deductible health plans with respect to the\ndeductible of such a plan after the enrollee has satisfied the plan\ndeductible, except for with respect to items or services that are\npreventive care pursuant to 26 USC 223(c)(2)(C), in which case the\nrequirements of this paragraph shall apply regardless of whether the\nplan deductible has been satisfied. This paragraph only applies to a\nprescription drug that is either (A) a brand-name drug without an AB\nrated generic equivalent, as determined by the United States Food and\nDrug Administration; or (B) a brand-name drug with an AB rated generic\nequivalent, as determined by the United States Food and Drug\nAdministration, and the insured has access to the brand-name drug\nthrough prior authorization by the insurer or through the insurer's\nappeal process, including any step-therapy process; or (C) a generic\ndrug the insurer will cover, with or without prior authorization or an\nappeal process.\n  * NB Effective January 1, 2027\n  * NB There are 2 par (21)'s\n  (22) Every group or blanket policy delivered or issued for delivery in\nthis state that provides coverage for antiretroviral prescription drugs\nfor the treatment or prevention of the human immunodeficiency virus\n(HIV) or acquired immunodeficiency syndrome (AIDS) shall not subject\nsuch drug to a prior authorization requirement.\n  * (23) (A) Every group or blanket accident and health insurance policy\nissued or issued for delivery in this state which provides medical,\nmajor medical or similar comprehensive-type coverage and provides\ncoverage for prescription drugs shall include coverage for inhalers for\nthe treatment of asthma if prescribed by a physician or other licensed\nhealth care provider legally authorized to prescribe under title eight\nof the education law.\n  (B) Coverage shall be provided for one form of rescue and one form of\nmaintenance inhaler that shall not be subject to a deductible,\ncopayment, coinsurance or any other cost-sharing requirement.\n  (C) If the policy is a high deductible health plan as defined in\nsection 223(c)(2) of the Internal Revenue Code of 1986, such coverage\nmay be subject to the plan's annual deductible if application of this\nrequirement would result in ineligibility for a health savings account.\n  * NB Effective January 1, 2027\n  * NB There are 2 par (23)'s\n  * (23) (A) Every policy which provides medical, major medical, or\nsimilar comprehensive-type coverage shall provide coverage for follow-up\nscreening or diagnostic services for lung cancer upon the recommendation\nof a health care provider acting within the provider's scope of practice\npursuant to title eight of the education law, and as recommended by\nnationally recognized clinical practice guidelines for the detection of\nlung cancer.\n  (B) Notwithstanding any other provision of law, any policy that\nprovides coverage required by this paragraph shall not impose patient\ncost sharing for follow-up screening or diagnostic services for lung\ncancer.\n  (C) For the purposes of this paragraph, "nationally recognized\nclinical practice guidelines" means evidence-based, peer reviewed\nclinical practice guidelines informed by a systematic review of evidence\nand an assessment of the benefits, and risks of alternative care options\nintended to optimize patient care developed by independent organizations\nor medical professional societies utilizing a transparent methodology\nand reporting structure and with a conflict of interest policy.\n  (D) Nothing in this paragraph shall be construed to prevent medical\nmanagement or utilization review of the services, including\npreauthorization, to ensure that such services are consistent with\nnationally recognized clinical practice guidelines for the detection of\nlung cancer.\n  (E) If the policy is a high deductible health plan as defined in\nsection 223(c)(2) of the Internal Revenue Code of 1986, such coverage\nmay be subject to the plan's annual deductible if application of this\nrequirement would result in ineligibility for a health savings account.\n  * NB Effective January 1, 2027\n  * NB There are 2 par (23)'s\n  (m) A group policy providing hospital, surgical or medical expense\ninsurance for other than accident only shall provide that if all or any\nportion of the insurance on an employee or member insured under the\npolicy ceases because of termination of employment or membership in the\nclass or classes eligible for coverage under the policy, such employee\nor member shall be entitled without evidence of insurability upon\napplication to continue his hospital, surgical or medical expense\ninsurance for himself or herself and his or her eligible dependents,\nsubject to all of the group policy's terms and conditions applicable to\nthose forms of benefits and to the following conditions:\n  (1) Continuation shall cease on the date which the employee, member or\ndependant first becomes, after the date of election: (A) entitled to\ncoverage under title XVIII of the United States Social Security Act\n(Medicare) as amended or superseded; or (B) covered as an employee,\nmember or dependent by any other insured or uninsured arrangement which\nprovides hospital, surgical or medical coverage for individuals in a\ngroup which does not contain any exclusion or limitation with respect to\nany pre-existing condition of such employee, member or dependent, except\nthe group insurance policy conversion option of this section shall not\nbe considered as such an arrangement under which an employee, member or\ndependent could become covered.\n  (2) (A) An employee or member who wishes continuation of coverage must\nrequest such continuation in writing within the sixty day period\nfollowing the later of: (i) the date of such termination; or (ii) the\ndate the employee is sent notice by first class mail of the right of\ncontinuation by the group policyholder.\n  (B) An employee or member who wishes continuation of coverage under\nsubparagraph (D) of paragraph four of this subsection must give notice\nto the employer or group policyholder within sixty days of the\ndetermination under title II or title XVI of the United States Social\nSecurity Act that such employee or member was disabled at the time of\ntermination of employment or membership or at any time during the first\nsixty days of continuation of coverage.\n  (3) An employee or member electing continuation must pay to the group\npolicyholder or his employer, but not more frequently than on a monthly\nbasis in advance, the amount of the required premium payment, but not\nmore than one hundred two percent of the group rate for the benefits\nbeing continued under the group policy on the due date of each payment.\nThe employee's or member's written election of continuation, together\nwith the first premium payment required to establish premium payment on\na monthly basis in advance, must be given to the policyholder or\nemployer within sixty days of the date the employee's or member's\nbenefits would otherwise terminate.\n  (4) Subject to paragraph one of this subsection, continuation of\nbenefits under the group policy for any person shall terminate at the\nfirst to occur of the following:\n  (A) The date thirty-six months after the date the employee's or\nmember's benefits under the policy would otherwise have terminated\nbecause of termination of employment or membership; or\n  (B) The end of the period for which premium payments were made, if the\nemployee or member fails to make timely payment of a required premium\npayment; or\n  (C) In the case of an eligible dependent of an employee or member, the\ndate thirty-six months after the date such person's benefits under the\npolicy would otherwise have terminated by reason of:\n  (i) the death of the employee or member;\n  (ii) the divorce or legal separation of the employee or member from\nhis or her spouse;\n  (iii) the employee or member becoming entitled to benefits under title\nXVIII of the United States Social Security Act (Medicare); or\n  (iv) a dependent child ceasing to be a dependent child under the\ngenerally applicable requirements of the policy; or\n  (D) The date on which the group policy is terminated or, in the case\nof an employee, the date his employer terminates participation under the\ngroup policy. However, if this clause applies and the coverage ceasing\nby reason of such termination is replaced by similar coverage under\nanother group policy, the following shall apply:\n  (i) The employee or member shall have the right to become covered\nunder that other group policy, for the balance of the period that he\nwould have remained covered under the prior group policy in accordance\nwith this subparagraph had a termination described in this subparagraph\nnot occurred, and\n  (ii) The minimum level of benefits to be provided by the other group\npolicy shall be the applicable level of benefits of the prior group\npolicy reduced by any benefits payable under that prior group policy,\nand\n  (iii) The prior group policy shall continue to provide benefits to the\nextent of its accrued liabilities and extension of benefits as if the\nreplacement had not occurred.\n  (5) A notification of the continuation privilege and the time period\nin which to request continuation shall be included in each certificate\nof coverage.\n  (6) This subsection shall not be applicable where a continuation\nbenefit is available to the employee or member pursuant to Chapter 18 of\nthe Employee Retirement Income Security Act, 29 U.S.C. § 1161 et seq or\nChapter 6A of the Public Health Service Act, 42 U.S.C. § 300 bb - 1 et\nseq. However, a group policy shall offer an insured who has exhausted\ncontinuation coverage pursuant to Chapter 18 of the Employee Retirement\nIncome Security Act, 29 U.S.C. § 1161 et seq. or Chapter 6A of the\nPublic Health Service Act, 42 U.S.C. § 300 bb - 1 et seq. the\nopportunity to continue coverage for up to thirty-six months from the\ndate the employee's or member's continuation coverage began, if the\nemployee or member is entitled to less than thirty-six months of\ncontinuation benefits under federal law.\n  (7)(A) Special enrollment period. An individual who does not have an\nelection of continuation coverage as described in this subsection in\neffect on the effective date of the American Recovery and Reinvestment\nact of 2009, but who would be an assistance eligible individual under\nTitle III of such act if such election were in effect, may elect\ncontinuation coverage pursuant to this subsection. Such election shall\nbe made no later than sixty days after the date the administrator of the\ngroup health plan (or other entity involved) provides the notice\nrequired by section 3001(a)(7) of the American Recovery and Reinvestment\nact of 2009. The administrator of the group health plan (or other entity\ninvolved) shall provide such individuals with additional notice of the\nright to elect coverage pursuant to this paragraph within sixty days of\nthe date of enactment of the American Recovery and Reinvestment act of\n2009.\n  (B) Continuation coverage elected pursuant to subparagraph (A) of this\nparagraph shall commence with the first period of coverage beginning on\nor after the date of the enactment of the American Recovery and\nReinvestment act of 2009 and shall not extend beyond the period of\ncontinuation coverage that would have been required if the coverage had\ninstead been elected pursuant to paragraph two of this subsection.\n  (C) With respect to an individual who elects continuation coverage\npursuant to subparagraph (A) of this paragraph, the period beginning on\nthe date of the qualifying event and ending on the date of the first\nperiod of coverage on or after the enactment of the American Recovery\nand Reinvestment act of 2009 shall be disregarded for purposes of\ndetermining the sixty-three day period referred to in section three\nthousand two hundred thirty-two of this article.\n  (8) For purposes of this subsection, the term "dependent" shall\ninclude a child as described in subsection (f) of section four thousand\ntwo hundred thirty-five of this chapter.\n  (n) In addition to all the rights of conversion and continuation\notherwise provided for herein, employees or members insured under the\npolicy who are also members of a reserve component of the armed forces\nof the United States, including the National Guard, shall be entitled to\nhave supplementary conversion and continuation rights in certain\ncircumstances as follows:\n  (1) If the employee or member insured enters upon active duty as\ndefined in subsection (o) of this section, and the employer or group\npolicyholder does not voluntarily maintain coverage for such employee or\nmember insured, the employee or member insured shall be entitled to have\nhis or her coverage continued under the group policy in accordance with\nthe conditions and limitations contained in paragraph seven of this\nsubsection and have issued at the end of the period of continuation an\nindividual conversion policy subject to the terms of this subsection.\nThe effective date for the conversion policy shall be the day following\nthe termination of insurance under the group policy, or if there is a\ncontinuation of coverage on the day following the end of the period of\ncontinuation.\n  (2) If the employer or group policyholder does not voluntarily\nmaintain coverage for the employee or member insured during the period\nof active duty, and such employee or member insured does not elect the\nsupplementary conversion and continuation rights provided for herein,\ncoverage for such employee or member insured shall be suspended during\nthe period of active duty.\n  (3) If the employee or member insured elects the supplementary\ncontinuation right provided for herein or coverage under the group plan\nis suspended, and such employee or member insured dies during the period\nof active duty, the conversion right provided by this section shall be\navailable to the surviving spouse and children, and shall be available\nto a child solely with respect to himself or herself upon his or her\nattaining the limiting age of coverage under the group policy while\ncovered as a dependent thereunder. It shall also be available upon the\ndivorce or annulment of the marriage of the employee or member insured,\nto the former spouse of such employee or member insured, if such divorce\nor annulment occurs during the period of active duty.\n  (4) If the employee or member insured elects the supplementary\nconversion and continuation right provided for herein or coverage under\nthe group plan is suspended, and such employee or member insured is\neither reemployed or restored to participation in the group upon return\nto civilian status, he or she shall be entitled to resume participation\nin insurance offered by the group pursuant to this section, with no\nlimitations or conditions imposed as a result of such period of active\nduty except as set forth in subparagraphs (A) and (B) herein. The right\nof resumption provided for herein shall extend to coverage for the\nspouse and dependents of the employee or member insured and shall be in\naddition to other existing rights granted pursuant to state and federal\nlaws and regulations and shall not be deemed to qualify or limit such\nrights in any way. No exclusion or waiting period may be imposed in\nconnection with coverage of a health or physical condition of a person\nentitled to such right of resumption, or a health or physical condition\nof any other person who is covered by the policy unless:\n  (A) the condition arose during the period of active duty and the\ncondition has been determined by the secretary of veterans affairs to be\na condition incurred in the line of duty; or\n  (B) a waiting period was imposed and had not been completed prior to\nthe period of suspension; in no event, however, shall the sum of the\nwaiting periods imposed prior to and subsequent to the period of\nsuspension exceed the length of the waiting period originally imposed.\n  (5) If the employee or member insured elects the supplementary\nconversion and continuation coverage provided for herein:\n  (A) when such employee or member insured is either reemployed or\nrestored to participation in the group, coverage under the supplementary\nrights provided for herein shall terminate on the date that coverage is\neffective due to resumption of participation in the group.\n  (B) when such employee or member insured is not reemployed or restored\nto participation in the group upon return to civilian status, he or she\nshall be entitled to the conversion and continuation rights provided by\nsubsections (e) and (m) of this section.\n  (i) To elect an individual conversion policy pursuant to subsection\n(e) of this section, the employee or member insured must apply to the\ninsurer within thirty-one days of the termination of active duty or\ndischarge from hospitalization incident to such active duty, which\nhospitalization continues for a period of not more than one year. Upon\ncommencement of coverage under the conversion right provided pursuant to\nsubsection (e) of this section, coverage under the supplementary\ncontinuation right provided for herein shall terminate.\n  (ii) To elect continuation of coverage pursuant to subsections (e) and\n(m) of this section, the employee or member insured must request such\ncontinuation of the employer within thirty-one days of the termination\nof active duty or discharge from hospitalization incident to such active\nduty, which hospitalization continues for a period of not more than one\nyear. Upon commencement of coverage under the continuation right\nprovided pursuant to subsection (e) of this section, coverage under the\nsupplementary continuation right provided for herein shall terminate.\nThe employee or member insured shall be entitled to have issued at the\nend of the period of continuation an individual conversion policy.\n  (6) If coverage under the group plan is suspended during the period of\nactive duty:\n  (A) when the employee or member insured returns to participation in\nthe group plan, coverage under the group plan shall be retroactive to\nthe date of termination of the period of active duty.\n  (B) when such employee or member insured is not reemployed or restored\nto participation in the group upon return to civilian status, he or she\nshall be entitled to the conversion and continuation rights provided by\nsubsections (e) and (m) of this section.\n  (i) To elect an individual conversion policy pursuant to subsection\n(e) of this section, the employee or member insured must apply to the\ninsurer within thirty-one days of the termination of active duty or\ndischarge from hospitalization incident to such active duty, which\nhospitalization continues for a period of not more than one year.\n  (ii) To elect continuation of coverage pursuant to subsections (e) and\n(m) of this section, the employee or member insured must request such\ncontinuation of the employer within thirty-one days of the termination\nof active duty or discharge from hospitalization incident to such active\nduty, which hospitalization continues for a period of not more than one\nyear. The employee or member insured shall be entitled to have issued at\nthe end of the period of continuation an individual conversion policy.\n  (7) A group policy providing hospital, surgical or medical expense\ninsurance for other than accident only shall provide that if all or any\nportion of the insurance on an employee or member insured under the\npolicy ceases because the employee or member insured is ordered to\nactive duty as defined in subsection (o) of this section, such employee\nor member insured shall be entitled, without evidence of insurability,\nupon application to continue his or her hospital, surgical or medical\nexpense insurance for himself or herself and his or her eligible\ndependents, under the supplementary conversion and continuation rights\nprovided for herein, subject to all of the group policy's terms and\nconditions applicable to those forms of benefits and to the following\nconditions:\n  (A) continuation shall not be available for: (i) any person who is\ncovered, becomes covered or could be covered by title XVIII of the\nUnited States Social Security Act (Medicare) as amended or superseded or\n(ii) an employee, member or dependent who is covered, becomes covered or\ncould become covered as an employee, member or dependent by any other\ninsured or uninsured arrangement which provides hospital, surgical or\nmedical coverage for individuals in a group, except that the coverage\navailable to active duty members of the uniformed services and their\nfamily members shall not be considered a group under the terms of this\nsubsection, and except that the group insurance policy conversion option\nof this section shall not be considered as such an arrangement under\nwhich an employee, member or dependent could become covered.\n  (B) an employee or member insured who wishes continuation of coverage\npursuant to this subsection must request such continuation in writing\nwithin sixty days of being ordered to active duty.\n  (C) an employee or member insured electing continuation pursuant to\nthis subsection must pay to the group policyholder or his or her\nemployer, but not more frequently than on a monthly basis in advance,\nthe amount of the required premium payment, but not more than the group\nrate for the benefits being continued under the group policy on the due\ndate of each payment.\n  (8) The supplementary conversion and continuation rights provided for\nherein shall apply to:\n  (A) policies not covered by Chapter 18 of the Employee Retirement\nIncome Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the\nPublic Health Service Act, 42 U.S.C. section 300bb-1 et seq;\n  (B) policies covered by Chapter 18 of the Employee Retirement Income\nSecurity Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the Public\nHealth Service Act, 42 U.S.C. section 300bb-1 et seq, when active duty\nfor reservists and the refusal of an employer to voluntarily maintain\ncoverage for such period of active duty is not considered a qualifying\nevent.\n  (o) To be entitled to the right defined in subsection (n) of this\nsection a person must be a member of a reserve component of the armed\nforces of the United States, including the National Guard, who either:\n  (A) voluntarily or involuntarily enters upon active duty (other than\nfor the purpose of determining his or her physical fitness and other\nthan for training), or\n  (B) has his or her active duty voluntarily or involuntarily extended\nduring a period when the president is authorized to order units of the\nready reserve or members of a reserve component to active duty, provided\nthat such additional active duty is at the request and for the\nconvenience of the federal government, and\n  (C) serves no more than four years of active duty.\n  (p)(1) Except as provided in this section, if an insurer delivers or\nissues for delivery in this state a group or blanket policy which\nprovides hospital, surgical or medical expense coverage for other than\naccident only, the insurer must renew or continue in force such coverage\nat the option of the policyholder.\n  (2) An insurer may nonrenew or discontinue coverage under such a group\nor blanket policy based only on one or more of the following:\n  (A) The policyholder or a participating entity has failed to pay\npremiums or contributions in accordance with the terms of the policy or\nthe insurer has not received timely premium payments.\n  (B) The policyholder or a participating entity has performed an act or\npractice that constitutes fraud or made an intentional misrepresentation\nof material fact under the terms of the coverage.\n  (C) The policyholder has failed to comply with a material plan\nprovision relating to employer contribution or group participation\nrules, as permitted under section four thousand two hundred thirty-five\nof this chapter.\n  (D) The insurer is ceasing to offer group or blanket policies in a\nmarket in accordance with paragraph three or seven of this subsection.\n  (E) The policyholder ceases to meet the requirements for a group under\nsection four thousand two hundred thirty-five of this chapter or a\nparticipating employer, labor union, association or other entity ceases\nmembership or participation in the group to which the policy is issued.\nCoverage terminated pursuant to this paragraph shall be done uniformly\nwithout regard to any health status-related factor relating to any\ncovered individual.\n  (F) In the case of an insurer that offers a group or blanket policy in\na market through a network plan, there is no longer any enrollee in\nconnection with such plan who lives, resides, or works in the service\narea of the insurer (or in the area for which the insurer is authorized\nto do business).\n  (G) Such other reasons as are acceptable to the superintendent and\nauthorized by the Health Insurance Portability and Accountability Act of\n1996, Public Law 104-191, and any later amendments or successor\nprovisions, or by any federal regulations or rules that implement the\nprovisions of the Act.\n  (3)(A) In any case in which an insurer decides to discontinue offering\na particular class of group or blanket policy of hospital, surgical or\nmedical expense insurance offered in the small or large group market,\nthe policy of such class may be discontinued by the insurer in\naccordance with this chapter in such market only if:\n  (i) the insurer provides written notice to each policyholder provided\ncoverage of this class in such market (and to all employees and member\ninsureds covered under such coverage) of such discontinuance at least\nninety days prior to the date of discontinuance of such coverage. In\naddition to any other information required of notices by the\nsuperintendent, this written notice shall conspicuously include an\nexplanation, in plain language, of the policyholder's and covered\nemployee's or member insured's rights under this subparagraph and (B) of\nthis paragraph, including:\n  (I) a statement that if the superintendent determines that the covered\nemployee, member insured, or a dependent has a serious medical\ncondition, and the covered employee, member insured or dependent within\nthe previous twelve months utilized a benefit under the policy related\nto the serious medical condition that is not covered by the replacement\ncoverage offered to the policyholder as a result of the discontinuance,\nthen the superintendent shall require the insurer to offer the\npolicyholder replacement coverage that includes a benefit that is the\nsame as or substantially similar to the benefit set forth in the policy\nthat the insurer discontinued; and\n  (II) an explanation as to how to contact the superintendent, and the\ndate by which the superintendent shall be contacted, if the\npolicyholder, covered employee or member insured believes that the\ncovered employee, member insured or a dependent has a serious medical\ncondition, and the covered employee, member insured or dependent within\nthe previous twelve months utilized a benefit related to the serious\nmedical condition that may not be covered by the replacement coverage\noffered to the policyholder as a result of the discontinuance;\n  (ii) the insurer offers to each policyholder provided coverage of this\nclass in such market, the option to purchase all (or, in the case of the\nlarge group market, any) other hospital, surgical and medical expense\ncoverage currently being offered by the insurer to a group in such\nmarket;\n  (iii) in exercising the option to discontinue coverage of this class\nand in offering the option of coverage under item (ii) of this\nsubparagraph, the insurer acts uniformly without regard to the claims\nexperience of those policyholders or any health status-related factor\nrelating to any particular covered employee, member insured or dependent\nor particular new employee, member insured or dependent who may become\neligible for such coverage, and the insurer is not discontinuing the\ncoverage of this class with the intent or as a pretext to discontinuing\nthe coverage of any such employee, member insured or dependent; and\n  (iv) at least ninety days prior to the date of discontinuance of such\ncoverage, the insurer provides written notice to the superintendent of\nsuch discontinuance, including the reason for the discontinuance, and an\nofficer or director of the insurer certifies to the superintendent that\nthe insurer has complied with items (i), (ii) and (iii) of this\nparagraph. If such notice does not include the date or dates that the\ninsurer mailed or delivered the notice to all policyholders, covered\nemployers and member insureds, the insurer shall notify the\nsuperintendent of such date within seven days of the completion of the\nmailing or delivery.\n  (B) If the superintendent determines that the insurer has not complied\nwith item (iii) of subparagraph (A) of this paragraph, then the\nsuperintendent may prohibit the insurer from discontinuing the class of\npolicies and require the insurer to promptly notify every policyholder,\ncovered employee and member insured that the insurer is not\ndiscontinuing the policies. If the superintendent determines that the\ninsurer wrongfully discontinued the class of policies pursuant to item\n(iii) of subparagraph (A), then the superintendent shall require that\nthe insurer take remedial action, including offering to group\npolicyholders the option of reinstating the discontinued policy forms.\nIf the superintendent determines that the insurer discontinued the class\nof policies without compliance with items (i), (ii), or (iv) of\nsubparagraph (A), and an employee, member insured or dependent covered\nunder the discontinued policy would have been entitled to relief under\nthis paragraph, then the superintendent may require that the insurer\noffer replacement coverage to an affected policyholder consistent with\nitem (ii) of subparagraph (C) of this paragraph.\n  (C) (i) If, within forty-five days after the insurer mails or delivers\nthe written notice of discontinuance required by item (i) of\nsubparagraph (A) of this paragraph, the superintendent is notified by a\npolicyholder or covered employee or member insured that a covered\nemployee, member insured or dependent has a serious medical condition\nand that a benefit utilized by the covered employee, member insured or\ndependent within the previous twelve months related to the serious\nmedical condition may not be covered by the replacement coverage offered\nto the policyholder as a result of the discontinuance, then the\nsuperintendent shall, within twenty days of the notification, ask the\ninsurer to confirm that the covered employee, member insured or\ndependent utilize a benefit within the previous twelve months to treat\nthe medical condition that the covered employee, member insured or\ndependent asserts is a serious medical condition, and that the benefit\nis not covered by the replacement coverage. The superintendent may\nrequest such additional information as the superintendent may require.\nThe insurer shall provide all requested information to the\nsuperintendent within five days of receipt of the request.\n  (ii) If, within twenty days of the superintendent's receipt of all\nadditional information requested from the insurer, the superintendent\ndetermines that (I) the covered employee, member insured or dependent\nhas a serious medical condition; and (II) the benefit utilized by the\ncovered employee, member insured or dependent within the previous twelve\nmonths related to the serious medical condition is not covered by the\nreplacement coverage offered to the policyholder as a result of the\ndiscontinuance, then the superintendent shall require the insurer to\noffer to the policyholder replacement coverage that includes a benefit\nthat is the same as or substantially similar to the benefit set forth in\nthe policy that the insurer discontinued. If the replacement coverage is\nnot available, at the time that the policy would otherwise be\ndiscontinued, then the insurer shall keep the existing policy in force\nfor the affected policyholder until the replacement coverage with the\nsubstantially similar benefit is available.\n  (D) The remedies as provided in this paragraph shall be in addition to\nand not in lieu of any other authority or power of the superintendent to\nimpose monetary or other penalties for violations of this paragraph.\n  (E) In any case in which an insurer elects to discontinue offering all\nhospital, surgical and medical expense coverage in the small group\nmarket or the large group market, or both markets, in this state, health\ninsurance coverage may be discontinued by the insurer only if:\n  (i) the insurer provides written notice to the superintendent and to\neach policyholder (and all employees and member insureds covered under\nsuch coverage) of such discontinuance at least one hundred eighty days\nprior to the date of the discontinuance of such coverage;\n  (ii) all hospital, surgical and medical expense coverage issued or\ndelivered for issuance in this state in such market (or markets) is\ndiscontinued and coverage under such policies in such market (or\nmarkets) is not renewed; and\n  (iii) in addition to the notice to the superintendent referred to in\nitem (i) of this subparagraph, the insurer shall provide the\nsuperintendent with a written plan to minimize potential disruption in\nthe marketplace occasioned by the insurer's withdrawal from the market.\n  (F) In the case of a discontinuance under subparagraph (E of this\nparagraph in a market, the insurer may not provide for the issuance of\nany group or blanket policy of hospital, surgical or medical expense\ninsurance in that market in this state during the five year period\nbeginning on the date of the discontinuance of the last health insurance\npolicy not so renewed.\n  (4) At the time of coverage renewal, an insurer may modify the health\ninsurance coverage for a group or blanket policy offered to a large or\nsmall group policyholder so long as such modification is consistent with\nthis chapter and effective on a uniform basis among all small group\npolicyholders with that policy form.\n  (5) For purposes of this subsection the term "network plan" shall mean\na health insurance policy under which the financing and delivery of\nhealth care (including items and services paid for as such care) are\nprovided, in whole or in part, through a defined set of providers under\ncontract either with the insurer or another entity which has contracted\nwith the insurer.\n  (6) For purposes of this subsection, the term "dependent" shall\ninclude a child as described in subsection (f) of section four thousand\ntwo hundred thirty-five of this chapter.\n  (7) Notwithstanding paragraph three of this subsection, an insurer may\ndiscontinue offering a particular class of group or blanket policy of\nhospital, surgical or medical expense insurance offered in the small or\nlarge group market, and instead offer a group or blanket policy of\nhospital, surgical or medical expense insurance that complies with the\nrequirements of section 2707 of the public health service act, § 42\nU.S.C. 300gg-6 that become applicable to such policy as of January\nfirst, two thousand fourteen, provided that the insurer:\n  (A) discontinues the existing class of policy in such market as of\neither December thirty-first, two thousand thirteen or the policy\nrenewal date occurring in two thousand fourteen in accordance with this\nchapter;\n  (B) provides written notice to each policyholder provided coverage of\nthe class in the market (and to all employees and member insureds\ncovered under such coverage) of the discontinuance at least ninety days\nprior to the date of discontinuance of such coverage. The written notice\nshall be in a form satisfactory to the superintendent;\n  (C) offers to each policyholder provided coverage of the class in the\nmarket, the option to purchase all (or, in the case of the large group\nmarket, any) other hospital, surgical and medical expense coverage that\ncomplies with the requirements of section 2707 of the public health\nservice act, 42 U.S.C. § 300gg-6 that become applicable to such coverage\nas of January first, two thousand fourteen, currently being offered by\nthe insurer to a group in that market;\n  (D) in exercising the option to discontinue coverage of the class and\nin offering the option of coverage under subparagraph (C) of this\nparagraph, acts uniformly without regard to the claims experience of\nthose policyholders or any health status-related factor relating to any\nparticular covered employee, member insured or dependent, or particular\nnew employee, member insured, or dependent who may become eligible for\nsuch coverage, and does not discontinue the coverage of the class with\nthe intent or as a pretext to discontinuing the coverage of any such\nemployee, member insured, or dependent; and\n  (E) at least one hundred twenty days prior to the date of the\ndiscontinuance of such coverage, provides written notice to the\nsuperintendent of the discontinuance, including certification by an\nofficer or director of the insurer that the reason for the\ndiscontinuance is to replace the coverage with new coverage that\ncomplies with the requirements of section 2707 of the public health\nservice act, § 42 U.S.C. 300gg-6 that become effective January first,\ntwo thousand fourteen. The written notice shall be in such form and\ncontain such information the superintendent requires.\n  (q)(1) No insurer delivering or issuing for delivery in this state a\ngroup or blanket policy which provides hospital, surgical or medical\nexpense coverage shall establish rules for eligibility (including\ncontinued eligibility) of any individual or dependent of the individual\nto enroll under the policy based on any of the following health\nstatus-related factors:\n  (A) Health status.\n  (B) Medical condition (including both physical and mental illnesses).\n  (C) Claims experience.\n  (D) Receipt of health care.\n  (E) Medical history.\n  (F) Genetic information.\n  (G) Evidence of insurability (including conditions arising out of acts\nof domestic violence).\n  (H) Disability.\n  (2) For purposes of paragraph one of this subsection, rules for\neligibility include rules defining any applicable waiting periods for\nsuch enrollment.\n  (3) No insurer may, on the basis of any health status-related factor\nin relation to the insured or dependent of the insured, require any\ninsured (as a condition of enrollment or continued enrollment under the\npolicy) to pay a premium or contribution which is greater than such\npremium for a similarly situated insured enrolled in the plan.\n  (4) Nothing in this subsection shall require an insurer to issue a\ngroup or blanket policy to a group comprised of fifty-one or more lives\nexclusive of spouses and dependents.\n  (5) Where an eligible insured or dependent of an insured rejects\ninitial enrollment in a group or blanket policy that provides hospital,\nsurgical or medical expense insurance, an insurer shall permit an\ninsured or dependent of an insured to enroll for coverage under the\nterms of the policy if each of the following conditions is met:\n  (A) The insured or dependent was covered under another plan or policy\nat the time coverage was initially offered.\n  (B)(i) Coverage under the other plan or policy was provided in\naccordance with continuation required by federal or state law and was\nexhausted; or\n  (ii) Coverage under the other plan or policy was subsequently\nterminated as a result of loss of eligibility for one or more of the\nfollowing reasons:\n  (I) termination of employment;\n  (II) termination of the other plan or policy;\n  (III) death of the spouse;\n  (IV) legal separation, divorce, or annulment;\n  (V) reduction in the number of hours of employment; or\n  (iii) Policyholder contributions toward the payment of premium for the\nother plan or contract were terminated.\n  (C) Coverage must be applied for within thirty days of termination for\none of the reasons set forth in subparagraph (B) of this paragraph.\n  (6) With respect to group or blanket policies delivered or issued for\ndelivery in this state covering between two and fifty employees or\nmembers, the provisions of this subsection shall in no way diminish the\nrights of such groups pursuant to section three thousand two hundred\nthirty-one of this article.\n  (7) For purposes of this subsection, the term "dependent" shall\ninclude a child as described in subsection (f) of section four thousand\ntwo hundred thirty-five of this chapter.\n  (r) (1) As used in this subsection, "child" means an unmarried child\nthrough age twenty-nine of an employee or member insured under a group\npolicy of hospital, medical or surgical expense insurance, regardless of\nfinancial dependence, who is not insured by or eligible for coverage\nunder any employer health benefit plan as an employee or member, whether\ninsured or self-insured, and who lives, works or resides in New York\nstate or the service area of the insurer and who is not covered under\ntitle XVIII of the United States Social Security Act (Medicare).\n  (2) In addition to the conversion privilege afforded by subsection (e)\nof this section and the continuation privilege afforded by subsection\n(m) of this section, every group policy delivered or issued for delivery\nin this state that provides hospital, medical or surgical expense\ninsurance coverage for other than specific diseases or accidents only,\nand which provides coverage of a child that terminates at a specified\nage, shall, upon application of the employee, member or child, as set\nforth in subparagraph (B) of this paragraph, provide coverage to the\nchild after that specified age and through age twenty-nine without\nevidence of insurability, subject to all of the terms and conditions of\nthe group policy and the following:\n  (A) An employer shall not be required to pay all or part of the cost\nof coverage for a child provided pursuant to this subsection;\n  (B) An employee, member or child who wishes to elect continuation of\ncoverage pursuant to this subsection shall request the continuation in\nwriting:\n  (i) within sixty days following the date coverage would otherwise\nterminate due to reaching the specified age set forth in the group\npolicy;\n  (ii) within sixty days after meeting the requirements for child status\nset forth in paragraph one of this subsection when coverage for the\nchild previously terminated; or\n  (iii) during an annual thirty-day open enrollment period, as described\nin the policy;\n  (C) An employee, member or child electing continuation as described in\nthis subsection shall pay to the group policyholder or employer, but not\nmore frequently than on a monthly basis in advance, the amount of the\nrequired premium payment on the due date of each payment. The written\nelection of continuation, together with the first premium payment\nrequired to establish premium payment on a monthly basis in advance,\nshall be given to the group policyholder or employer within the time\nperiods set forth in subparagraph (B) of this paragraph. Any premium\nreceived within the thirty-day period after the due date shall be\nconsidered timely;\n  (D) For any child electing coverage within sixty days of the date the\nchild would otherwise lose coverage due to reaching a specified age, the\neffective date of the continuation coverage shall be the date coverage\nwould have otherwise terminated. For any child electing to resume\ncoverage during an annual open enrollment period, the effective date of\nthe continuation coverage shall be prospective no later than thirty days\nafter the election and payment of first premium;\n  (E) Coverage for a child pursuant to this subsection shall consist of\ncoverage that is identical to the coverage provided to the employee or\nmember parent. If coverage is modified under the policy for any group of\nsimilarly situated employees or members, then the coverage shall also be\nmodified in the same manner for any child;\n  (F) Coverage shall terminate on the first to occur of the following:\n  (i) the date the child no longer meets the requirements of paragraph\none of this subsection;\n  (ii) the end of the period for which premium payments were made, if\nthere is a failure to make payment of a required premium payment within\nthe period of grace described in subparagraph (C) of this paragraph; or\n  (iii) the date on which the group policy is terminated and not\nreplaced by coverage under another group policy; and\n  (G) The insurer shall provide written notification of the continuation\nprivilege described in this subsection and the time period in which to\nrequest continuation to the employee or member:\n  (i) in each certificate of coverage; and\n  (ii) at least sixty days prior to termination at the specified age as\nprovided in the policy.\n  (3)(A) Insurers shall submit such reports as may be requested by the\nsuperintendent to evaluate the effectiveness of coverage pursuant to\nthis subsection including, but not limited to, quarterly enrollment\nreports.\n  (B) The superintendent may promulgate regulations to ensure the\norderly implementation and operation of the continuation coverage\nprovided pursuant to this subsection, including premium rate\nadjustments.\n  (s) An insurer subject to the provisions of this article or an\ninsurance producer subject to this chapter shall not permit the renewal\nof a small group policy that provides hospital, surgical or medical\nexpense coverage that renews on or after January first, two thousand\nfourteen, but before July first, two thousand fourteen, so as to renew\nthe same policy prior to the policy's annual renewal date for the sole\npurpose of evading the requirements of the affordable care act and\nregulations promulgated thereunder with respect to such policy. An\nisolated, inadvertent renewal date change which was not made for the\nsole purpose of evading the requirements of the affordable care act\nshall not be deemed a violation of this subsection.\n  (t) (1) Any insurer that delivers or issues for delivery in this state\nhospital, surgical or medical expense group policies in the small group\nor large group market shall offer to any employer in this state all such\npolicies in the applicable market, and shall accept at all times\nthroughout the year any employer that applies for any of those policies.\n  (2) The requirements of paragraph one of this subsection shall apply\nwith respect to an employer that applies for coverage either directly\nfrom the insurer or through an association or trust to which the insurer\nhas issued coverage and in which the employer participates.\n  (u) (1) Every policy that provides coverage for physician services,\nmedical, major medical or similar comprehensive-type coverage shall,\nupon the referral of a physician, provide coverage for comprehensive\nneuropsychological examinations for dyslexia when performed by a health\ncare professional licensed, certified, or authorized pursuant to title\neight of the education law and acting within their scope of practice and\nin accordance with this subsection and shall not exclude coverage for\nthe screening, diagnosis or treatment of medical conditions otherwise\ncovered by the policy.\n  (2) Nothing in this subsection shall be construed to prevent the\nmedical management or utilization review of the services or prevent a\npolicy from requiring that services be provided through a network of\nparticipating providers.\n  * (v) With respect to high deductible health plans offered in\nconjunction with a health savings account, if application of any cost\nsharing requirements would result in health savings account\nineligibility under section two hundred twenty-three of the internal\nrevenue code, such coverage may be subject to the plan's annual\ndeductible.\n  * NB Effective January 1, 2027\n